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Using the Videoplan equipment at 40 screen magnification arthritis pain relief elbow purchase celecoxib 100mg on line, the area of the new ingrown bone can be measured by circumscribing it on a digitizing table arthritis in dogs can't walk order celecoxib without a prescription. This area includes graft remnants and marrow cavities that had been circled or covered by new bone arthritis pain natural supplements purchase celecoxib 100 mg with visa. The mean bone ingrowth distance (d) can be calculated on each slide by dividing the new bone area with the width of the specimens arthritis relief oils purchase celecoxib without prescription. Fibrous tissue had advanced further into the chamber ahead of the new bone in all cases and the total tissue ingrowth distance was measured in the same way as bone ingrowth Classically, a Merz grid ocular lens (Merz and Schenk 1970) with 6 6 crossing lines forming 36 points of an area of interest were used to measure the bone density by a manual point counting method ad modum Cavalieri. An area fraction assessment, expressed as bone area/total area, can be made of both the remaining dead graft as well as living new-formed bone within the area of the point count. The volume (V) of the new formed remodeled bone and remaining graft bone in the specimens below and including the edge of the bone formation can be calculated using the mean bone ingrowth distance into the graft (d) and the radius of the chamber (r=1mm), V=d r2. It was possible to do a distinction between dead graft bone and new living bone by grading the matrix staining and the existence of osteocytes. In the long term follow-up of the untreated series (Jureus 2013), the size of the lesion was associated with an inferior outcome but in the bisphosphonate series such association was not found 16. In the short-term outcome after 1-7 years, 10 patients had a good radiographic outcome and 30 were considered failures, developing osteoarthritis. The mean follow up time, from diagnosis until death, revision or end of study, was 15 (1-30) years. None of the 7 patients from the initial report, with a lesion visible only with scintigraphy but not with radiography, were ever operated. At the time of this review, 17/40 patients had been treated operatively, either with a unicompartmental (n=6), a total knee arthroplasty (n=9) or an osteotomy (n=2. All but 1 of the 7 patients with an initial Lotke index of 40 were eventually operated with knee prosthesis. With the exception of this patient, all the patients undergoing major 48 surgery were in the “failure group (developing osteoarthritis) in the initial study 1991. The median time to knee surgery was 1,5 (0,5-11) years and 14/17 of the operations were carried out within the first 4 years. No major knee surgery was performed later than 12 years after the diagnosis and in 2012 only 4 un-operated patients were still alive. A Kaplan–Meier failure estimate was calculated and presented as a graph 17), showing the proportion of patients needing to undergo knee surgery with either osteotomy or arthroplasty over the years. The age of the patients operated with knee prosthesis or osteotomy was 68 (48-85) years at the time of symptom onset, compared to 74 (64-84, p= 0,1) in the group who were never operated but were considered failures in the initial report. No gender-specific differences could be shown in terms of the need to undergo a knee prosthesis surgery. Kaplan-Meier failure estimate Kaplan–Meier failure estimate, illustrates the proportion of patients undergoing knee surgery with arthroplasty or high tibial osteotomy over the years. Patients with definitive lack of femoral head circulation had been prescribed non-weight-bearing and bisphosphonates for a minimum of 6 months. All patients were followed for minimum of one year with radiographic examinations. Radiological changes were classified according to the Stulberg and the Ficat and Arlet scores (Table 2 and 3) respectivly (Ficat 1985, Stulberg 1981) In 3 patients, the femoral head had normal circulation postoperatively and all 3 had normal radiographs at follow-up. The patients with normal circulation were non weightbearing for mean 3 months (1-6. In 3 patients the entire femoral head was avascular post-operatively, and at follow-up 1 patient had normal radiographs, 1 had subchondral sclerosis but normal sphericity and 1 had both subchondral sclerosis and flattening. The patients with complete avascularity underwent a longer period of non weightbearing after surgery, (mean 12. The 4 patients with retained vascularity in parts of the femoral head were non-weight-bearing for mean 3,5 months (1,5-6) and none were treated with bisphosphonates. Systemically administered zoledronate prevents collapse in mechanically loaded osteochondral grafts. Bone grafts were harvested, measured with a caliper and placed in a bone chamber inserted into the tibia of a rat. Pressure was applied by hand using a specially designed dynamometer once a day, five days a week until the rats were harvested after 6 weeks. The specimens were fixed, cut and stained with haematoxylin/eosin and used for histological and histomorphometric analyses. The cysts were punctured and if pus was present (n=2, both saline controls) the rats were excluded and if the fluid was opalescent (n=6), the animal remained in the study. Histologically, the whole graft had revascularized and fibrous tissue had grown in to replace the bone marrow. In the controls, the graft was almost totally resorbed and had been replaced by fatty tissue but in the bisphosphonate treated specimens the graft remained with new formed bone appositioned. Left, saline treated control specimen after 2 weeks of non-loading followed by 4 weeks of loading. Right, zoledronate treated specimen after 2 weeks of non-loading followed by 4 weeks of loading. The ingrowth openings are in the lower end and vessels grow in upwards in the bone part towards the cartilage part (C) of the osteocartilaginous graft. An experimental animal study was performed in a rat model to study remodeling of dead bone under load. If no factors related to the osteonecrotic lesion can be found the lesion is said to occur “spontaneously. Regardless of cause, vascular compromise is the final pathway that leads to cellular death. Three of the papers, including the animal study, comprises bisphosphonate treatment studies of the osteonecrotic lesions. In the paper on osteonecrosis following hip fracture, the focus was not primarily on treatment with bisphosphonates, although 3 patients were treated with this drug, but on the diagnosis and prognosis related to the remaining postoperative blood circulation in the femoral cervical head. Only 4 non-operated patients were still alive at the end of the study making it an almost lifelong follow up, with an mean follow-up period of 15 years ranging from 1 to 30 years. Patients with a good outcome in the initial 1-7 year follow-up (al-Rowaih 1991) of our series continued to do well in the long time follow-up of the same 40 patients (Jureus 2013. Only 1 patient without radiographic osteoarthritic changes in the initial study deteriorated and was operated after 9 years. Older patients with large lesions and early radiological signs of secondary osteoarthritis should be considered for early intervention with knee prosthesis. The clinical results in the bisphosphonate series was significantly better with 59% of the patients having a complete recovery in plain radiographs compared to 25% in the original study. There are however well recognized problems in the comparison of historical series. Our hypothesis was that an anticatabolic drug would delay the remodeling of the dead bone. Systemic treatment with bisphosphonates has been suggested to postpone the resorption of the necrotic bone during the revascularization and new bone formation. In a randomized human study bisphosphonates given to patients with femoral head osteonecrosis substantially reduced the risk of secondary osteoarthritis and hip arthroplasty (Lai 2005. Only a direct comparison in a long-term prospective randomized study would be able to determine if bisphosphonates are capable of changing the outcome with regard to development of osteoarthritis and need for major surgery. Such a study may, however be difficult to perform due to the low incidence of the condition. Cervical hip fracture In our study Vascular impairment after cervical hip fractures in children and younger adults we found evaluation of the vascularity of the femoral head to be a useful tool to predict the outcome after cervical or basocervical fractures in children and younger adults. Without pharmacological or other treatment, other than a shorter period of restricted weight-bearing, all patients with a normal bone perfusion investigation healed without signs of radiographic lesions after a follow-up of mean 18 months. Amongst those patients, where scintigraphy revealed reduced vascularity in parts of the femoral head, 3/4 patients healed without signs of radiographic deterioration. The avascular part corresponded to the final radiographic lesion seen in this patient at follow up. On reflection, it is possible a prolonged period of non-weight-bearing and/or addition of a bone resorptive agent such as bisphosphonate in this patient may have decreased or hindered the development of secondary radiographic changes. Partial avascularity in the subchondral bone 1 patient, diagnosed as having a partially impaired uptake, developed secondary radiographic lesions.
Collaboration between clients and providers in the measuring and the analysis of results can be effective in driving the continuous improvement in outcomes arthritis pain during sleep celecoxib 200mg mastercard, particularly arthritis pictures order 100mg celecoxib, for example arthritis toe joint pain order celecoxib in india, in improving adherence to proven therapies arthritis new treatments 2012 order celecoxib discount. Identify individuals with Information Systems: specific diseases or conditions and at-risk, • Client registries (e. Facilitate collaboration among team members, and integrate client services across the health system! Track performance of guideline-informed care and receive feedback on performance for evaluation and continuous quality improvement! To accomplish this, information systems must have the functionality to produce registries or at a minimum, have the ability to query population data to sort clients into disease, risk and/or condition-specific sub-populations. Registries are most successful in improving care delivery when they are augmented by client management software that generates automatic reminders and other follow-up. The use of registries and reminders to maintain surveillance of patients with hypertension, for example, has consistently been shown to 17 improve care for clients with high blood pressure. As many clients with chronic 27 disease suffer from co-morbid conditions, information systems must be capable of linking data across different disease registries. If their registry showed that most of their clients smoked, for example, a practice team might increase smoking cessation counseling during visits, or increase referrals to community cessation classes. Registries can play an important role in identifying unmet local health needs and underserved populations. Client registries are most useful to population level prevention/promotion when they record clients socio-demographic and lifestyle risk factors. Provider Portals Information systems need to be fully integrated to ensure client information is accessible to all members of the practice team in order to support case management and care coordination; and to improve decisions about preventative care, diagnosis and treatment. Information systems within clinical practices and within the community need to be linked effectively to tertiary care centres and other external health care services that provide acute, primary, rehabilitation, long-term, and palliative care. Information systems employed in various telehealth initiatives use technology to link providers and individuals in remote locations, link providers to one another, decision support resources, specialist care and to community resources. Some client portals provide access to information on best practices guidelines, community resources, educational tools and reference materials to support self-management. Neither clinical practices nor community providers can be expected to generate all this data, but both should have the capacity to use it to set priorities and shape programs. It refers to the development and implementation of policies aimed at improving individual and population health and to address inequities among groups within the general population. These policies include, for • Organizational policies and programs example, smoking bans, healthy menus in school cafeterias, workplace fitness facilities, improved food labeling and zoning by-laws to create bike lanes. However, preventing chronic disease through healthy public policy also requires a focus on the social determinants of health. Developing and promoting healthy public policies is a shared responsibility of individuals, communities, the private sector and governments. For example, legislation to reduce smoking rates was found to be more effective than 45 individual-level interventions such as physician counseling. Legislation and regulations, including by-laws that prohibit smoking in public places, that provide good facilities, such as bike lanes and green spaces, and provide affordable 30 housing and transportation have helped reduce threats to health, improve living 46 conditions, and encourage healthier behaviours. Fiscal policies Fiscal policies are an effective tool to reduce social inequities and remove economic barriers to healthier choices. Financial disincentives can be created to make it more costly to partake in unhealthy behaviours, such as raising taxes on cigarettes, junk food or driving fuel-inefficient automobiles. The translation of the Canada Food Guide into several languages, as well as ensuring that it is culturally appropriate, is an example of how guidelines can also reduce inequities in access to new immigrants. Organizational policies and programs Organizations can develop policies and programs to support individuals and families in their efforts to maintain their health. For example, a coalition of over 25 agencies serving homeless young parents in downtown Toronto were effective in securing funding for the development of social housing for their clients. The health care sector can play an important role in fostering healthy public policies that help reduce chronic diseases and enable clients to self-manage chronic conditions. Fundamental to supportive environments is Creating Supportive Environments the recognition that individuals are more likely to be healthy if they live in surroundings that! Supportive Social and Community means increasing peoples access to Environments resources for health, increasing opportunities for healthy lifestyles, minimizing threats to health and enhancing individuals self-reliance. The incorporation of supportive environments into the framework acknowledges that high quality health care is not enough to effect a healthy population. Health care services need to be supported by community environments that allow 32 people information, time and opportunities to care for themselves in ways that do 28 not compromise their health or financial security. Supportive Social and Community Environments Supportive social and community environments include social networks to minimize social isolation, foster positive family relationships, safe schools and workplaces, and communities that create an overall sense of security due to low crimes rates, and community services, programs and information that support people to be healthy. They help individuals and families make healthier choices by ensuring, for example, that local grocery stores sell fresh fruit and vegetables to its clients, or ensuring that smoking cessation programs are readily available. Other examples of social supports provided by the community include schools that encourage students to be physically active every day, workplace health promotion programs, and community-based support networks for seniors, young families and new immigrants. For example, rates of quitting smoking among adults have been correlated to the level of media 51 coverage of smoking and health issues. In countries with strong tobacco 33 control movements and where people understand and accept the health risk from 52 53 smoking, one-third or more of smokers attempt to quit each year. Creating supportive environments is a shared responsibility Creating supportive environments involves actions that influence social and economic processes, or increase the level of resources in a community. Creating supportive environments calls for collaboration among diverse sectors, organizations and individuals – it is a shared enterprise among all who help shape the local environments. Individuals and community organizations within the local community can be expected to initiate and lead most of these efforts. The health care system can play an important role in creating supportive environments. These partnerships can be one in which stakeholders and health care providers organize programs and resources such as the initiative between a large corporation and the local public health unit to initiate a healthy workplace. Or they may involve organizing community members, who then work with local health professionals, to address an issue such as asthma that is due to the poor air quality in a high rise building in their community. By understanding the challenges that their clients face, health care providers can advocate for new resources, and coordinate community services, information and programs for their clients. For example, health care providers can work with community organizations to co-ordinate self-help groups to support their clients with chronic disease, and they can arrange a variety of social support programs for their newer immigrant clients to reduce their isolation and enhance their mental health. As well, health care providers can collaborate with community organizations to advocate for a community sponsored congregant meal program or community programs that offer social support for their senior clients. Collaboration such as these can enhance the health and well-being of seniors, who are often at risk for poor nutrition and social isolation. Collaborative partnerships like these represent an excellent opportunity to augment the services provided by health care organizations. It can be strengthened by skills, and resources consistent leadership, by building social networks and learning from experience, by developing knowledge and skills, and learning how to access resources. Community action is not merely an adjunct to the health care system but rather, it is a necessary intervention to remove barriers to healthy living and quality of life for particular individuals and groups in the community. This begins with them working together to identify their key problems, assessing gaps in available services and working to find solutions. As the problems confronting a community are often complex, such as poverty, accessible transportation, inadequate housing and social exclusion, collaboration across sectors is required to mobilize relevant resources and expertise to identify and meet the needs of the population. Through Public Health they identify the health related issues utilizing its information systems and collaborate with community partners to advocate, identify gaps and design strategies to deal with the issues. Building partnerships is an on-going process that is encouraged by strong local leadership and requires building capacity for action within individual organizations and institutions. Public Participation Strengthening community action also involves mobilizing individuals and families to participate in organized community action. A communitys success in improving the health status of its residents is affected by the degree to which its citizens participate in the decision-making processes, and that those most affected are involved in finding the solutions. Mechanisms need to be put in place to mobilize individuals and families to participate in organized community action. Community settings such as schools, workplaces and recreational sites are often used as venues for public consultation. This requires mobilizing a variety of sectors with resources and expertise to work together in developing policies, programs and services. The health sector has, and often plays, a major role in strengthening community action by bringing their knowledge, expertise, strengths and resources to build a healthier community. Working in partnership, local community groups and the health sector use this data to identify local needs, high risk populations and to develop chronic disease prevention and management strategies that address these local needs. These profiles can included such information as socio-demographic data, 36 health status data as well as community assets and strengths.
American Academy of Family Physicians arthritis in dogs hips symptoms celecoxib 100 mg cheap, American College of Obstetricians and Gynecologists signs of arthritis in your neck purchase genuine celecoxib. This glossary is provided for information and reference purposes to clarify these various require ments arthritis in dogs jaw order celecoxib uk, qualifications and standards arthritis in small fingers generic celecoxib 200 mg. It is inclusive of the range of midwifery terms, including nurse–midwifery, and is representative of current activity across the country. The year an organization was formed and when a term first came into use is also noted. American Association of Birth Centers: A nonprofit, multidisciplinary mem bership organization founded by Childbirth Connection (formerly Maternity Center Association) over 25 years ago. The American Association of Birth Centers establishes national standards and accreditation for birth centers and advocates federally and in the states for birth center reimbursement and other concerns. The American College of Nurse–Midwives sets standards for academic preparation and clinical practice. They are licensed in only three states: 1) New Jersey, 2) New York, and 3) Rhode Island. New York had the first certified midwife training program and was the first state to recognize the certified midwife credential. Certified Nurse–Midwife: A midwife who is educated at the baccalaureate level or higher in the two disciplines of nursing and midwifery. These midwives typically have prescriptive authority for most drugs, third-party reimbursement, including Medicaid, and practice independently or in collaborative practice with physicians. Certified Professional Midwife (also licensed midwives, licensed direct-entry midwives, and registered midwives): In the mid-1990s, the certified profes sional midwife credential was developed jointly by the Midwives Alliance of North America, the North American Registry of Midwives and the Midwifery Education Accreditation Council. There is no single standard for education, and both apprentice-only trained midwives and midwives who undergo a uni versity-affiliated training use the title certified professional midwife. A certified professional midwife can learn through a structured program, through appren Appendix E 493 ticeship, or through self study. Another route to the credential is current legal recognition to practice in Britain. According to the Midwives Alliance of North America, in 2009, 24 states recognized the certified professional mid wife credential as the basis for licensure or used the North American Registry of Midwives written examination. For example, licensed midwife is used in California, Idaho, Oregon, and Washington; licensed direct-entry midwife is used in Utah, and registered midwife is used in Colorado. Childbirth Connection: Established in 1918, Childbirth Connection (formerly Maternity Center Association) is a national nonprofit organization whose mis sion is to improve the quality of maternity care through research, education, advocacy, and policy. The following definition, approved by the American College of Obstetricians and Gynecologists Executive Board, appears on page one of that document: Collaborative practice in the health care of women is a comprehen sive, dynamic system of patient-centered health care delivered by a multidisci plinary team. The team consists of obstetrician–gynecologists and other health care professionals who function within their educational preparation and scope of practice. Although the responsibilities of obstetrician–gynecologists place them in the role of ultimate authority because of their education and training, the contributions of each team member are valued and important to the quality of patient outcomes. The concept of a team guided by one of its own mem bers and the acceptance of shared responsibility for outcomes promote shared accountability. Both certified professional midwives and certified midwives are considered direct-entry midwives, although their level of education and training varies markedly. According to the Midwives Alliance of North America, direct-entry midwives can practice legally in 26 states. Some states prohibit, by statute or judicial interpretation, direct-entry midwifery practice. Other states allow midwifery practice without licensure or have stat utes that require licensure but do not have a mechanism in place to issue the license (see also “Lay Midwife. It defines a midwife as an individual who, “having been regularly admitted to a midwifery education program duly recognized in the country in which it is located, has successfully completed the prescribed course of studies in midwifery and acquired the requisite quali fications to be registered and/or legally licensed to practice midwifery. In some states still today, any lay person may attend or assist a woman giving birth, but in a gratuitous, nonprofessional, nonbusiness capacity. These lay midwives act outside of state recognition and oversight and, in fact, are not licensed by the state. In the 1980s, the Midwives Alliance of North America developed the first national certifying examination for direct-entry midwives and in 1986 launched a national regis try of midwives. Midwives Alliance of North Americas Core Competencies delineate the clinical skills for direct-entry midwife practice. Midwives Alliance of North America conducts consumer education and grassroots lobby ing campaigns nationally and in individual states. The Midwifery Education Accreditation Council requires that midwifery schools incorporate the Core Competencies adopted by Midwives Alliance of North America and the clinical experi ence requirements and essential knowledge and skills identified by the North American Registry of Midwives, an international certifying agency. Secretary of Education as a national accrediting agency for direct-entry mid wifery educational programs and institutions. The North American Registry of Midwives is accredited by the National Commission for Certifying Agencies, the accrediting body of the National Organization for Competency Assurance. The North American Registry of Midwives administers certification for certified professional midwives who are qualified to provide the Midwives Model of Care™. In many states, midwifery licensure laws and regulations 496 Guidelines for Perinatal Care refer to and adopt the North American Registry of Midwives and Midwives Alliance of North America standards of practice. Certification is based on clinical experience and understand ing of core competencies. The Portfolio Evaluation Process meets National Commission for Certifying Agencies recommendations stating that programs have an education evaluation process so that candidates who have been edu cated outside of established pathways can have their qualifications evaluated for credentialing. The reduction of maternal and infant mortality and the improvement of the health of our nations women and infants are the ultimate goals. The col lection and analysis of reliable statistical data are an essential part of in-depth investigations and incorporate case finding, individual review, and analysis of risk factors. These studies could then yield valuable clinical information for practitioners, aiding them in improved case management for patients at high risk, which would result in decreased morbidity and mortality. Both the collection and the use of statistics have been hampered by lack of understanding of differences in definitions, statistical tabulations, and reporting requirements among state, national, and international bodies. Misapplication and misinterpretation of data may lead to erroneous comparisons and conclu sions. For example, specific requirements for reporting of fetal deaths often have been misinterpreted as implying a weight or gestational age for viability. Distinctions can and should be made among the definition of an event, the reporting requirements for the event, and the statistical tabulation and inter pretation of the data. The definition indicates the meaning of a term (eg, live birth, fetal death, or maternal death. A reporting requirement is that part of the defined event for which reporting is mandatory or desired. Statistical tabulations connote the presentation of data for the purpose of analysis and *Different states use different birth weight and gestational age criteria to define fetal death. The Committee on Obstetric Practice of the American College of Obstetricians and Gynecologists recommends that perinatal mortality statistics be based on a gestational weight of 500 g. The data should be collected in a manner that will allow them to be presented in different ways for different users. Adjustments should be made for variations in reporting before compari sons among data are attempted. If information is collected and presented in a standardized manner, com parisons between the new data and the data obtained by previous reporting requirements can be delineated clearly and can contribute to improved public understanding of reproductive health statistics. For ease in assimilating this information, this appendix is divided into three sections: 1) definitions, 2) sta tistical tabulations, and 3) reporting requirements and recommendations. Some of the definitions and recommendations are a departure from those currently or historically accepted; however, these recommendations were agreed on by an interorganizational group that was brought together in the mid 1980s to review terminology related to reproductive health issues. Definitions* Birth Weight: the weight of a neonate determined immediately after delivery or as soon thereafter as feasible. Fetal Death: Death before the complete expulsion or extraction from the mother of a product of human conception, irrespective of the duration of preg nancy that is not an induced termination of pregnancy. The death is indicated by the fact that, after such expulsion or extraction, the fetus does not breathe or show any other evidence of life, such as beating of the heart, pulsation of the umbilical cord, or definite movement of voluntary muscles. Heartbeats are to be distinguished from transient cardiac contractions; respirations are to be distinguished from fleeting respiratory efforts or gasps. For statistical purposes, fetal deaths are further subdivided as early (20–27 weeks of gestation) or late (28 weeks of gestation. The term stillbirth also is used to describe fetal deaths at 20 weeks of gestation or more.
Such a context arthritis knee dislocation generic celecoxib 100mg without prescription, Thinking about the institutional context also raises whether in terms of the service infrastructure or the the matter of the constituent and contiguous policy history and acceptability of state intervention arthritis in back shoulder discount 100mg celecoxib otc, does spaces in relation to family support and parenting not obtain to the same extent in most low and middle support can arthritis in neck cause ear pain order 200mg celecoxib with mastercard. More usually arthritis back pain relief 200 mg celecoxib with amex, family support and parenting things, measures oriented to family support and support provisions extend into a number of existing parenting support in these countries or regions are policy domains. The evidence suggests that six less specialized, less formal and more likely to be policy domains are interlinked (to various degrees in grounded in community and peer support than in the different settings): high-income countries. There are many examples of ¦¦ social or family services differential resource access and use within and across ¦¦ child protection countries. Among them are the use in South Africa of ¦¦ early childhood education paraprofessionals to deliver family support with early ¦¦ health child development and health components (family and ¦¦ education community motivators) and in Jamaica the community ¦¦ social protection programmes, including cash health workers who engage in home visiting. Figure 2 illustrates the and maintenance of safe, stable and nurturing universe of potential actors. This is not foretold or necessarily locked family and/or child development may also promote in, but usually the policy and other resources of the family support and parenting support. Examples state, especially the history, institutional capacity include the World Bank and the International Monetary and background of child and family policy, exert an Fund. The World Bank in particular promotes early important infuence on the degree to which family childhood development as a policy and exerts a support and parenting support are taken up as a considerable infuence on cash transfer policy in the policy approach in a country and the ways in which global South. In high-income countries, with their well-established One can also see family support and parenting support infrastructure of service provision and where social on regional intergovernmental agendas. In a European intervention per se is not widely contested, family context, the Council of Europe in 2006 issued a support and parenting support are an additional Recommendation that commits its member states to element to an existing palette of provisions. In many of the lowest-income member states are encouraged to take all appropriate countries, state engagement in family support and legislative, administrative and fnancial measures parenting support may only be possible with the help to create the best possible conditions for positive of international organizations. The Recommendation specifcally proposes that psycho-educational resources such as parenting international and intergovernmental organizations programmes should be made available to all parents. With other international organizations, they research and training, in order to guarantee adequate frequently work in association with the national or and effective support to parents. This has been in parenting, especially in a context of child poverty reinstated through the adoption of the Addis Ababa and social exclusion. Its Recommendation on Investing Declaration on Strengthening the African Family for in Children of February 2013 proposes an integrated Inclusive Development, which calls on member states approach to reducing child disadvantage, which to defne a minimum package of social protection and emphasizes access to adequate fnancial resources and allocate resources for social protection for children, in affordable quality services (European Commission, the form of cash and services. Among the latter, specifc mention is made of supporting parents in their role as the main educators In the Middle East and North African region, initiatives of their children during the early years and encouraging are led by the Doha International Family Institute. In Latin America, the Inter-American Commission on In Africa, in 2004 the African Union adopted a Human Rights recently issued a report on the right of Plan of Action on the Family in Africa to guide boys and girls to family or alternative care. It attempts member states in developing national structures, to address the issue of poverty and lack of material policies and programmes in response to challenges means as a reason for children to be separated from facing African families (African Union, 2004. The Commission states that interference Unions understanding, the family can be seen in in private family life must be in compliance with the three dimensions: as a psycho-biological unit, where law and respond to the best interests of the child members are linked by blood ties, kinship, relationships, (Inter-American Commission on Human Rights, 2013. In Europe, Eurochild – a network of organizations and individuals working 19 Among the actions taken was an agreement by the member states in and across Europe to improve the quality of life of in 2002 on targets for early childhood and education and care children and young people – has been a relatively strong services (the so-called Barcelona targets. It 33 per cent of the 0–2-year-old cohort to be in early childhood and education and care services, and 90 per cent of those aged has lobbied consistently on the issues and has convened between 3 and 6 years by 2010. Internationally, Save the or to have the resources or capacity to offer family Children has played a key role, especially in setting up support and parenting support, especially in areas services and interventions oriented to positive discipline that are poorly resourced and have faced struggle and and family strengthening so as to prevent separation and poverty over a long period. This may be for One way in which a community mobilizes itself is resource-related reasons, because government services through volunteers. In some situations most appropriate providers or are the most widely it is volunteers who initiate a service and they are a available. This research came across many provisions in acted as champions of family support and/or parenting the different countries that are staffed by volunteers or support. For example, the China country case study have migrated for work; fathers as volunteer trainers in shows that building strong partnerships between the the Father School in Belarus; and mentor mothers in state, volunteers and the private sector appears to South Africa who are trained by one project – the Philani be a distinctive characteristic of emerging efforts in Project – to help improve maternal skills and achieve family support and parenting support in that country. Another volunteer-based initiative its cooperation with international agencies and the is the Neighbourhood Parenting Effectiveness Assembly government is gathering momentum. Faith-based organizations may be important actors and often demonstrate leadership in regard to family support other possible actors and parenting support (although this varies by context. As Figure 1 (in the executive summary) makes clear, the the South African case study refers to the key role environment or context of family support and parenting played by religious organizations as service providers support is complex and hence the range of possible and facilitators of a range of actions at local level. For example, the programmes by their domain of family certainly is a complex and varied entity. Looking tend to treat parents as recipients of information rather across countries, the private sector is sometimes than as leaders involved as a sectoral interest group. For example, some of the parenting programmes are commercially Overall, agency on the part of children and young owned, hence they involve a commercial element. Indeed, in many of the the commercial entities involved may be universities parenting interventions children and young people are or units associated with them, since the most popular not active participants – they may not even be present parenting programmes (Triple P, Incredible Years) were and if they are their role is most commonly equivalent developed by academics. Therefore, others, the scientifc community – researchers and some of the interventions being developed under the practitioners – plays a role in the general universe objectives of family support and parenting support surrounding family support and parenting support. This is another reason why the felds China a programme entitled Purposeful Parenting for of family support and parenting support contain many Working Parents targeted at migrant parents is run at underlying tensions and potential points of conficting the workplace with the support of employers. Having seen what is unfolding in practice, we are now in a better Figure 1 (page 10) shows the overview framework position to put detail and substance on the three (for greater detail see the detailed framework in the main elements investigated and to add outcomes appendix. What might such a conceptualized by context, driving infuences, forms framework be used for Some brief and contributions are further mapping and monitoring discussion of each now follows, with more attention of practice and progress, assessing effectiveness devoted to outcomes and information and knowledge and outcomes, investigating gaps in information gaps (which have not been considered to date. Context Context, as a broad overview dimension, encompasses this part of the report has two sections. The frst the setting, discourses and background conditions in presents the framework and the second considers which the policy and provisions or interventions are set. An ¦¦ cultural: encompassing such factors as the general appendix presents a methodological note to accompany value or belief system, prevailing public and other the framework. This sets out the elements comprising discourses and the ways that they frame childhood, each factor in more detail and lists key questions to parenting, adolescence, child-rearing and family operationalize the framework. These ¦¦ policy: the policy system (consisting of all relevant are broad clusters of factors, though, and so what policies and programmes), legal background and the is required now is to specify the elements and foci administrative and other components of the national of analysis that comprise each cluster. These could be conceived of Research project on family support and parenting as part of the context but they are kept as a specifc support. In regard to policy and have been integrated here (whereas for driving infuences, the research results suggest the need the background research and the presentation of the to enquire about, frst, what the precipitating problems fndings they were treated separately. The case hardly needs to be made for why evidence in confguring the problem and identifying these are important: to gauge the use of resources; possible solutions is part of what should be considered to assess effectiveness; to evaluate effciency; to here. Second, one has to examine the identity and role understand the forms and motors of change and the of the key actors as driving infuences on developments linkages between certain programmatic features and in family support and/or parenting support. The study be grouped into types of actors (as in the discussion of outcomes also helps to systematize expectations earlier; for the universe as a whole see Figure 2, p. Among the key typical or usual actors are the state, public authorities and political actors; the international As mentioned, the research did not specifcally examine organizations; and community-based and civil society outcomes and impact. The place and role of parents and children insights suggest that the outcomes and impact of family and adolescents should also be analysed, especially support and parenting support interventions have to investigating the amount and type of agency that they be conceived as relatively complex. There may also be others obvious point to make – but one that bears emphasis involved, such as professional groupings, employers, in the context of rapid policy development and high market-based actors, and volunteers and staff who act expectations – that the designation of outcomes for as providers or enablers. To a large extent, the outcomes or provision expected and associated with family support and the third element – and by far the largest and most parenting support (and indeed any provision) depend complicated – is the characteristics and features of the on factors such as how the policy and/or provision are policy and/or provision. This draws on structural and defned and conceptualized, the objectives and aims systemic features as well as operational characteristics. The different dimensions For the purposes of setting out an analytical are too numerous to detail here (but see the detailed framework, one must go beyond such relativity and framework in the appendix. Suffce to say that the be more specifc about and open to unintended dimensions are of two main types. One way of achieving both is to details about the characteristics of the policy or conceive of outcomes in terms of particular categories intervention, such as mode of operation and way encompassing the situation of the child and adolescent, of working, the targets, the type and volume of parents, families and the community (understood in resources provided, conditions of access, identity of an immediate sense as the actors involved locally and the provider(s), and level or degree of intervention more generally as the resources and capacities of the involved. A second type of element is more doing justice to the diversity of possible outcomes is to strategic than descriptive in nature. The differentiations are not hard and noted that the latter encompass the theoretical and fast in practice and, to refect this, the dividing lines in philosophical foundations. Information about the outcomes and impact of services 20 Evidence of the impact of cash transfers on family-related oriented towards family support and parenting support outcomes and child well-being is increasingly well documented in emerges from this research as a major gap.
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