Journal articles on the topic 'Development of Health Centre Services Project (Malawi)'

Purpose The purpose of this paper is to describe progress in an across sectorial approach to primary health care at the district health service (DHS) level in Thailand in response to recent innovative national public policy directions which have been enshrined in constitutional doctrine and publicly endorsed by the Prime Minister. This paper describes one response to the Prime Minister’s challenge for Thailand to become the centre of learning in the sub-region in health management. Design/methodology/approach The authors utilised a descriptive case study approach utilising an analysis of the Naresuan University initiative of establishing the College of Health Systems Management (NUCHSM). Within that case study, there is a focus on challenges relevant to the socio-economic determinants of health (SOED) and an emphasis on utilising Sustainable Development Goals (SDGs) within the DHS structure. Findings The findings describe the establishment of the NUCHSM. A Master of Science (Health Systems Management) by research and a PhD degree have been created and supported by an international faculty. The Thailand International Cooperation Agency recognised NUCHSM by providing scholarships. International students are from Bangladesh, Bhutan, Kenya, Malawi and Timor Leste. Research consultancy projects include two in Lao People’s Democratic Republic; plus, a prototype DHS management system responsive to SDG attainment; and a project to establish a sustainable Ageing Society philosophy for a Thai municipality. Originality/value The case study on NUCHSM and its antecedents in its development have demonstrated originality in a long-standing international collaboration, and it has been recognised by the national government to provide scholarships to citizens of the countries in the sub-region to undertake postgraduate studies in health management. The concept of learning from each other and together, simultaneously as a group, through action research projects funded to enhance the evolution of DHSs is innovative.

The Manitoba Centre for Health Policy and Evaluation (MCHPE) is a university-based centre funded by the provincial government to provide analyses for use in policy development and management of the health care system. At the government's request, the MCHPE undertook an analysis of bed use in the major hospitals in the province. This article reviews the formulation, execution and delivery of the project to illustrate how health services researchers, administrative data and key actors in the health care system can interact in the policy process.

This project aims to provide selected follow-up healthcare services via Internet technologies. A usercentered approach and qualitative method of inquiry taken in the development of a prostate cancer Internet Clinical Communication Centre (iC3) to provide clinicians and patients access to portions of the electronic health record, illustrates the critical importance of security, privacy, and the patient-provider relationship.

This paper will present evidence from the interim results of a large scale longitudinal project designed to track the development of partnership working between the new primary care organisations (Primary Care Groups and Trusts) entrusted with the commissioning and in some cases provision of health care, and local authority social services departments, regarding health and social care services for older people in the UK. Drawing on theoretical work concerning the role of partnership working in the governance of welfare, the author uses a framework originally devised by the Nuffield Centre for Health at the University of Leeds to analyse the interim data, and to draw conclusions about the feasibility of current policy pushes towards partnership working and service integration around health and social care for older people.

SAFE 21 is a pan-European research and development project which will take social alarms into the twenty-first century. It is run by a consortium of eight organizations, with financial support from the European Commission. SAFE 21 will use existing infrastructure to deliver a much broader range of services and extend availability to users who are currently excluded. The project aims: to develop a social alarm that will work from anywhere inside the home, using a neck-worn speech-pendant and outside the home making use of radio cellphone and global positioning technology; to demonstrate how telemedicine can be incorporated at marginal costs, by exploiting the existing social alarm infrastructure; to demonstrate a shared control centre that facilitates emergency services, medical, welfare and social professionals working together to support a broad-based social alarm system; to provide access to social alarms for deaf users, who are currently excluded.

The article was written as part of the development project entitled “Dressing kit for protecting injuries suffered by uniformed services while performing official duties” No. DOB-BIO6/19/98/2014, co-financed by the funds from the National Centre for Research and Development under competition No. 6/2014 for the implementation of projects in the field of scientific research or development work, within the area of state defence and security. The project's result will be the PLEMODS dressing kit, intended for saving the life and health of uniformed service officers who have suffered injuries while performing their duties. The kit was developed in response to the needs of both the police and the Polish army. The project owner is the police, however, in line with the project assumptions, the kit is dedicated to be used as service equipment of other uniformed services as well. The article presents the premises and conditions that the project team followed when developing the concept of the dressing kit and the functionality of its individual elements. The answers obtained from the research conducted to verify the functional properties of the PLEMODS dressing kit, indicated the need to introduce design changes in the developed model. At the same time, the high comfort of using the PLEMODS dressing kit while performing official duties was confirmed, as well as the effectiveness of the applied innovative solutions in the scope of treating bleeding wounds.

Background: Anganwadi centres under integrated child development services is the largest Project in India to improve not only child health but reproductive, maternal and adolescent health. The aim of the present study is to compare the infrastructure of urban and rural anganwadi which is one of the basic need to provide quality services.Methods: A total of 30 anganwadi centres are involved in our study in which 20 are from rural and 10 are from urban field practice area of Department of Community Medicine, Bangalore Medical College and Research Institute, Bangalore. This study employed interview method with anganwadi worker’s and observation of anganwadi centre using pre-designed, semi structured questionnaire and checklist.Results: 85% of rural and 60% urban anganwadi centres have their own buildings to carry out the services. 20% of rural anganwadi centres lack fixed name boards compared to urban anganwadi centres. 55% of rural anganwadi centres and 90% of urban anganwadi centres lack separate storage for raw food materials. 15% of rural anganwadi centres lack functional toilet facility. 40% of rural anganwadi centres lack functional weighing machine.Conclusions: Anganwadi centres are remote contact point of health care system within the community. The infrastructure of anganwadi centre such as type of building, space for cooking and activities, availability of functional equipments ensure the quality service deliveries which in turn are enhanced by timely supervision from higher authorities.

BackgroundThe global health community and funding agencies are currently engaged in ensuring that worthwhile research-based programmes are sustainable. Despite its importance, few studies have analysed the sustainability of global health interventions. In this paper, we aim to explore barriers and facilitators for the wider implementation and sustainability of a mobile health (mHealth) intervention (Supporting LIFE Community Case Management programme) in Malawi, Africa.MethodsBetween January and March 2017, a qualitative approach was used to carry out and analyse 13 in-depth semi-structured interviews with key stakeholders across all levels of healthcare provision in Malawi to explore their perceptions with regards to the implementation and sustainability of the mHealth programme. Data were analysed thematically by two reviewers. ResultsOverall, our analysis found that the programme was successful in achieving its goals. However, there are many challenges to the wider implementation and sustainability of this programme, including the absence of monetary resources, limited visibility outside the healthcare sector, the lack of integration with community-based and nationwide programmes, services and information and communication technologies, and the limited local capacity in relation to the maintenance, further development, and management.ConclusionsFuture developments should be aligned with the strategic goals and interests of the Ministry of Health and engage with national and international stakeholders to develop shared goals and strategies for nationwide scale-up. These developments should also focus on building local capacity by educating trainers and ensuring that training methods and guidelines are appropriately accredited based on national policies. Our findings provide a framework for a variety of stakeholders who are engaged in sustaining mHealth programmes in resource-poor settings and can be used to develop an evidence-based policy for the utilization of technology for healthcare delivery across developing countries.

ObjectivesTo (1) apply the Framework to Assess the Impact from Translational health research (FAIT) to Lessons from the Best to Better the Rest (LFTB), (2) report on impacts from LFTB and (3) assess the feasibility and outcomes from a retrospective application of FAIT.SettingThree Indigenous primary healthcare (PHC) centres in the Northern Territory, Australia; project coordinating centre distributed between Townsville, Darwin and Cairns and the broader LFTB learning community across Australia.ParticipantsLFTB research team and one representative from each PHC centre.Primary and secondary outcome measuresImpact reported as (1) quantitative metrics within domains of benefit using a modified Payback Framework, (2) a cost-consequence analysis given a return on investment was not appropriate and (3) a narrative incorporating qualitative evidence of impact. Data were gathered through in-depth stakeholder interviews and a review of project documentation, outputs and relevant websites.ResultsLFTB contributed to knowledge advancement in Indigenous PHC service delivery; enhanced existing capacity of health centre staff, researchers and health service users; enhanced supportive networks for quality improvement; and used a strengths-based approach highly valued by health centres. LFTB also leveraged between $A1.4 and $A1.6 million for the subsequent Leveraging Effective Ambulatory Practice (LEAP) Project to apply LFTB learnings to resource development and creation of a learning community to empower striving PHC centres.ConclusionRetrospective application of FAIT to LFTB, although not ideal, was feasible. Prospective application would have allowed Indigenous community perspectives to be included. Greater appreciation of the full benefit of LFTB including a measure of return on investment will be possible when LEAP is complete. Future assessments of impact need to account for the limitations of fully capturing impact when intermediate/final impacts have not yet been realised and captured.

BackgroundThe EDCTP-funded project ‘Institutional capacity development for multi-disciplinary health research to support the health system rebuilding phase in Sierra Leone’ (RECAP-SL) created a solid platform on which sustainable research capacity can be built at the College of Medicine and Allied Health Sciences (COMAHS) at the University of Sierra Leone. This in turn will support the much-needed evidence-based health systems reconstruction phase in Sierra Leone and support the evolution of the research landscape at COMAHS.Methods and resultsWe established a research centre at COMAHS and conducted a research needs assessment. This informed the development of short- and long-term action plans to support sustainable institutional research capacity development and enabled the development of a four-year research strategy. These plans also served as a guide for subsequent research partnerships in terms of capacity building efforts to address identified challenges.We also focused on training four research fellows and developed a wider student engagement platform to help cultivate a research culture. The research fellows will support other researchers at COMAHS, thus promoting sustainability of the research centre. Continued professional development opportunities for the fellows are also being actively sought, to develop them up to doctoral level, which addresses one of the gaps identified in the capacity assessment report.ConclusionTo support sustainability, capacity building efforts are being designed to ensure that these gains are maintained over time, with international and national research partners and funders recognising the importance of further developing local research capacity. Through a multi-pronged approach, health systems research capacity has been strengthened in Sierra Leone. This will support the generation of evidence that will inform building sustainable health systems fit for responding cohesively to outbreaks and for delivering services across the country, especially for the most disadvantaged populations.

In 2006, the Azerbaijan Ministry of Health and the World Bank launched the 6-year Health Sector Reform Project (HSRP). The principal goal of the Project is to prepare and implement a fundamental and comprehensive reform of the health system in Azerbaijan, including a major emphasis on strengthening the primary care system (Ministry of Health Project Implementation Unit, 2007). The project envisions the development of a new optimised system of services, with the integration of mental health into general healthcare. In the line of this process, the Public Health and Reform Centre (PHRC) of the Ministry of Health has developed evidence-based clinical practice guidelines on depression, for implementation within primary care (Ministry of Health, 2009). At the same time, representatives from the PHRC and the Departments of Psychiatry and Family Medicine of Azerbaijan Medical University, as well as the State Institute for Advanced Training of Physicians (in cooperation with the World Health Organization Country Office), formed a task force to carry out a survey to assess the need for education in mental health for primary care doctors. A total of 308 primary care doctors (see Table 1) working in 14 settings in different regions of the country were randomly selected and interviewed by the research team.

Evaluation is a continuing dilemma in health promotion initiatives. However, for projects to be sustained effective indicators and tools need to be implemented in order for resources and funding to be channeled into such enterprises. The capacity building model developed by New South Wales Health (1998) provided one model for evaluating a collaborative endeavor between the School of Nursing, Flinders University and Noarlunga Health Services, a generic community health centre in the southern urban/rural area of South Australia. The Community Enrichment Program (CEP), is in the final year of a four year funded project that aimed, in part, to determine what impact an integrated knowledge of Primary Health Care (PHC) would have on students and new graduates' nursing practice and, whether enough evidence would be generated to effect ongoing curriculum change. This paper considers capacity building in relation to the CEP and how the Ottawa Charter and the Jakarta Declaration are supported by this ideal. Argument is forwarded that workforce development, organizational structure and resource allocation, seen as tenets of capacity building, have been demonstrated in the CEP. Recommendations flowing from the project include the allocation of resources into a sustained, overt and integration of PHC philosophy and health promotion principles into nursing curriculum.

In a developing country like India, village-centric development is very critical for improving Human Development Index of the country. In this direction, corporate contribution assumes significance for rehabilitation and resettlement of project affected people and overall intervention under its corporate social responsibility (CSR) initiative. Since India is a country of villages, CSR has to be more sensitive towards the economic, social and cultural needs of rural society of the country. In this paper, it is proposed to gear all interventions for promoting model villages. Model village presents a credible vehicle for bringing about sustainability of a village community unit. A model village must have three significant components of infrastructure development, livelihood promotion and provision of services. Infrastructure development must cater to creating basic physical as well as social infrastructure like approach road, school building, community centre and social capital. Promotion of livelihood includes skill training, self-employment, employment opportunities and village enterprise development, while provision for services for the villagers includes health care, education, sanitation, recreational and other community services. Model village plan envisages a self-contained village community at the apex of all the pillars of sustainability, namely, livelihood, infrastructure and services. The future of Indian economy and the prospect of industry are going to depend largely on building sustainable and self-maintained smallest self-governing units called model villages.

Although most victims of disasters recover on their own, a minority of survivors, uniformed services, and relatives develop long-term disaster related psychic disorders such as Posttraumatic Stress Disorder (PTSD). Especially this subgroup should receive timely and appropriate psychosocial help. In many EU countries is offered post-disaster psychosocial care by a variety of caregivers (i.e. professionals and volunteers, NGOs, church or commercial organizations). Therefore, European standardization of providing post-disaster psychosocial support is currently required. The presentation describes the project supported by the European Commission and named European Guideline for Target Group Oriented Psychosocial Aftercare – Implementation (EUTOPA-IP), supported by the European Commission. EUTOPA-IP has integrated two materials: German “Target Group Intervention Programme” and Dutch “Multidisciplinary guideline”, also with the experiences of experts in the area of psychosocial support from the EU countries. Main target is to develop a guideline for the uniformed services on the basis of the Multidisciplinary guideline for early psychosocial interventions, the adaptation of the Target group Oriented Intervention Program (TGIP) to the International Classification of Functioning, Disability and Health (ICF) and preparation and implementation of training program for various professional groups. The project aims at standardization of psychosocial aftercare in case of disasters as well as at the development of European network based on current findings in psychotraumatology. Early screening, supportive context, early preventive and curative psychosocial interventions, management of interventions, implications for the clinical field and future research are topics discussed in the project. Project consortium: – City of Cologne (Germany)– Centre of Psychotraumatology (Germany)– Impact (The Netherlands)– Spanish Society for Psychotraumatology and Traumatic Stress (Spain)– Charles University in Prague (Czech Republic)– Capital City of Dusseldorf, Department of Public Health (Germany).

In the midst of a global pandemic the need for health and social care providers to commit to, and deliver on, integrated patient-centered care services has been accelerated. Globally, health and social care programme administrators are turning to digital devices and applications to provide supporting infrastructure which can offer safe access to health information at the point of care. Digitalisation is increasingly considered a key requirement to support diagnostics and therapeutic care services in health care delivery. The open source community are responding to this need to advance integrated care and digital services by providing targeted resources to address the interoperability challenge. Addressing interoperability in health systems is a core part of achieving sustainable enterprise wide integrated care. Using Open Innovation 2.0 methods for advancing knowledge on interoperability, this paper describes the development of a micro credential for knowledge transfer on interoperability created by the Centre for eIntegrated Care (CeIC). Designed and developed to signpost interested stakeholders to targeted material and build understanding and capacity on the topic. The design approach and initial resource content are explained through the lens of a specific research project funded by an Elite S Fellowship to advance leadership and standardisation for Information and Communications Technology (ICT) in Europe.

Purpose – The purpose of this paper is to test the feasibility of utilising an Asset-Based Community Development (ABCD) model in the context of an Alcohol and Other Drug Therapeutic Community, and to use this as a way of assessing how TCs can contribute to the local communities in which they are sited. Design/methodology/approach – This is a qualitative action research project, based on an evolving model in which key stakeholders from participating sites were instrumental in shaping processes and activities, that is a partnership between a research centre, Turning Point in Melbourne, Australia and two Recovery Services operated by the Salvation Army Australia Eastern Territory (TSA). One of these is the Dooralong Transformation Centre on the Central Coast of New South Wales and the other, Fairhaven, is in the Gold Coast hinterland of Queensland, Australia. The project was designed to create “rehabilitation without walls” by building bridges between the treatment centres and the communities they are based in, and improving participation in local community life. This was done through a series of structured workshops that mapped community asset networks and planned further community engagement activities. Findings – Both of the TCs already had strong connections in their local areas including but not restricted to involvement with the mutual aid fellowships. Staff, residents and ex-residents still in contact with the service were strongly committed to community engagement and were able to identify a wide range of connections in the community and to build these around existing Salvation Army connections and networks. Research limitations/implications – This is a pilot study with limited research findings and no assessment of the generalisability of this method to other settings or TCs. Practical implications – Both TCs are able to act as “community resources” through which residents and ex-residents are able to give back to their local communities and develop the social and community capital that can prepare them for reintegration and can positively contribute to the experience of living in the local community. Social implications – This paper has significant ramifications for how TCs engage with their local communities both as a mechanism for supporting resident re-entry and also to challenge stigma and discrimination. Originality/value – The paper and project extend the idea of ABCD to a Reciprocal Community Development model in which TCs can act as active participants in their lived communities and by doing so can create a “therapeutic landscape for recovery”.

Background: A practice development project was undertaken with nurses from acute, older persons, primary care and rehabilitation services across two counties in the north east of the Republic of Ireland over a 12-month period in 2018-19. For acute hospital patients aged over 65 years, the average length of stay in 2017 was 44.44 days; for medical patients it was 55.69 days. The average length of stay on the pre-discharge unit was 36.5 days, after which 54% of patients transferred to nursing homes, 14% to rehabilitation services and 18% to home. Aims and objectives: The objectives were to provide a more person-centred, integrated approach to care across the services, to facilitate patient and family involvement in care planning and to understand why so few patients transferred home, with the aims of reducing lengths of stay in the acute hospital and increasing the number of patients going home. Methods: Person-centred and Lean Six Sigma approaches were combined. Lean Six Sigma provided the framework for data collection, analysis, planning and scheduling, while engagement within the team and with other colleagues, patients and their families was underpinned by person-centred principles. Results: The project resulted in an average reduction in length of stay on the pre-discharge unit of 16 days. More than 47% of patients are now being discharged home compared with 18% in 2017. Conclusion: A combination of Lean Six Sigma and person-centred approaches was used to shift from the status quo and transform care by implementing process changes that promoted better communication and facilitated a smoother transition for patients through the services. This combination was effective in promoting a culture that supports patients and their families to determine and achieve their preferred health outcomes. Implications for practice: Understanding culture and context within healthcare organisations is an essential part of practice development, especially in cross-service initiatives Creating a shared vision across all services that puts the patient at the centre of care supports patients and families to choose and achieve their care preferences Lean Six Sigma and person-centredness can be used in combination to design person-centred improvements that benefit staff, patients and their families

Nowadays, the penetration of sensors and actuators in different application fields is revolutionizing all aspects of our daily life. One of the major sectors that is taking advantage of such cutting-edge cheap smart devices is healthcare. In this context, Remote Patient Monitoring (RPM) at home represents a tempting opportunity for hospitals to reduce clinical costs and to improve the quality of life of both patients and their families. It allows patients to be monitored remotely by means networks of Internet of Things (IoT) medical devices equipped with sensors and actuators that collect healthcare data from patients and send them to a Cloud-based Hospital Information System (HIS) for processing. Up to now, many different proprietary software systems have been developed as stand-along expensive solutions, presenting interoperability, extensibility, and scalability issues. In recent years, the European Commission (EC) has promoted the wide adoption of FIWARE technology, launching 16 Industrial Accelerators focusing on different application fields. One of these, i.e., FICHe, is specialized in healthcare, providing the guidelines on how to develop eHealth systems. This paper focuses on how to compose new cutting-edge IoT and Cloud-based Cyber Physical Health Sytem (CPHS) services and applications interconnected with remote medical sensors and actuators using FIWARE technology in the context envisioned by FICHe. In particular, we discuss the design and development of an RPM system implemented through the collaboration between the Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) “Bonino Pulejo” (i.e., a clinical and research healthcare centre specialized in the treatment of neuro lesions), University of Messina, IBM Research, Telefónica, and the University of the Western Cape in South Africa. The description of our best practice provides a model and guidelines for the development of lightweight and low cost RPM services for rural and isolated areas, with the expectation of expanding healthcare to the developing world and in general allows us to outline how to deal with the real adoption of the FIWARE technology in an e-health project.

Background: In contemporary health and social care services and systems, there is a critical need for nursing care that is agile in its delivery, integrated across sectors, responsive to complex need, and focused on prevention, self-care and wellbeing. Community nurses are at the centre of these services, working in and across a variety of complex systems that depend on the expertise they bring to individuals, communities and populations. However, ensuring this capability is brought to the forefront of quality frameworks is a challenge as care practices are often reduced to moments of interaction or intervention that are tangible and objectively measured. We know, though, that community nurses bring vital and wide-ranging expertise to the health of populations. The Queen’s Nursing Institute Scotland has re-established the Queen’s Nurse Development Programme to address these contemporary agendas and ensure the potential of expert community nursing is demonstrated and recognised. Aim: To engage in a participatory evaluation of the experience of the nine-month development journey of the 2019 Queen’s Nurse Development Programme participants. Methods: A Collaborative Critical Creative Inquiry (CCCI) methodology was used, operationalised through a five-phase inquiry process, informed by Theory U ‘presencing ’and its five movements for attending to and co-shaping reality to achieve presencing. Our embedded and embodied data-collection methods drew specifically on participants ’creative expressions, reflective diaries and journals, and project notes. Findings: The results of each phase of inquiry informed subsequent phases, culminating in a final phase (synthesis) where key themes representing the findings from all phases were derived. These themes were self-growth, community and practical impacts. Conclusion and implications for practice: The importance of slowing and stillness, linked to the spaces created for creative reflective learning and development has been significant in this programme. Being present to listen to self, and engage in self-care and self-growth is something the programme provides and that is highly valued. We would argue that if health systems are serious about the transformation of services and people, then these kinds of programmes are critical to success.

Colorectal cancer is a significant health burden. Several screening options exist that can detect colorectal cancer at an early stage, leading to a more favourable prognosis. However, despite years of knowledge on best practice, screening rates are still very low in Canada, particularly in Ontario. The present paper reports on efforts to increase the flexible sigmoidoscopy screening capacity in Ontario by training nurses to perform this traditionally physician-performed procedure. Drawing on American, British and local experience, a professional regulatory framework was established, and training curriculum and assessment criteria were developed. Training was initiated at Princess Margaret Hospital and Sunnybrook and Women’s College Health Sciences Centre in Toronto, Ontario. (During the study, Sunnybrook and Women’s College Health Sciences Centre was deamalgamated into two separate hospitals: Women’s College Hospital and Sunnybrook Health Sciences Centre.) Six registered nurses participated in didactic, simulator and practical training. These nurses performed a total of 77 procedures in patients, 23 of whom had polyps detected and biopsied. Eight patients were advised to undergo colonoscopy because they had one or more neoplastic polyps. To date, six of these eight patients have undergone colonoscopy, one patient has moved out of the province and another patient is awaiting the procedure. Classifying the six patients according to the most advanced polyp histology, one patient had a negative colonoscopy (no polyps found), one patient’s polyps were hyperplastic, one had a tubular adenoma, two had advanced neoplasia (tubulovillous adenomas) and one had adenocarcinoma. All these lesions were excised completely at colonoscopy. Overall, many difficulties were anticipated and addressed in the development of the training program; ultimately, the project was affected most directly by challenges in encouraging family physicians to refer patients to the program. As health human resource strategies continue to evolve, it is believed that lessons learned from experience make an important contribution to the knowledge of how nontraditional health services can be organized and delivered.

Telemedicine (distance medicine) represents a field of medicine that has been in a tremendous expansion over the last couple of years thanks to the fast development of telecommunications and reduction of their costs. It enables a direct communication (visual) between the peripheral hospitals and referral facilities in the interior of the country as well as a connection of centres with referral centres abroad in the fields of diagnostics, consultations or education. The main objective is to encourage interest in telemedicine among physicians and other health care experts, initiate an exchange of opinions, and experience about the application of telecommunication technology in medicine, so to reach a common perception of its role in the context of future development of the health care system in Bosnia and Herzegovina. As a standard, current equipment consists of computers, which are equipped with frame grabbers and communication modem for communication through a public telecommunication system. Input data can all be visual data (X-Ray, CT, MRI, ultrasound, ECG, histological finding, cariogram, and of course photos of the patients, of operational/surgical field. The Institute of Pathology of the Sarajevo Medical Faculty has actively participated in the experimental project “SHARED” (1996-2000) together with the Radiology and Ophthalmology Clinic of the Sarajevo Clinical Centre. The past experience in using telemedicine has shown that the introduction of such a telemedicine system in B&H would be of great significance in the future in the context of providing better and more efficient health services to the patients. In practice, that means a more simple approach to some services and data for patients, a better and faster circulation of information and experience of medical experts and health care workers with cost control at the same time.

BackgroundThe Salford Integrated Care Programme (SICP) was a large-scale transformation project to improve care for older people with long-term conditions and social care needs. We report an evaluation of the ability of the SICP to deliver an enhanced experience of care, improved quality of life, reduced costs of care and improved cost-effectiveness.ObjectivesTo explore the process of implementation of the SICP and the impact on patient outcomes and costs.DesignQualitative methods (interviews and observations) to explore implementation, a cohort multiple randomised controlled trial to assess patient outcomes through quasi-experiments and a formal trial, and an analysis of routine data sets and appropriate comparators using non-randomised methodologies.SettingSalford in the north-west of England.ParticipantsOlder people aged ≥ 65 years, carers, and health and social care professionals.InterventionsA large-scale integrated care project with three core mechanisms of integration (community assets, multidisciplinary groups and an ‘integrated contact centre’).Main outcome measuresPatient self-management, care experience and quality of life, and health-care utilisation and costs.Data sourcesProfessional and patient interviews, patient self-report measures, and routine quantitative data on service utilisation.ResultsThe SICP and subsequent developments have been sustained by strong partnerships between organisations. The SICP achieved ‘functional integration’ through the pooling of health and social care budgets, the development of the Alliance Agreement between four organisations and the development of the shared care record. ‘Service-level’ integration was slow and engagement with general practice was a challenge. We saw only minor changes in patient experience measures over the period of the evaluation (both improvements and reductions), with some increase in the use of community assets and care plans. Compared with other sites, the difference in the rates of admissions showed an increase in emergency admissions. Patient experience of health coaching was largely positive, although the effects of health coaching on activation and depression were not statistically significant. Economic analyses suggested that coaching was likely to be cost-effective, generating improvements in quality of life [mean incremental quality-adjusted life-year gain of 0.019, 95% confidence interval (CI) –0.006 to 0.043] at increased cost (mean incremental total cost increase of £150.58, 95% CI –£470.611 to £711.776).LimitationsThe Comprehensive Longitudinal Assessment of Salford Integrated Care study represents a single site evaluation, with consequent limits on external validity. Patient response rates to the cohort survey were < 40%.ConclusionsThe SICP has been implemented in a way that is consistent with the original vision. However, there has been more rapid success in establishing new integrated structures (such as a formal integrated care organisation), rather than in delivering mechanisms of integration at sufficient scale to have a large impact on patient outcomes.Future workFurther research could focus on each of the mechanisms of integration. The multidisciplinary groups may require improved targeting of patients or disease subgroups to demonstrate effectiveness. Development of a proven model of health coaching that can be implemented at scale is required, especially one that would provide cost savings for commissioners or providers. Similarly, further exploration is required to assess the longer-term benefits of community assets and whether or not health impacts translate to reductions in care use.Trial registrationCurrent Controlled Trials ISRCTN12286422.FundingThis project was funded by the NIHR Health Services and Delivery Research programme and will be published in full inHealth Services and Delivery Research; Vol. 6, No. 31. See the NIHR Journals Library website for further project information.

Background Australia’s mental health care system has long been fragmented and under-resourced, with services falling well short of demand. In response, the World Economic Forum has recently called for the rapid deployment of smarter, digitally enhanced health services to facilitate effective care coordination and address issues of demand. The University of Sydney’s Brain and Mind Centre (BMC) has developed an innovative digital health solution that incorporates 2 components: a highly personalized and measurement-based (data-driven) model of youth mental health care and a health information technology (HIT) registered on the Australian Register of Therapeutic Goods. Importantly, research into implementation of such solutions considers education and training of clinicians to be essential to adoption and optimization of use in standard clinical practice. The BMC’s Youth Mental Health and Technology Program has subsequently developed a comprehensive education and training program to accompany implementation of the digital health solution. Objective This paper describes the protocol for an evaluation study to assess the effectiveness of the education and training program on the adoption and optimization of use of the digital health solution in service delivery. It also describes the proposed tools to assess the impact of training on knowledge and skills of mental health clinicians. Methods The evaluation study will use the Kirkpatrick Evaluation Model as a framework with 4 levels of analysis: Reaction (to education and training), Learning (knowledge acquired), Behavior (practice change), and Results (client outcomes). Quantitative and qualitative data will be collected using a variety of tools, including evaluation forms, pre- and postknowledge questionnaires, skill development and behavior change scales, as well as a real-time clinical practice audit. Results This project is funded by philanthropic funding from Future Generation Global. Ethics approval has been granted via Sydney Local Health District’s Human Research Ethics Committee. At the time of this publication, clinicians and their services were being recruited to this study. The first results are expected to be submitted for publication in 2021. Conclusions The education and training program teaches clinicians the necessary knowledge and skills to assess, monitor, and manage complex needs; mood and psychotic syndromes; and trajectories of youth mental ill-health using a HIT that facilitates a highly personalized and measurement-based model of care. The digital health solution may therefore guide clinicians to help young people recover low functioning associated with subthreshold diagnostic presentations and prevent progression to more serious mental ill-health. International Registered Report Identifier (IRRID) PRR1-10.2196/24697

Introduction: Emergency Departments (EDs) are frequently the first point of entry to access health services for First Nation (FN) members. In Alberta, FN members visit EDs at almost double the rate of non-FN persons. Furthermore, preliminary evidence demonstrates differences in ED experience for FN members as compared to the general population. The Alberta First Nations Information Governance Centre, Maskwacis Health Services, Yellowhead Tribal Council, Treaty 8 First Nations of Alberta, and Alberta Health Services are working together to research FN members ED experiences and concerns. Methods: This is participatory research guided by a two-eyed seeing approach that acknowledges the equal value of both Western and Indigenous worldviews. FN and non-FN leaders researchers are full partners in the development of the research project. Six sharing circles will be held in February 2018 across Alberta, with Elders, FN patients, FN and non-FN clinicians and FN and non-FN administrators. Sharing circles are similar to focus groups, but emphasize everyone having a turn to speak and demonstrating respect among participants in accordance with FN protocols. Elders will select the questions for discussion based on topics that arose in initial team meetings. Sharing circle discussions will be audio recorded and transcribed. Analysts will include both Western and Indigenous worldview researchers, who will collaboratively interpret findings. Elders will review, discuss, contextualize and expand upon study findings. The research is also guided by FN principles of Ownership, Control, Access, and Possession of FN information. It is through these principles that First Nation research projects can truly be classified as FN lead and driven. Results: Based on initial team meeting discussions, results of sharing circles are expected to provide insights on issues such as: healing, patient-provider communication (verbal and non-verbal), shared decision making, respect for patient preferences, experiences leading to trust or distrust, understandings of wait times and triage, times when multiple (repeat) ED presentations occur, distances travelled for care, choosing specific EDs when seeking care, impacts of stereotypes about FN patients, and racism and reconciliation. Conclusion: Understanding FN ED experience and bringing FN perspectives to Western conceptions of the goals and provision of ED care are important steps toward reconciliation.

ObjectiveThis study aimed to investigate the challenges in implementing a Zambian electronic health records (EHR) system labelled ‘SmartCare’ from diverse stakeholder perspectives in order to improve prevention of mother-to-child transmission (PMTCT) data collection so that SmartCare can be used for clinic performance strengthening and programme monitoring.DesignThis is a qualitative retrospective study.Setting and participantsSmartCare is a Zambian Ministry of Health (MoH)-led project funded by the US Centre for Disease Control and Prevention. Data were collected using in-depth interviews, observations and focus group discussions (FGDs) between September and November 2016. Seventeen in-depth interviews were held with a range of key informants from the MoH and local and international organisations implementing SmartCare. Four data entry observations and three FGDs with 22 pregnant and lactating women seeking PMTCT services were conducted. Data were analysed using a thematic content approach.ResultsThe SmartCare system has evolved from various patient tracking systems into a multifunctional system. There is a burden of information required so that sometimes not all is collected and entered into the database, resulting in poor data quality. Funding challenges impede data collection due to manpower constraints and shortages of supplies. Challenges associated with data collection depend on whether a paper-based or computer-based system is used. There is no uniformity in the data quality verification and submission strategies employed by various IPs. There is little feedback from the EHR system at health facility level, which has led to disengagement as stakeholders do not see the importance of the system.ConclusionSmartCare has structural challenges which can be traced from its development. Funding gaps have resulted in staffing and data collection disparities within IPs. The lack of feedback from the system has also led to complacency at the operational level, which has resulted in poor data quality in later years.

IntroductionSecond-generation antipsychotics (SGAs) are widely used in the paediatric population. It is currently established that SGAs may induce metabolic adverse events (AEs) such as weight gain, perturbation of blood lipids or glucose with risk of potential cardiovascular morbidity and mortality. The Canadian Alliance for Monitoring Effectiveness and Safety of Antipsychotics in children (CAMESA) has published recommendations for monitoring the metabolic AEs of SGAs. Factors that may be associated with the onset of SGA’s metabolic AEs and long-term consequences are less studied in the literature. The objectives of our research are to evaluate some factors that can influence the development of the SGA’s metabolic AEs and to study clinical adherence to CAMESA guidelines.Methods and analysisThe Monitoring des Effets Métaboliques des Antipsychotiques de Seconde Génération study is a multicenter, prospective, longitudinal observational study with repeated measures of metabolic monitoring over 24 months. Two recruiting centres have been selected for patients under 18 years of age, previously naive of antipsychotics, starting an SGA or who have started an SGA for less than 4 weeks regardless of the diagnosis that motivated the prescription. Assessments are performed for anthropometric measures, blood pressure, blood tests at baseline and 1, 2, 3, 6, 9, 12 and 24 months of follow-up.Ethics and disseminationThe study protocol was approved by the CHU Sainte-Justine’s Research Ethics Board (MP-21-2016-1201) in 2016 and obtained institutional suitability for the ‘Centre Intégré Universitaire de Santé et de Services Sociaux du Nord-de-l’Île-de-Montréal’ Research Center in May 2018. For all participants, written consent will be obtained from parents/caregivers as well as the participant’s assent in order to enable their participation in this research project. The results of this research will be published.Trial registration numberClinicalTrials.gov (number NCT04395326).

Background: Norwegian health authorities place emphasis on recovery oriented practices in mental health services. Recovery is described as an active process with a focus on personal resources and supportive contexts. In the recovery process, the relationship between the person and the carer is of great importance. Conversation is a meaningful approach for developing a trusting relationship. Conversation also has importance in itself, because it establishes the foundation for human contact and gives the client the opportunity to be acknowledged as a person. Aim: The aim of the study was to describe and explore what health professionals focused on in recovery oriented conversations with patients in a Norwegian mental healthcare centre. Methods: This study was part of an action research project and had a qualitative and explorative design. Data were collected in multistage focus groups and were analysed using qualitative content analysis. Findings: The findings highlighted the prerequisites for conversation, the content of conversation and different views on the topics of conversation. Conclusions: The findings contribute knowledge about what promotes or inhibits recovery oriented conversations. Such conversations focus on the patients’ everyday life, appreciating them as actors in their own lives, and facilitate shared decision making processes and working with hope. The study demonstrates that individual, cultural and contextual aspects play an important part in recovery oriented conversations. Implications for practice: Practice development involves acknowledging and re-evaluating the possibilities for using conversations with patients as an approach and as a tool in person-centred and recovery oriented practices Relational competence is an essential part of enhancing recovery oriented conversation, and needs to be attended to in skills training and competence building Awareness and critical analysis of the clinical context is important to promote an active and participative patient role. Authoritarian cultures with concern about what is permitted or not may well be a barrier to shared decision making

BackgroundApproximately 670,000 people in the UK have dementia. Previous literature suggests that physical exercise could slow dementia symptom progression.ObjectivesTo estimate the clinical effectiveness and cost-effectiveness of a bespoke exercise programme, in addition to usual care, on the cognitive impairment (primary outcome), function and health-related quality of life (HRQoL) of people with mild to moderate dementia (MMD) and carer burden and HRQoL.DesignIntervention development, systematic review, multicentred, randomised controlled trial (RCT) with a parallel economic evaluation and qualitative study.Setting15 English regions.ParticipantsPeople with MMD living in the community.InterventionA 4-month moderate- to high-intensity, structured exercise programme designed specifically for people with MMD, with support to continue unsupervised physical activity thereafter. Exercises were individually prescribed and progressed, and participants were supervised in groups. The comparator was usual practice.Main outcome measuresThe primary outcome was the Alzheimer’s Disease Assessment Scale – Cognitive Subscale (ADAS-Cog). The secondary outcomes were function [as measured using the Bristol Activities of Daily Living Scale (BADLS)], generic HRQoL [as measured using the EuroQol-5 Dimensions, three-level version (EQ-5D-3L)], dementia-related QoL [as measured using the Quality of Life in Alzheimer’s Disease (QoL-AD) scale], behavioural symptoms [as measured using the Neuropsychiatric Inventory (NPI)], falls and fractures, physical fitness (as measured using the 6-minute walk test) and muscle strength. Carer outcomes were HRQoL (Quality of Life in Alzheimer’s Disease) (as measured using the EQ-5D-3L) and carer burden (as measured using the Zarit Burden Interview). The economic evaluation was expressed in terms of incremental cost per quality-adjusted life-year (QALY) gained from a NHS and Personal Social Services perspective. We measured health and social care use with the Client Services Receipt Inventory. Participants were followed up for 12 months.ResultsBetween February 2013 and June 2015, 494 participants were randomised with an intentional unequal allocation ratio: 165 to usual care and 329 to the intervention. The mean age of participants was 77 years [standard deviation (SD) 7.9 years], 39% (193/494) were female and the mean baseline ADAS-Cog score was 21.5 (SD 9.0). Participants in the intervention arm achieved high compliance rates, with 65% (214/329) attending between 75% and 100% of sessions. Outcome data were obtained for 85% (418/494) of participants at 12 months, at which point a small, statistically significant negative treatment effect was found in the primary outcome, ADAS-Cog (patient reported), with a mean difference of –1.4 [95% confidence interval (CI) –2.62 to –0.17]. There were no treatment effects for any of the other secondary outcome measures for participants or carers: for the BADLS there was a mean difference of –0.6 (95% CI –2.05 to 0.78), for the EQ-5D-3L a mean difference of –0.002 (95% CI –0.04 to 0.04), for the QoL-AD scale a mean difference of 0.7 (95% CI –0.21 to 1.65) and for the NPI a mean difference of –2.1 (95% CI –4.83 to 0.65). Four serious adverse events were reported. The exercise intervention was dominated in health economic terms.LimitationsIn the absence of definitive guidance and rationale, we used a mixed exercise programme. Neither intervention providers nor participants could be masked to treatment allocation.ConclusionsThis is a large well-conducted RCT, with good compliance to exercise and research procedures. A structured exercise programme did not produce any clinically meaningful benefit in function or HRQoL in people with dementia or on carer burden.Future workFuture work should concentrate on approaches other than exercise to influence cognitive impairment in dementia.Trial registrationCurrent Controlled Trials ISRCTN32612072.FundingThis project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full programme and will be published in full inHealth Technology AssessmentVol. 22, No. 28. See the NIHR Journals Library website for further project information. Additional funding was provided by the Oxford NIHR Biomedical Research Centre and the Oxford NIHR Collaboration for Leadership in Applied Health Research and Care.

Objective To describe the design and implementation of a culturally mediated case management model at Winnunga Nimmityjah Aboriginal Health Service (Winnunga) for Indigenous clients who consume alcohol at problematic levels. Methods Our research took place from March 2008 to March 2010 in the Australian Capital Territory and built on previous research partnerships between Winnunga and The Australian National University’s National Centre for Epidemiology and Population Health. We conducted a review of existing models to determine elements for consideration in the community controlled setting, and conducted staff surveys to assess current levels of skill and confidence around alcohol screening, brief intervention and care planning. Using the information from the review and staff surveys, we then undertook staff capacity building to build confidence and skills in conducting alcohol screening, brief intervention and care planning. This process was driven by Winnunga’s social health team. To meet Medicare benefits schedule requirements, and frame the study within the Aboriginal and Torres Strait Islander Chronic Disease Package framework, we included team care arrangements, care planning and health checks. Results Elements of case management were suggested by staff and incorporated into the final model. Forty staff in the health service participated in identifying training needs for the development of the case management model and undertook a range of training before the model was implemented. Staff working within the social health team decided that the focus of the case management was to build a stronger future for their clients, hence the name of the case management model ‘Walan Girri’ (Wiradjuri language for strong future). The model included a package of screening instruments and brief intervention, related polices and discussion of ‘mob’ and ‘country.’ Changes in Winnunga management and staff, the composition of the research team and the way Walan Girri evolved led to protracted development and implementation. Conclusions This project highlights considerations for implementing a case management model in a dynamic health service environment. Capacity building for Winnunga staff and for an Indigenous PhD scholar were part of the process and were integral in maintaining momentum in the project. What is known about the topic? Case management for chronic disease and other health conditions is currently recommended in assisting to resolve those issues. Case management aims to involve a range of healthcare practitioners (general practitioners, nurses and Aboriginal health workers) and providers in conjunction with the client to improve their health status. Currently, there is limited description of how case management models are used within the Aboriginal community controlled context. What does this paper add? This paper adds to the knowledge base in this field by describing the results of a method of case management driven by the community controlled health sector. It also introduces a simple approach that may be useful in a range of contexts in the health setting in building trust and rapport with clients, while engaging the healthcare practitioner in the Aboriginal and Torres Strait Islander cultural contexts of relationships to country and family (mob). What are the implications for practitioners? The implication may be that healthcare practitioners working in Aboriginal and/or Torres Strait Islander Health Services adopt Aboriginal and Torres Strait Islander cultural protocols, such as talking with clients about ‘mob’ and ‘country’, to build trust and rapport.

Introduction: MAVORIC was an open-label, multicenter, randomized phase 3 study evaluating the safety and efficacy of mogamulizumab (moga) compared to vorinostat (vori) in patients with mycosis fungoides (MF) or Sézary syndrome (SS) who had failed at least one prior course of systemic therapy (NCT01728805). Primary results have been reported (Kim et al. Lancet Oncol 2018) and were based on a data cutoff date of December 31, 2016. The primary endpoint was progression-free survival (PFS); patients in the moga treatment arm experienced significantly longer PFS compared to patients in the vori treatment arm (median 7.7 months vs 3.1 months; p<0.0001). The most common treatment-emergent adverse events (TEAEs) of any cause or grade reported in patients randomized to moga were: infusion-related reaction (33.2%), drug eruption (ie, skin rash attributed to moga [23.9%]), diarrhea (23.4%), and fatigue (23.4%). This report provides the final safety results of MAVORIC as of the data available on January 3, 2019. Methods: Patients were randomized 1:1 to moga 1.0 mg/kg administered intravenously on Days 1, 8, 15, and 22 of the first cycle and on Days 1 and 15 of subsequent cycles or vori 400 mg administered orally once daily. Patients randomized to vori were allowed to cross over to moga upon progression or intolerable toxicity. Safety was assessed by reported adverse events (AEs), changes in physical examinations, vital sign measurements, electrocardiograms, and laboratory analyses. Results: In total, 372 patients were randomized (moga, 186; vori, 186), of whom 370 received study drug and were included in the safety analysis (moga, 184; vori, 186). For the final safety analysis, median duration of follow-up was 34.5 months (range, 0.13-70.0) in the randomized part of the study. Median treatment exposure was 170 days (range, 1-1813) for moga and 84 days (4-1230) for vori, which represent the same median values but broader ranges compared to the primary analysis (primary analysis, 170 days [1-1379] for moga and 84 days [4-1058] for vori). The type and frequency of AEs in either the moga or vori treatment groups (Table) were consistent with those reported in the primary analysis. TEAEs, regardless of causality, that were reported at similar rates in the two treatment groups included constipation, peripheral edema, headache, and anemia. TEAEs (all causality) that occurred at higher frequency in the moga vs vori arm included infusion-related reaction (33.2% vs 0.5%) and drug eruption (25.0% vs 1.1%); the majority of these events were grade 1 or 2 (Table). The types and frequencies of AEs attributable to moga (per Investigator assessment) included infusion-related reaction (33.2% [61/184]), drug eruption (23.9% [44/184]), and fatigue (18.5% [34/184]), and for vori, diarrhea (55.4% [103/186]), nausea (38.2% [71/186]), and fatigue (33.3% [62/186]). In patients who crossed over from the vori to moga arm and received study drug (n=135), the most frequently reported AEs attributable to moga were infusion-related reaction (37.8% [51/135]), drug eruption (24.4% [33/135]), fatigue (7.4% [10/135]), increased alanine aminotransferase (7.4% [10/135]), and increased aspartate aminotransferase (7.4% [10/135]). Discontinuation rates due to AEs were similar between treatment arms and in crossover patients (moga, 21.7% [40/184]; vori, 23.7% [44/186]; crossover, 25.9% [35/135]). The most common AEs leading to discontinuation were drug eruption in the moga arm (7.1% [13/184]) and fatigue in the vori arm (4.3% [8/186]). Overall, the rates of drug-related serious TEAEs were similar between treatment arms and in crossover patients (moga, 19.6% [36/184]; vori, 16.7% [31/186]; crossover, 11.9% [16/135]). After the data cutoff for the primary analysis, 1 additional patient randomized to moga (decreased appetite, general physical health deterioration, hypoalbuminemia) and 1 crossover patient (cerebral hemorrhage) experienced TEAEs with an outcome of death, all considered unrelated to study treatment per Investigator. Conclusions: This final safety analysis from the MAVORIC study in patients with previously treated MF and SS demonstrates that moga was generally well tolerated. Longer follow-up and treatment exposure did not identify any new safety signals. The type and incidence of treatment-related AEs among patients receiving moga after crossover were similar to those observed for patients initially randomized to moga. Disclosures Kim: Merck: Research Funding; Portola Pharmaceuticals: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Horizon: Research Funding; Corvus: Honoraria, Membership on an entity's Board of Directors or advisory committees; Galderma: Research Funding; Elorac: Research Funding; Soligenix: Research Funding; Kyowa Hakko Kirin: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Eisai: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Takeda: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Forty Seven Inc: Research Funding; Seattle Genetics: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Medivir: Honoraria, Membership on an entity's Board of Directors or advisory committees; Innate Pharma: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Trillium: Research Funding; Neumedicine: Research Funding; miRagen: Research Funding. Bagot:Innate Pharma: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding. Zinzani:MSD: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Eusapharma: Consultancy, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Sanofi: Consultancy; Celltrion: Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Gilead: Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Janssen-Cilag: Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; BMS: Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Servier: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Sandoz: Membership on an entity's Board of Directors or advisory committees; Immune Design: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Celgene: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Portola: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Roche: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Kyowa Kirin: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; TG Therapeutics: Honoraria, Speakers Bureau; Verastem: Consultancy, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau. Duvic:Seattle Genetics: Consultancy, Honoraria, Research Funding; Eisai: Research Funding; Shape: Research Funding; UT MD Anderson Cancer Center: Employment; USCLC Registry: Consultancy, Membership on an entity's Board of Directors or advisory committees, Other: Secretary/treasurer of Item h; Spatz Foundation: Research Funding; Tetralogic: Research Funding; Millennium (formerly Takeda): Research Funding; Mallinckrodt Pharmaceuticals (formeraly Therakos, Inc): Research Funding; Kyowa Hakko Kirin Co., Ltd.: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Forty Seven Inc: Membership on an entity's Board of Directors or advisory committees; Cutaneous Lymphoma Foundation: Membership on an entity's Board of Directors or advisory committees; PleXus Communications: Speakers Bureau; Guidepoint Global: Consultancy; Evidera, Inc.: Consultancy; Cell Medica Inc.: Consultancy; Allos: Research Funding; Rhizen Pharma: Research Funding; Oncoceuticals: Research Funding; Soligenetics: Research Funding; Cell Medica Ltd.: Honoraria; Therakos: Speakers Bureau; Jonathan Wood & Assoc.: Speakers Bureau; Hawaiian Dermatology Society: Speakers Bureau; Hemedicus: Speakers Bureau; Janssen Pharmaceuticals (div of Johnson & Johnson): Speakers Bureau. Morris:Guys Hospital: Employment. Kim:Medimmune: Research Funding; Soligenix: Research Funding; Kyowa Kirin: Research Funding; Galderma: Consultancy, Research Funding; Actelion: Consultancy, Research Funding. Musiek:Menlo: Other: Investigator; Helsinn: Membership on an entity's Board of Directors or advisory committees; Soligenix: Other: Investigator; Pfizer: Other: Investigator; Elorac: Other: Investigator; Kyowa: Honoraria, Other: Above honoraria: for Ad Board; miRagen: Other: Investigator. Ortiz-Romero:Actelion: Consultancy, Membership on an entity's Board of Directors or advisory committees; Kyowa: Membership on an entity's Board of Directors or advisory committees; Takeda: Membership on an entity's Board of Directors or advisory committees; PLCG1: Patents & Royalties; miRagen: Membership on an entity's Board of Directors or advisory committees; MEDA: Research Funding; Innate Pharma: Membership on an entity's Board of Directors or advisory committees; 4SC: Membership on an entity's Board of Directors or advisory committees. Eradat:Kyowa: Research Funding; Kite: Research Funding; Pharmacyclics: Consultancy, Honoraria, Research Funding, Speakers Bureau; Roche: Research Funding; Genentech: Consultancy, Honoraria, Research Funding, Speakers Bureau; AbbVie: Consultancy, Honoraria, Research Funding, Speakers Bureau; Gilead: Research Funding. Magnolo:University Hospital of Muenster, Center of Innovative Dermatology: Employment. Scarisbrick:Kyowa Kirin: Consultancy, Membership on an entity's Board of Directors or advisory committees; Takeda: Consultancy, Membership on an entity's Board of Directors or advisory committees; Recordat: Consultancy; 4SC: Consultancy, Membership on an entity's Board of Directors or advisory committees; Innate Pharma: Consultancy, Membership on an entity's Board of Directors or advisory committees; Helsinn: Consultancy, Membership on an entity's Board of Directors or advisory committees. Dalle:Kyowa: Other: Principal Investigator in clinical trials promoted by Kyowa. Fisher:Kyowa Kirin: Consultancy. Poligone:Stemline Therapeutics: Consultancy, Speakers Bureau; Regeneron: Consultancy, Speakers Bureau; Actelion: Consultancy, Speakers Bureau; Astex Pharmaceuticals: Research Funding; Bioniz: Research Funding; Celgene: Consultancy; Helsinn: Research Funding, Speakers Bureau; Innate Pharma: Research Funding; Kyowa Hakko Kirin: Consultancy, Honoraria, Research Funding, Speakers Bureau; miRagen: Research Funding; Soligenix: Research Funding. Pro:Takeda: Consultancy, Honoraria, Other: Travel Expenses; Celgene: Consultancy, Honoraria; Kyowa Hakka Kirin: Consultancy, Honoraria; Seattle Genetics: Consultancy, Honoraria, Other: Travel Expenses, Research Funding. Quaglino:Actelion: Honoraria, Other: Advisory Board; Innate Pharma: Honoraria, Other: Advisory Board; Takeda: Honoraria, Other: Advisory Board; Kyowa Kirin: Honoraria, Other: Advisory Board; Helsinn: Honoraria, Other: Advisory Board; Therakos: Honoraria, Other: Advisory Board. Reddy:AbbVie: Honoraria; Janssen: Honoraria; KITE: Honoraria; Merck: Research Funding; Celgene: Honoraria, Speakers Bureau. Geskin:Merck: Other: Supported/Contracted Research; UpToDate: Patents & Royalties: Royalty, Receipt of Intellectual Property Rights / Patent Holder; Actelion: Other: Supported/Contracted Research; Helsinn: Consultancy, Honoraria, Other: Supported/Contracted Research; Stratpharma: Other: Supported/Contracted Research; Mallinckrodt: Consultancy, Honoraria, Other: Supported/Contracted Research; Medscape: Speakers Bureau; Medivir: Consultancy, Honoraria. Halwani:Amgen: Other: Investigator; Takeda: Other: PI; Seattle Genetics: Other: PI; Pharmacyclics: Other: Investigator; miRagen: Other: PI; Kyowa Hakko Kirin: Other: PI; Immune Design: Other: PI; Genentech, Inc.: Other: Investigator; Bristol-Myers Squibb: Other: PI; AbbVie: Other: PI. Khot:Peter MacCallum Cancer Centre: Employment; Amgen: Consultancy, Speakers Bureau; Celgene: Consultancy; Janssen: Consultancy; Kyowa Hakko Kirin: Consultancy. Korman:Genentech: Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Dermira: Research Funding; Glaxo: Honoraria, Membership on an entity's Board of Directors or advisory committees; Immune Pharma: Honoraria, Membership on an entity's Board of Directors or advisory committees; Janssen: Honoraria, Membership on an entity's Board of Directors or advisory committees; Kyowa: Research Funding; Leo: Research Funding; Menlo: Research Funding; Merck: Research Funding; Novartis: Consultancy, Honoraria, Speakers Bureau; Pfizer: Research Funding; Principia: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Prothena: Research Funding; Regeneron: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Rhizen: Research Funding; Sun: Honoraria, Membership on an entity's Board of Directors or advisory committees; Syntimmune: Research Funding; UCB: Research Funding; Valeant: Honoraria, Membership on an entity's Board of Directors or advisory committees; Eli Lilly: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Celgene: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Bristol-Myers Squibb: Research Funding; AbbVie: Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau. Horwitz:Seattle Genetics: Consultancy, Research Funding; Affimed: Consultancy; Astex: Consultancy; Portola: Consultancy; ADCT Therapeutics: Research Funding; Kyowa Hakko Kirin: Consultancy; Infinity/Verastem: Consultancy, Research Funding; Miragen: Consultancy; Seattle Genetics: Consultancy, Research Funding; Forty-Seven: Research Funding; Celgene: Consultancy, Research Funding; Millennium/Takeda: Consultancy, Research Funding; Miragen: Consultancy; Innate Pharma: Consultancy; Kura: Consultancy; Corvus Pharmaceuticals: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Miragen: Consultancy; Infinity/Verastem: Consultancy, Research Funding; Millennium/Takeda: Consultancy, Research Funding; Portola: Consultancy; Kura: Consultancy; Celgene: Consultancy, Research Funding; Kura: Consultancy; Kyowa Hakko Kirin: Consultancy; Infinity/Verastem: Consultancy, Research Funding; Forty-Seven: Research Funding; Trillium: Research Funding; Corvus Pharmaceuticals: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Celgene: Consultancy, Research Funding; Astex: Consultancy; Affimed: Consultancy; ADCT Therapeutics: Research Funding; Aileron: Research Funding; Corvus Pharmaceuticals: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Kyowa Hakko Kirin: Consultancy; Trillium: Research Funding; Millennium/Takeda: Consultancy, Research Funding; Mundipharma: Consultancy; Millennium/Takeda: Consultancy, Research Funding; Kyowa Hakko Kirin: Consultancy; Portola: Consultancy; Aileron: Research Funding; Mundipharma: Consultancy; Celgene: Consultancy, Research Funding; Mundipharma: Consultancy; Seattle Genetics: Consultancy, Research Funding; ADCT Therapeutics: Research Funding; Portola: Consultancy; Kura: Consultancy; ADCT Therapeutics: Research Funding; Corvus Pharmaceuticals: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Infinity/Verastem: Consultancy, Research Funding; Aileron: Research Funding; Affimed: Consultancy; Trillium: Research Funding; Innate Pharma: Consultancy; Affimed: Consultancy; Astex: Consultancy; Mundipharma: Consultancy; Aileron: Research Funding; Miragen: Consultancy; Trillium: Research Funding; Innate Pharma: Consultancy; Forty-Seven: Research Funding; Forty-Seven: Research Funding; Innate Pharma: Consultancy; Astex: Consultancy; Seattle Genetics: Consultancy, Research Funding. Lamar:Seattle Genetics: Consultancy; Kyowa: Consultancy, Membership on an entity's Board of Directors or advisory committees. Moskowitz:Cell Medica: Consultancy; ADC Therapeutics: Consultancy; Merck: Research Funding; Erytech Pharma: Consultancy; Takeda Pharmaceuticals: Consultancy; Erytech Pharma: Consultancy; Merck: Research Funding; Kyowa Hakko Kirin Pharma: Consultancy, Research Funding; Erytech Pharma: Consultancy; Incyte: Research Funding; Kyowa Hakko Kirin Pharma: Consultancy, Research Funding; Merck: Research Funding; Erytech Pharma: Consultancy; ADC Therapeutics: Consultancy; ADC Therapeutics: Consultancy; Bristol-Myers Squibb: Consultancy, Research Funding; Bristol-Myers Squibb: Consultancy, Research Funding; Erytech Pharma: Consultancy; Bristol-Myers Squibb: Consultancy, Research Funding; miRagen Therapeutics Inc: Consultancy, Research Funding; Kyowa Hakko Kirin Pharma: Consultancy, Research Funding; Takeda Pharmaceuticals: Consultancy; Seattle Genetics: Consultancy, Honoraria, Research Funding; Cell Medica: Consultancy; Erytech Pharma: Consultancy; Seattle Genetics: Consultancy, Honoraria, Research Funding; 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Education in Oceania continues to reflect the embedded implicit and explicit colonial practices and processes from the past. This paper conceptualises a cultural approach to education and leadership appropriate and relevant to the Republic of the Marshall Islands. As elementary school leaders, we highlight Kanne Lobal, a traditional Marshallese navigation practice based on indigenous language, values and practices. We conceptualise and develop Kanne Lobal in this paper as a framework for understanding the usefulness of our indigenous knowledge in leadership and educational practices within formal education. Through bwebwenato, a method of talk story, our key learnings and reflexivities were captured. We argue that realising the value of Marshallese indigenous knowledge and practices for school leaders requires purposeful training of the ways in which our knowledge can be made useful in our professional educational responsibilities. Drawing from our Marshallese knowledge is an intentional effort to inspire, empower and express what education and leadership partnership means for Marshallese people, as articulated by Marshallese themselves. Introduction As noted in the call for papers within the Waikato Journal of Education (WJE) for this special issue, bodies of knowledge and histories in Oceania have long sustained generations across geographic boundaries to ensure cultural survival. For Marshallese people, we cannot really know ourselves “until we know how we came to be where we are today” (Walsh, Heine, Bigler & Stege, 2012). Jitdam Kapeel is a popular Marshallese concept and ideal associated with inquiring into relationships within the family and community. In a similar way, the practice of relating is about connecting the present and future to the past. Education and leadership partnerships are linked and we look back to the past, our history, to make sense and feel inspired to transform practices that will benefit our people. In this paper and in light of our next generation, we reconnect with our navigation stories to inspire and empower education and leadership. Kanne lobal is part of our navigation stories, a conceptual framework centred on cultural practices, values, and concepts that embrace collective partnerships. Our link to this talanoa vā with others in the special issue is to attempt to make sense of connections given the global COVID-19 context by providing a Marshallese approach to address the physical and relational “distance” between education and leadership partnerships in Oceania. Like the majority of developing small island nations in Oceania, the Republic of the Marshall Islands (RMI) has had its share of educational challenges through colonial legacies of the past which continues to drive education systems in the region (Heine, 2002). The historical administration and education in the RMI is one of colonisation. Successive administrations by the Spanish, German, Japanese, and now the US, has resulted in education and learning that privileges western knowledge and forms of learning. This paper foregrounds understandings of education and learning as told by the voices of elementary school leaders from the RMI. The move to re-think education and leadership from Marshallese perspectives is an act of shifting the focus of bwebwenato or conversations that centres on Marshallese language and worldviews. The concept of jelalokjen was conceptualised as traditional education framed mainly within the community context. In the past, jelalokjen was practiced and transmitted to the younger generation for cultural continuity. During the arrival of colonial administrations into the RMI, jelalokjen was likened to the western notions of education and schooling (Kupferman, 2004). Today, the primary function of jelalokjen, as traditional and formal education, it is for “survival in a hostile [and challenging] environment” (Kupferman, 2004, p. 43). Because western approaches to learning in the RMI have not always resulted in positive outcomes for those engaged within the education system, as school leaders who value our cultural knowledge and practices, and aspire to maintain our language with the next generation, we turn to Kanne Lobal, a practice embedded in our navigation stories, collective aspirations, and leadership. The significance in the development of Kanne Lobal, as an appropriate framework for education and leadership, resulted in us coming together and working together. Not only were we able to share our leadership concerns, however, the engagement strengthened our connections with each other as school leaders, our communities, and the Public Schooling System (PSS). Prior to that, many of us were in competition for resources. Educational Leadership: IQBE and GCSL Leadership is a valued practice in the RMI. Before the IQBE programme started in 2018, the majority of the school leaders on the main island of Majuro had not engaged in collaborative partnerships with each other before. Our main educational purpose was to achieve accreditation from the Western Association of Schools and Colleges (WASC), an accreditation commission for schools in the United States. The WASC accreditation dictated our work and relationships and many school leaders on Majuro felt the pressure of competition against each other. We, the authors in this paper, share our collective bwebwenato, highlighting our school leadership experiences and how we gained strength from our own ancestral knowledge to empower “us”, to collaborate with each other, our teachers, communities, as well as with PSS; a collaborative partnership we had not realised in the past. The paucity of literature that captures Kajin Majol (Marshallese language) and education in general in the RMI is what we intend to fill by sharing our reflections and experiences. To move our educational practices forward we highlight Kanne Lobal, a cultural approach that focuses on our strengths, collective social responsibilities and wellbeing. For a long time, there was no formal training in place for elementary school leaders. School principals and vice principals were appointed primarily on their academic merit through having an undergraduate qualification. As part of the first cohort of fifteen school leaders, we engaged in the professional training programme, the Graduate Certificate in School Leadership (GCSL), refitted to our context after its initial development in the Solomon Islands. GCSL was coordinated by the Institute of Education (IOE) at the University of the South Pacific (USP). GCSL was seen as a relevant and appropriate training programme for school leaders in the RMI as part of an Asia Development Bank (ADB) funded programme which aimed at “Improving Quality Basic Education” (IQBE) in parts of the northern Pacific. GCSL was managed on Majuro, RMI’s main island, by the director at the time Dr Irene Taafaki, coordinator Yolanda McKay, and administrators at the University of the South Pacific’s (USP) RMI campus. Through the provision of GCSL, as school leaders we were encouraged to re-think and draw-from our own cultural repository and connect to our ancestral knowledge that have always provided strength for us. This kind of thinking and practice was encouraged by our educational leaders (Heine, 2002). We argue that a culturally-affirming and culturally-contextual framework that reflects the lived experiences of Marshallese people is much needed and enables the disruption of inherent colonial processes left behind by Western and Eastern administrations which have influenced our education system in the RMI (Heine, 2002). Kanne Lobal, an approach utilising a traditional navigation has warranted its need to provide solutions for today’s educational challenges for us in the RMI. Education in the Pacific Education in the Pacific cannot be understood without contextualising it in its history and culture. It is the same for us in the RMI (Heine, 2002; Walsh et al., 2012). The RMI is located in the Pacific Ocean and is part of Micronesia. It was named after a British captain, John Marshall in the 1700s. The atolls in the RMI were explored by the Spanish in the 16th century. Germany unsuccessfully attempted to colonize the islands in 1885. Japan took control in 1914, but after several battles during World War II, the US seized the RMI from them. In 1947, the United Nations made the island group, along with the Mariana and Caroline archipelagos, a U.S. trust territory (Walsh et al, 2012). Education in the RMI reflects the colonial administrations of Germany, Japan, and now the US. Before the turn of the century, formal education in the Pacific reflected western values, practices, and standards. Prior to that, education was informal and not binded to formal learning institutions (Thaman, 1997) and oral traditions was used as the medium for transmitting learning about customs and practices living with parents, grandparents, great grandparents. As alluded to by Jiba B. Kabua (2004), any “discussion about education is necessarily a discussion of culture, and any policy on education is also a policy of culture” (p. 181). It is impossible to promote one without the other, and it is not logical to understand one without the other. Re-thinking how education should look like, the pedagogical strategies that are relevant in our classrooms, the ways to engage with our parents and communities - such re-thinking sits within our cultural approaches and frameworks. Our collective attempts to provide a cultural framework that is relevant and appropriate for education in our context, sits within the political endeavour to decolonize. This means that what we are providing will not only be useful, but it can be used as a tool to question and identify whether things in place restrict and prevent our culture or whether they promote and foreground cultural ideas and concepts, a significant discussion of culture linked to education (Kabua, 2004). Donor funded development aid programmes were provided to support the challenges within education systems. Concerned with the persistent low educational outcomes of Pacific students, despite the prevalence of aid programmes in the region, in 2000 Pacific educators and leaders with support from New Zealand Aid (NZ Aid) decided to intervene (Heine, 2002; Taufe’ulungaki, 2014). In April 2001, a group of Pacific educators and leaders across the region were invited to a colloquium funded by the New Zealand Overseas Development Agency held in Suva Fiji at the University of the South Pacific. The main purpose of the colloquium was to enable “Pacific educators to re-think the values, assumptions and beliefs underlying [formal] schooling in Oceania” (Benson, 2002). Leadership, in general, is a valued practice in the RMI (Heine, 2002). Despite education leadership being identified as a significant factor in school improvement (Sanga & Chu, 2009), the limited formal training opportunities of school principals in the region was a persistent concern. As part of an Asia Development Bank (ADB) funded project, the Improve Quality Basic Education (IQBE) intervention was developed and implemented in the RMI in 2017. Mentoring is a process associated with the continuity and sustainability of leadership knowledge and practices (Sanga & Chu, 2009). It is a key aspect of building capacity and capabilities within human resources in education (ibid). Indigenous knowledges and education research According to Hilda Heine, the relationship between education and leadership is about understanding Marshallese history and culture (cited in Walsh et al., 2012). It is about sharing indigenous knowledge and histories that “details for future generations a story of survival and resilience and the pride we possess as a people” (Heine, cited in Walsh et al., 2012, p. v). This paper is fuelled by postcolonial aspirations yet is grounded in Pacific indigenous research. This means that our intentions are driven by postcolonial pursuits and discourses linked to challenging the colonial systems and schooling in the Pacific region that privileges western knowledge and learning and marginalises the education practices and processes of local people (Thiong’o, 1986). A point of difference and orientation from postcolonialism is a desire to foreground indigenous Pacific language, specifically Majin Majol, through Marshallese concepts. Our collective bwebwenato and conversation honours and values kautiej (respect), jouj eo mour eo (reciprocity), and jouj (kindness) (Taafaki & Fowler, 2019). Pacific leaders developed the Rethinking Pacific Education Initiative for and by Pacific People (RPEIPP) in 2002 to take control of the ways in which education research was conducted by donor funded organisations (Taufe’ulungaki, 2014). Our former president, Dr Hilda Heine was part of the group of leaders who sought to counter the ways in which our educational and leadership stories were controlled and told by non-Marshallese (Heine, 2002). As a former minister of education in the RMI, Hilda Heine continues to inspire and encourage the next generation of educators, school leaders, and researchers to re-think and de-construct the way learning and education is conceptualised for Marshallese people. The conceptualisation of Kanne Lobal acknowledges its origin, grounded in Marshallese navigation knowledge and practice. Our decision to unpack and deconstruct Kanne Lobal within the context of formal education and leadership responds to the need to not only draw from indigenous Marshallese ideas and practice but to consider that the next generation will continue to be educated using western processes and initiatives particularly from the US where we get a lot of our funding from. According to indigenous researchers Dawn Bessarab and Bridget Ng’andu (2010), doing research that considers “culturally appropriate processes to engage with indigenous groups and individuals is particularly pertinent in today’s research environment” (p. 37). Pacific indigenous educators and researchers have turned to their own ancestral knowledge and practices for inspiration and empowerment. Within western research contexts, the often stringent ideals and processes are not always encouraging of indigenous methods and practices. However, many were able to ground and articulate their use of indigenous methods as being relevant and appropriate to capturing the realities of their communities (Nabobo-Baba, 2008; Sualii-Sauni & Fulu-Aiolupotea, 2014; Thaman, 1997). At the same time, utilising Pacific indigenous methods and approaches enabled research engagement with their communities that honoured and respected them and their communities. For example, Tongan, Samoan, and Fijian researchers used the talanoa method as a way to capture the stories, lived realities, and worldviews of their communities within education in the diaspora (Fa’avae, Jones, & Manu’atu, 2016; Nabobo-Baba, 2008; Sualii-Sauni & Aiolupotea, 2014; Vaioleti, 2005). Tok stori was used by Solomon Islander educators and school leaders to highlight the unique circles of conversational practice and storytelling that leads to more positive engagement with their community members, capturing rich and meaningful narratives as a result (Sanga & Houma, 2004). The Indigenous Aborigine in Australia utilise yarning as a “relaxed discussion through which both the researcher and participant journey together visiting places and topics of interest relevant” (Bessarab & Ng’andu, 2010, p. 38). Despite the diverse forms of discussions and storytelling by indigenous peoples, of significance are the cultural protocols, ethics, and language for conducting and guiding the engagement (Bessarab & Ng’andu, 2010; Nabobo-Baba, 2008; Sualii-Sauni & Aiolupotea, 2014). Through the ethics, values, protocols, and language, these are what makes indigenous methods or frameworks unique compared to western methods like in-depth interviews or semi-structured interviews. This is why it is important for us as Marshallese educators to frame, ground, and articulate how our own methods and frameworks of learning could be realised in western education (Heine, 2002; Jetnil-Kijiner, 2014). In this paper, we utilise bwebwenato as an appropriate method linked to “talk story”, capturing our collective stories and experiences during GCSL and how we sought to build partnerships and collaboration with each other, our communities, and the PSS. Bwebwenato and drawing from Kajin Majel Legends and stories that reflect Marshallese society and its cultural values have survived through our oral traditions. The practice of weaving also holds knowledge about our “valuable and earliest sources of knowledge” (Taafaki & Fowler, 2019, p. 2). The skilful navigation of Marshallese wayfarers on the walap (large canoes) in the ocean is testament of their leadership and the value they place on ensuring the survival and continuity of Marshallese people (Taafaki & Fowler, 2019; Walsh et al., 2012). During her graduate study in 2014, Kathy Jetnil-Kijiner conceptualised bwebwenato as being the most “well-known form of Marshallese orality” (p. 38). The Marshallese-English dictionary defined bwebwenato as talk, conversation, story, history, article, episode, lore, myth, or tale (cited in Jetnil Kijiner, 2014). Three years later in 2017, bwebwenato was utilised in a doctoral project by Natalie Nimmer as a research method to gather “talk stories” about the experiences of 10 Marshallese experts in knowledge and skills ranging from sewing to linguistics, canoe-making and business. Our collective bwebwenato in this paper centres on Marshallese ideas and language. The philosophy of Marshallese knowledge is rooted in our “Kajin Majel”, or Marshallese language and is shared and transmitted through our oral traditions. For instance, through our historical stories and myths. Marshallese philosophy, that is, the knowledge systems inherent in our beliefs, values, customs, and practices are shared. They are inherently relational, meaning that knowledge systems and philosophies within our world are connected, in mind, body, and spirit (Jetnil-Kijiner, 2014; Nimmer, 2017). Although some Marshallese believe that our knowledge is disappearing as more and more elders pass away, it is therefore important work together, and learn from each other about the knowledges shared not only by the living but through their lamentations and stories of those who are no longer with us (Jetnil-Kijiner, 2014). As a Marshallese practice, weaving has been passed-down from generation to generation. Although the art of weaving is no longer as common as it used to be, the artefacts such as the “jaki-ed” (clothing mats) continue to embody significant Marshallese values and traditions. For our weavers, the jouj (check spelling) is the centre of the mat and it is where the weaving starts. When the jouj is correct and weaved well, the remainder and every other part of the mat will be right. The jouj is symbolic of the “heart” and if the heart is prepared well, trained well, then life or all other parts of the body will be well (Taafaki & Fowler, 2019). In that light, we have applied the same to this paper. Conceptualising and drawing from cultural practices that are close and dear to our hearts embodies a significant ontological attempt to prioritize our own knowledge and language, a sense of endearment to who we are and what we believe education to be like for us and the next generation. The application of the phrase “Majolizing '' was used by the Ministry of Education when Hilda Heine was minister, to weave cultural ideas and language into the way that teachers understand the curriculum, develop lesson plans and execute them in the classroom. Despite this, there were still concerns with the embedded colonized practices where teachers defaulted to eurocentric methods of doing things, like the strategies provided in the textbooks given to us. In some ways, our education was slow to adjust to the “Majolizing '' intention by our former minister. In this paper, we provide Kanne Lobal as a way to contribute to the “Majolizing intention” and perhaps speed up yet still be collectively responsible to all involved in education. Kajin Wa and Kanne Lobal “Wa” is the Marshallese concept for canoe. Kajin wa, as in canoe language, has a lot of symbolic meaning linked to deeply-held Marshallese values and practices. The canoe was the foundational practice that supported the livelihood of harsh atoll island living which reflects the Marshallese social world. The experts of Kajin wa often refer to “wa” as being the vessel of life, a means and source of sustaining life (Kelen, 2009, cited in Miller, 2010). “Jouj” means kindness and is the lower part of the main hull of the canoe. It is often referred to by some canoe builders in the RMI as the heart of the canoe and is linked to love. The jouj is one of the first parts of the canoe that is built and is “used to do all other measurements, and then the rest of the canoe is built on top of it” (Miller, 2010, p. 67). The significance of the jouj is that when the canoe is in the water, the jouj is the part of the hull that is underwater and ensures that all the cargo and passengers are safe. For Marshallese, jouj or kindness is what living is about and is associated with selflessly carrying the responsibility of keeping the family and community safe. The parts of the canoe reflect Marshallese culture, legend, family, lineage, and kinship. They embody social responsibilities that guide, direct, and sustain Marshallese families’ wellbeing, from atoll to atoll. For example, the rojak (boom), rojak maan (upper boom), rojak kōrā (lower boom), and they support the edges of the ujelā/ujele (sail) (see figure 1). The literal meaning of rojak maan is male boom and rojak kōrā means female boom which together strengthens the sail and ensures the canoe propels forward in a strong yet safe way. Figuratively, the rojak maan and rojak kōrā symbolise the mother and father relationship which when strong, through the jouj (kindness and love), it can strengthen families and sustain them into the future. Figure 1. Parts of the canoe Source: https://www.canoesmarshallislands.com/2014/09/names-of-canoe-parts/ From a socio-cultural, communal, and leadership view, the canoe (wa) provides understanding of the relationships required to inspire and sustain Marshallese peoples’ education and learning. We draw from Kajin wa because they provide cultural ideas and practices that enable understanding of education and leadership necessary for sustaining Marshallese people and realities in Oceania. When building a canoe, the women are tasked with the weaving of the ujelā/ujele (sail) and to ensure that it is strong enough to withstand long journeys and the fierce winds and waters of the ocean. The Kanne Lobal relates to the front part of the ujelā/ujele (sail) where the rojak maan and rojak kōrā meet and connect (see the red lines in figure 1). Kanne Lobal is linked to the strategic use of the ujelā/ujele by navigators, when there is no wind north wind to propel them forward, to find ways to capture the winds so that their journey can continue. As a proverbial saying, Kanne Lobal is used to ignite thinking and inspire and transform practice particularly when the journey is rough and tough. In this paper we draw from Kanne Lobal to ignite, inspire, and transform our educational and leadership practices, a move to explore what has always been meaningful to Marshallese people when we are faced with challenges. The Kanne Lobal utilises our language, and cultural practices and values by sourcing from the concepts of jouj (kindness, love), kautiej (respect), and jouj eo mour eo (reciprocity). A key Marshallese proverb, “Enra bwe jen lale rara”, is the cultural practice where families enact compassion through the sharing of food in all occurrences. The term “enra” is a small basket weaved from the coconut leaves, and often used by Marshallese as a plate to share and distribute food amongst each other. Bwe-jen-lale-rara is about noticing and providing for the needs of others, and “enra” the basket will help support and provide for all that are in need. “Enra-bwe-jen-lale-rara” is symbolic of cultural exchange and reciprocity and the cultural values associated with building and maintaining relationships, and constantly honouring each other. As a Marshallese practice, in this article we share our understanding and knowledge about the challenges as well as possible solutions for education concerns in our nation. In addition, we highlight another proverb, “wa kuk wa jimor”, which relates to having one canoe, and despite its capacity to feed and provide for the individual, but within the canoe all people can benefit from what it can provide. In the same way, we provide in this paper a cultural framework that will enable all educators to benefit from. It is a framework that is far-reaching and relevant to the lived realities of Marshallese people today. Kumit relates to people united to build strength, all co-operating and working together, living in peace, harmony, and good health. Kanne Lobal: conceptual framework for education and leadership An education framework is a conceptual structure that can be used to capture ideas and thinking related to aspects of learning. Kanne Lobal is conceptualised and framed in this paper as an educational framework. Kanne Lobal highlights the significance of education as a collective partnership whereby leadership is an important aspect. Kanne Lobal draws-from indigenous Marshallese concepts like kautiej (respect), jouj eo mour eo (reciprocity), and jouj (kindness, heart). The role of a leader, including an education leader, is to prioritise collective learning and partnerships that benefits Marshallese people and the continuity and survival of the next generation (Heine, 2002; Thaman, 1995). As described by Ejnar Aerōk, an expert canoe builder in the RMI, he stated: “jerbal ippān doon bwe en maron maan wa e” (cited in Miller, 2010, p. 69). His description emphasises the significance of partnerships and working together when navigating and journeying together in order to move the canoe forward. The kubaak, the outrigger of the wa (canoe) is about “partnerships”. For us as elementary school leaders on Majuro, kubaak encourages us to value collaborative partnerships with each other as well as our communities, PSS, and other stakeholders. Partnerships is an important part of the Kanne Lobal education and leadership framework. It requires ongoing bwebwenato – the inspiring as well as confronting and challenging conversations that should be mediated and negotiated if we and our education stakeholders are to journey together to ensure that the educational services we provide benefits our next generation of young people in the RMI. Navigating ahead the partnerships, mediation, and negotiation are the core values of jouj (kindness, love), kautiej (respect), and jouj eo mour eo (reciprocity). As an organic conceptual framework grounded in indigenous values, inspired through our lived experiences, Kanne Lobal provides ideas and concepts for re-thinking education and leadership practices that are conducive to learning and teaching in the schooling context in the RMI. By no means does it provide the solution to the education ills in our nation. However, we argue that Kanne Lobal is a more relevant approach which is much needed for the negatively stigmatised system as a consequence of the various colonial administrations that have and continue to shape and reframe our ideas about what education should be like for us in the RMI. Moreover, Kannel Lobal is our attempt to decolonize the framing of education and leadership, moving our bwebwenato to re-framing conversations of teaching and learning so that our cultural knowledge and values are foregrounded, appreciated, and realised within our education system. Bwebwenato: sharing our stories In this section, we use bwebwenato as a method of gathering and capturing our stories as data. Below we capture our stories and ongoing conversations about the richness in Marshallese cultural knowledge in the outer islands and on Majuro and the potentialities in Kanne Lobal. Danny Jim When I was in third grade (9-10 years of age), during my grandfather’s speech in Arno, an atoll near Majuro, during a time when a wa (canoe) was being blessed and ready to put the canoe into the ocean. My grandfather told me the canoe was a blessing for the family. “Without a canoe, a family cannot provide for them”, he said. The canoe allows for travelling between places to gather food and other sources to provide for the family. My grandfather’s stories about people’s roles within the canoe reminded me that everyone within the family has a responsibility to each other. Our women, mothers and daughters too have a significant responsibility in the journey, in fact, they hold us, care for us, and given strength to their husbands, brothers, and sons. The wise man or elder sits in the middle of the canoe, directing the young man who help to steer. The young man, he does all the work, directed by the older man. They take advice and seek the wisdom of the elder. In front of the canoe, a young boy is placed there and because of his strong and youthful vision, he is able to help the elder as well as the young man on the canoe. The story can be linked to the roles that school leaders, teachers, and students have in schooling. Without each person knowing intricately their role and responsibility, the sight and vision ahead for the collective aspirations of the school and the community is difficult to comprehend. For me, the canoe is symbolic of our educational journey within our education system. As the school leader, a central, trusted, and respected figure in the school, they provide support for teachers who are at the helm, pedagogically striving to provide for their students. For without strong direction from the school leaders and teachers at the helm, the students, like the young boy, cannot foresee their futures, or envisage how education can benefit them. This is why Kanne Lobal is a significant framework for us in the Marshall Islands because within the practice we are able to take heed and empower each other so that all benefit from the process. Kanne Lobal is linked to our culture, an essential part of who we are. We must rely on our own local approaches, rather than relying on others that are not relevant to what we know and how we live in today’s society. One of the things I can tell is that in Majuro, compared to the outer islands, it’s different. In the outer islands, parents bring children together and tell them legends and stories. The elders tell them about the legends and stories – the bwebwenato. Children from outer islands know a lot more about Marshallese legends compared to children from the Majuro atoll. They usually stay close to their parents, observe how to prepare food and all types of Marshallese skills. Loretta Joseph Case There is little Western influence in the outer islands. They grow up learning their own culture with their parents, not having tv. They are closely knit, making their own food, learning to weave. They use fire for cooking food. They are more connected because there are few of them, doing their own culture. For example, if they’re building a house, the ladies will come together and make food to take to the males that are building the house, encouraging them to keep on working - “jemjem maal” (sharpening tools i.e. axe, like encouraging workers to empower them). It’s when they bring food and entertainment. Rubon Rubon Togetherness, work together, sharing of food, these are important practices as a school leader. Jemjem maal – the whole village works together, men working and the women encourage them with food and entertainment. All the young children are involved in all of the cultural practices, cultural transmission is consistently part of their everyday life. These are stronger in the outer islands. Kanne Lobal has the potential to provide solutions using our own knowledge and practices. Connie Joel When new teachers become a teacher, they learn more about their culture in teaching. Teaching raises the question, who are we? A popular saying amongst our people, “Aelon kein ad ej aelon in manit”, means that “Our islands are cultural islands”. Therefore, when we are teaching, and managing the school, we must do this culturally. When we live and breathe, we must do this culturally. There is more socialising with family and extended family. Respect the elderly. When they’re doing things the ladies all get together, in groups and do it. Cut the breadfruit, and preserve the breadfruit and pandanus. They come together and do it. Same as fishing, building houses, building canoes. They use and speak the language often spoken by the older people. There are words that people in the outer islands use and understand language regularly applied by the elderly. Respect elderly and leaders more i.e., chiefs (iroj), commoners (alap), and the workers on the land (ri-jerbal) (social layer under the commoners). All the kids, they gather with their families, and go and visit the chiefs and alap, and take gifts from their land, first produce/food from the plantation (eojōk). Tommy Almet The people are more connected to the culture in the outer islands because they help one another. They don’t have to always buy things by themselves, everyone contributes to the occasion. For instance, for birthdays, boys go fishing, others contribute and all share with everyone. Kanne Lobal is a practice that can bring people together – leaders, teachers, stakeholders. We want our colleagues to keep strong and work together to fix problems like students and teachers’ absenteeism which is a big problem for us in schools. Demetria Malachi The culture in the outer islands are more accessible and exposed to children. In Majuro, there is a mixedness of cultures and knowledges, influenced by Western thinking and practices. Kanne Lobal is an idea that can enhance quality educational purposes for the RMI. We, the school leaders who did GCSL, we want to merge and use this idea because it will help benefit students’ learning and teachers’ teaching. Kanne Lobal will help students to learn and teachers to teach though traditional skills and knowledge. We want to revitalize our ways of life through teaching because it is slowly fading away. Also, we want to have our own Marshallese learning process because it is in our own language making it easier to use and understand. Essentially, we want to proudly use our own ways of teaching from our ancestors showing the appreciation and blessings given to us. Way Forward To think of ways forward is about reflecting on the past and current learnings. Instead of a traditional discussion within a research publication, we have opted to continue our bwebwenato by sharing what we have learnt through the Graduate Certificate in School Leadership (GCSL) programme. Our bwebwenato does not end in this article and this opportunity to collaborate and partner together in this piece of writing has been a meaningful experience to conceptualise and unpack the Kanne Lobal framework. Our collaborative bwebwenato has enabled us to dig deep into our own wise knowledges for guidance through mediating and negotiating the challenges in education and leadership (Sanga & Houma, 2004). For example, bwe-jen-lale-rara reminds us to inquire, pay attention, and focus on supporting the needs of others. Through enra-bwe-jen-lale-rara, it reminds us to value cultural exchange and reciprocity which will strengthen the development and maintaining of relationships based on ways we continue to honour each other (Nimmer, 2017). We not only continue to support each other, but also help mentor the next generation of school leaders within our education system (Heine, 2002). Education and leadership are all about collaborative partnerships (Sanga & Chu, 2009; Thaman, 1997). Developing partnerships through the GCSL was useful learning for us. It encouraged us to work together, share knowledge, respect each other, and be kind. The values of jouj (kindness, love), kautiej (respect), and jouj eo mour eo (reciprocity) are meaningful in being and becoming and educational leader in the RMI (Jetnil-Kijiner, 2014; Miller, 2010; Nimmer, 2017). These values are meaningful for us practice particularly given the drive by PSS for schools to become accredited. The workshops and meetings delivered during the GCSL in the RMI from 2018 to 2019 about Kanne Lobal has given us strength to share our stories and experiences from the meeting with the stakeholders. But before we met with the stakeholders, we were encouraged to share and speak in our language within our courses: EDP05 (Professional Development and Learning), EDP06 (School Leadership), EDP07 (School Management), EDP08 (Teaching and Learning), and EDP09 (Community Partnerships). In groups, we shared our presentations with our peers, the 15 school leaders in the GCSL programme. We also invited USP RMI staff. They liked the way we presented Kannel Lobal. They provided us with feedback, for example: how the use of the sail on the canoe, the parts and their functions can be conceptualised in education and how they are related to the way that we teach our own young people. Engaging stakeholders in the conceptualisation and design stages of Kanne Lobal strengthened our understanding of leadership and collaborative partnerships. Based on various meetings with the RMI Pacific Resources for Education and Learning (PREL) team, PSS general assembly, teachers from the outer islands, and the PSS executive committee, we were able to share and receive feedback on the Kanne Lobal framework. The coordinators of the PREL programme in the RMI were excited by the possibilities around using Kanne Lobal, as a way to teach culture in an inspirational way to Marshallese students. Our Marshallese knowledge, particularly through the proverbial meaning of Kanne Lobal provided so much inspiration and insight for the groups during the presentation which gave us hope and confidence to develop the framework. Kanne Lobal is an organic and indigenous approach, grounded in Marshallese ways of doing things (Heine, 2002; Taafaki & Fowler, 2019). Given the persistent presence of colonial processes within the education system and the constant reference to practices and initiatives from the US, Kanne Lobal for us provides a refreshing yet fulfilling experience and makes us feel warm inside because it is something that belongs to all Marshallese people. Conclusion Marshallese indigenous knowledge and practices provide meaningful educational and leadership understanding and learnings. They ignite, inspire, and transform thinking and practice. The Kanne Lobal conceptual framework emphasises key concepts and values necessary for collaborative partnerships within education and leadership practices in the RMI. The bwebwenato or talk stories have been insightful and have highlighted the strengths and benefits that our Marshallese ideas and practices possess when looking for appropriate and relevant ways to understand education and leadership. 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Climate change induced sea-level rise (SLR) is on its increase globally. Regionally the lowlands of China, Vietnam, Bangladesh, and islands of the Malaysian, Indonesian and Philippine archipelagos are among the world’s most threatened regions. Sea-level rise has major impacts on the ecosystems and society. It threatens coastal populations, economic activities, and fragile ecosystems as mangroves, coastal salt-marches and wetlands. This paper provides a summary of the current state of knowledge of sea level-rise and its effects on both human and natural ecosystems. The focus is on coastal urban areas and low lying deltas in South-East Asia and Vietnam, as one of the most threatened areas in the world. About 3 mm per year reflects the growing consensus on the average SLR worldwide. The trend speeds up during recent decades. The figures are subject to local, temporal and methodological variation. In Vietnam the average values of 3.3 mm per year during the 1993-2014 period are above the worldwide average. Although a basic conceptual understanding exists that the increasing global frequency of the strongest tropical cyclones is related with the increasing temperature and SLR, this relationship is insufficiently understood. Moreover the precise, complex environmental, economic, social, and health impacts are currently unclear. SLR, storms and changing precipitation patterns increase flood risks, in particular in urban areas. Part of the current scientific debate is on how urban agglomeration can be made more resilient to flood risks. Where originally mainly technical interventions dominated this discussion, it becomes increasingly clear that proactive special planning, flood defense, flood risk mitigation, flood preparation, and flood recovery are important, but costly instruments. Next to the main focus on SLR and its effects on resilience, the paper reviews main SLR associated impacts: Floods and inundation, salinization, shoreline change, and effects on mangroves and wetlands. The hazards of SLR related floods increase fastest in urban areas. This is related with both the increasing surface major cities are expected to occupy during the decades to come and the increasing coastal population. In particular Asia and its megacities in the southern part of the continent are increasingly at risk. The discussion points to complexity, inter-disciplinarity, and the related uncertainty, as core characteristics. An integrated combination of mitigation, adaptation and resilience measures is currently considered as the most indicated way to resist SLR today and in the near future.References Aerts J.C.J.H., Hassan A., Savenije H.H.G., Khan M.F., 2000. Using GIS tools and rapid assessment techniques for determining salt intrusion: Stream a river basin management instrument. 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I completed a 16-week practicum at the SickKids Centre for Global Child Health where I was a part of the stunting team led by Dr. Nadia Akseer under the research portfolio of Dr. Zulfiqar A. Bhutta. Linear growth stunting, or low height-for-age, is a visible and easily measurable physical manifestation of chronic malnutrition. Children who are stunted have higher rates of mortality and morbidity, as well as experience suboptimal cognitive and motor development. At the time of my placement, one of the team's main projects was a mixed-methods study involving an in-depth evaluation of policies, programs, and factors that have contributed to the decline of under-5 stunting in Ethiopia from 2000-2016. I worked on a variety of components of the manuscript for this study. These included narratives for country demographics, background statistics as well as migration and remittance trends. I also contributed to a literature review on factors that have contributed to a reduction in stunting in Ethiopia in relation to an adapted version of UNICEF's conceptual framework for malnutrition. In addition to the manuscript, I conducted a multivariable analysis of the 2016 determinants of under-5 wasting in Ethiopia. Wasting, or low weight for height, is a form of acute malnutrition and is also a risk factor for mortality. I applied a hierarchical analysis to wasting indicators such as disease, household wealth, maternal education and access to health services. I used Ethiopia's 2016 Demographic and Health Survey data and additional data sources provided through various Ethiopian government ministries. Overall my practicum was a rich interdisciplinary learning experience which allowed me to develop my quantitative and qualitative research skills. I also gained a deeper understanding of global health research processes and the multi-sectoral nature of combating child malnutrition.

Abstract Issue Initial health assessment is crucial for identification of healthcare needs and screening of acute health problems among new asylum seekers. As in other countries, practices across reception centres in Finland varied and health data was inconsistently recorded, making systematic monitoring through the electronic health record system (EHR) challenging. Description of the issue The main objectives of the national Developing the health examination protocol for asylum seekers in Finland project (TERTTU, 2017-2019) were to unify practices across reception centres through development of health assessment content and the quality of EHR recordings. The project consisted of three phases: 1) baseline evaluation; 2) conduct of a population-based health examination survey among asylum seeking adults and children; 3) development work guided by findings of stages 1 and 2, supplemented with thematic qualitative interviews with end-users (reception centre nurses, asylum seekers and authorities supervising services). Results The project exceeded expectations. Altogether 1087 adults and children participated in the survey (participation rate 76 %). Survey findings were published in a national report, providing the main evidence-base for development work. This was complemented by thematic interviews with 15 reception centre nurses, 19 asylum seekers and 3 authority representatives. Health assessment protocol was piloted and further developed based on feedback from end-users and transferred into the reception centres EHR. A handbook for the health assessment was published, supported with educational short videos. Lessons Successful implementation required close collaboration with authorities responsible for providing services for asylum seekers and involvement of end users at all stages. Results of this project benefit all other countries receiving asylum seekers. The study protocol is available in English, Somali, Kurdish (Sorani), Dari, Arabic, Russian, French and Finnish. Key messages The initial health assessment protocol for asylum seekers and supporting materials developed in the TERTTU project benefits all receiving countries. Systematic recording of health data was also developed, which will be used for planning health system response according to the health care needs of new asylum seekers.

Abstract Background Increasing the capacity of higher education institutes to address students' vulnerabilities has been deemed necessary due to the financial crisis. Multilevel interventions have thus been initiated at the Hellenic Mediterranean University of Crete, as part of a project co-financed by Greece and the European Union (European Social Fund-ESF) through the Operational Programme &lt;&lt;Human Resources Development, Education and Lifelong Learning 2014- 2020 &gt;&gt; (MIS 5045937). The project aims to offer support to students with low family income or a certified disability, monitor their bio-psychosocial needs, increase their accessibility to health and psychosocial care, and improve their academic outcomes. Methods As part of the project, a primary health care unit has been set up to offer medical and nursing care (medical unit) as well as psychosocial support (counseling centre) to students in need. An observatory has also been set up to monitor their health and psychosocial needs and their academic progress. Results A total of 228 eligible students used the services in the second half of 2019 (counseling centre 37; medical unit 191). Out of the 37 individuals who used the counseling centre, 30 (81.0%) were female and 16 (43.2%) were at the first 2 years of their studies. A total of 36 (97.3%) requested psychological support, 6 (16.2%) warranted social welfare services and 1 (2.7%) support for learning disabilities. As for the 191 individuals who used the medical services, 101 (52.8%) were male and 88 (46.0%) were at first 2 years of their studies. Most of them had a health examination to receive a health certificate (74.8%) followed by those who received emergency care (e.g. respiratory infection, allergic reaction, injury, etc), chronic disease management and medicine subscription, as well as vaccination. Conclusions Complex bio-psychosocial needs have been identified, recorded and analyzed to explain the academic progress of socially vulnerable students. Key messages The students’ journey through medical and counseling services is being mapped to offer important information for educational policy. Assessment and monitoring of students’ complex needs are important to achieve quality in higher education.

Abstract Background Diabetes Self-Management Education and Support (DSMES) programmes are vital for type 2 diabetes mellitus (T2DM) management. However, they are limited in Sub-Saharan Africa (SSA). To address this gap, a DSMES, namedEXTEND was developed in Lilongwe (Malawi) and Maputo (Mozambique). This qualitative study aimed to explore factors that influence the implementation of DSMES in these settings. Methods The Socio-ecological model was applied to explore factors influencing the implementation of DSMES in SSA. Data was analysed using the Framework method and constant comparative techniques. Sixty-six people participated in the study: people with T2DM who participated in the EXTEND programme; healthcare professionals (HCPs), EXTEND educators, EXTEND trainers, and stakeholders. Results Our findings indicate that there is a need to develop an integrated and dedicated diabetes services in SSA healthcare systems, incorporating culturally adapted DSMES and tailored diabetes training to all professions involved in diabetes management. Traditional media and the involvement of community leaders were proposed as important elements to help engage and promote DSMES programmes in local communities. During the design and implementation of DSMES, it is important to consider individual and societal barriers to self-care. Conclusion Findings from this study suggest that multi-faceted factors play a significant role to the implementation of DSMES programmes in LICs. In the future, EXTEND could be incorporated in the development of diabetes training and dedicated diabetes services in SSA healthcare systems, acting as an educational tool for both people with T2DM and HCPs. This project was supported by the Medical Research Council GCRF NCDs Foundation Awards 2016 Development Pathway Funding.

IntroductionA newly developed BC Ministry of Health geography classification has enabled a standardized approach for community-level analysis of health needs and service provision. An innovative methodology was developed and applied to health administrative data, creating more opportunities to identify variations in health status and utilization across the health system. Objectives and ApproachTwo design principles informed the development of the new geographies. Firstly, they reflect where people live and the communities with which they identify, and secondly, they will assist with identifying where health services are needed for local populations. The objective was to provide the Ministry and health authorities with a framework to identify and work towards providing the optimal delivery of services at the local level. A working group was established for this project and included representatives from the Ministry, each regional health authority, Provincial Health Services Authority, First Nations Health Authority, and BC Stats. ResultsThe building block for the geography classification is the Census Dissemination Block, the lowest unit of geography available in the Standard Geography Classification maintained by Statistics Canada. The geographies were assigned urban-rural designations based on an algorithm that considered the presence of a population centre, the size of the population centre, and the proportion of the population living in it, among other aspects. One of the main goals of the urban-rural designations was to provide meaningful peer groups for cross-jurisdictional studies. The project also reengineered the methods to geocode addresses to improve accuracy to use street addresses (over past method that used postal codes) so that assignment to Census Dissemination Block would be precise. The end result was 218 community geographies with urban-rural designations. Conclusion/ImplicationsThis geography standard allows health system stakeholders to better understand of geographic variation in utilization and access to health care. The ability to link and share information to profile community health between health administrative data and Census data available from Statistics Canada is better due to improved geocoding of addresses.

In a developing country like India, village-centric development is very critical for improving Human Development Index of the country. In this direction, corporate contribution assumes significance for rehabilitation and resettlement of project affected people and overall intervention under its corporate social responsibility (CSR) initiative. Since India is a country of villages, CSR has to be more sensitive towards the economic, social and cultural needs of rural society of the country. In this paper, it is proposed to gear all interventions for promoting model villages. Model village presents a credible vehicle for bringing about sustainability of a village community unit. A model village must have three significant components of infrastructure development, livelihood promotion and provision of services. Infrastructure development must cater to creating basic physical as well as social infrastructure like approach road, school building, community centre and social capital. Promotion of livelihood includes skill training, self-employment, employment opportunities and village enterprise development, while provision for services for the villagers includes health care, education, sanitation, recreational and other community services. Model village plan envisages a self-contained village community at the apex of all the pillars of sustainability, namely, livelihood, infrastructure and services. The future of Indian economy and the prospect of industry are going to depend largely on building sustainable and self-maintained smallest self-governing units called model villages.

Scotland has witnessed a remarkable reduction in violent crime in recent years. In part, the success of this reduction has been attributed to a ‘public health’ approach, which includes improvements in partnership working across multiple agencies – especially law enforcement and public health. Nevertheless, the emergency services continue to deal with a high volume of violent incidents, an increasing number of which involve some aspect of underlying vulnerability. Policy makers are keen to understand more about how aspects of vulnerability impact on violent crime, especially as this is a primary driver for policies like the public health approach to reducing violence. In a project that brings together stakeholders from the Scottish Government, Police Scotland and the Scottish Ambulance Service, the Scottish Centre for Administrative Data Research aims to examine patterns of ambulance callouts and/or hospital admissions involving people who experience violence. The study, which will link together a range of health datasets, will bring together data about violence-related incidents with wider information about an individual’s history of drug misuse, alcohol-related conditions and mental health problems. The study will also examine the extent to which violence and vulnerability contribute to increasing risk of premature death. This paper will focus on the development of the research proposal and the opportunities and challenges of trying to bring together data from different emergency service organisations. If possible, it will present preliminary findings from the research. It is anticipated that this study will support the development of further violence prevention policies in Scotland, especially in terms of helping to identify opportunities for better partnership working and points of intervention that could reduce demand on blue light services to deal with violent incidents.

Abstract Background Early adolescence is an important period to lay the foundation for positive sexual health development that can overcome sexual and reproductive health (SRH) challenges faced by very young adolescents (VYAs) as they reach puberty and sexual debut. In this study, we explored the following questions: first, what are the experiences of VYA girls on DREAMS’ Go Girl club participation? Second, how does club participation influence the VYAs SRH knowledge to reduce their risk for HIV and negative sexual health outcomes? Methods This was a qualitative study in which twenty-three in-depth interviews were conducted with VYA girls aged 12–14 years. These girls were enrolled in girl-only clubs in two rural southern districts in Malawi. The clubs were a part of larger comprehensive HIV prevention project called DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe) which provided an evidence-based core package of interventions to VYAs to prevent HIV. Interventions included improved access to key health services, education support, social skills, asset building, and economic strengthening. Narrative inquiry was used to generate first-hand accounts of the girls’ experiences with club participation. Thematic analysis was used to generate themes from the transcribed stories. Results Six main themes were generated: 1) reasons for joining the clubs with desire to learn about SRH as a motivation for joining the clubs.; 2) influence on gender norms and roles whereby participants described a change of gender roles and norms at home; 3) influence on child abuse practices whereby participants reported a decline in child abusive practices at home;4) influence on life skills and social networks whereby participants described learning about networking; 5) support to go back to school whereby out-of-school girls described how economic empowerment of their guardians facilitated their return to school; and 6) influence of clubs on SRH knowledge acquisition and behaviours whereby participants described acquiring knowledge on sexual health issues. Conclusion Girls-only HIV and SRH programs coupled with economic empowerment for their families can be effective in keeping VYA girls in school and improving SRH knowledge and health seeking behavior.

Settler introduction of tobacco to Inuit Nunangat (homeland of Inuit in Canada) has led to high tobacco use prevalence among Inuit. Inuit are moving from traditional territories to the province of Ontario to access resources, including health services. Indigenous-specific tobacco cessation approaches in Ontario lack cultural relevance among Inuit, as they often reflect First Nations and Métis worldviews. To improve effectiveness of tobacco cessation services for Inuit living in Ontario, materials reflective of Inuit culture and worldviews were developed through a community-based participatory approach. The Centre for Addiction and Mental Health collaborated with Tungasuvvingat Inuit and members of an Engagement Circle who work with Inuit or identify as Inuk (n = 25) to initiate a knowledge translation project aimed at co-creating a toolkit of Inuit-specific cessation resources. Development was guided by Two-Eyed Seeing, whereby Inuit and Western worldviews come together to support a strengths-based approach. The toolkit was evaluated through a pilot session and focus group with Inuit living in Ottawa who use tobacco (n = 13) and an online survey administered with a group of helpers who work with Inuit (n = 11). Analysis of qualitative data from the focus group and online survey highlighted five themes: choice, cultural relevance and safety, capacity-building, access, and impact. Focus group participants reported they learned quitting was possible and identified new strategies to quit through the session. Our findings emphasize the importance of engagement and co-creation with Indigenous Peoples to ensure cultural relevance and appropriateness of healthcare interventions.

This article describes the development and implementation process of an innovative 10-year partnership that draws on the strengths of existing community-based rehabilitation programs to support new education and leadership development activities in Ethiopia. Current global estimates indicate that over 17 million people may be affected by disability in Ethiopia. The national population projection for 2017 indicates that approximately 80 per cent of the population resides in underserved rural areas, with limited to no access to necessary health, rehabilitation, or social services. The University of Gondar (UoG) in Ethiopia has been serving people with disabilities in and around the North Gondar Zone since its inception in the mid-1950s. Over the years, its various units have designed and implemented numerous projects, employing alternative institutional and community-based models to promote the wellbeing of people with disabilities. Lessons drawn from these initiatives and shifts in health and social work practice informed UoG’s decision to establish its Community-Based Rehabilitation (CBR) program in 2005. Given a shared commitment to the principles and practice of CBR, the UoG is presently collaborating with the International Centre for the Advancement of Community Based Rehabilitation (ICACBR) at Queen’s University in Canada to create new disability-related education and mentorship opportunities. These include community-based research and internship opportunities for undergraduate and graduate scholars through a shared Mastercard Foundation Scholars Program. The two institutions, in collaboration with the Mastercard Foundation, have an overall goal of creating a disability-inclusive campus and regional rehabilitation hub at UoG. In this article, the authors discuss the unique collaborative structure of project management and implementation, and the embeddedness of university-community engagement to meet project objectives informed by the North–South/South–North partnership models. They also provide critical insights to, and reflections on, the challenges inherent in international, interdisciplinary university-community collaboration and the benefits from enhancing higher education in both Ethiopia and Canada. In contrast to shorter term or smaller projects that rely heavily on individual champions, this article focuses on larger scale, process-oriented institutional learning.

Background/rationaleThe Western Australian (WA) government and the Centre for Data Linkage (CDL) at Curtin University are creating a large, de-identified researchable database – the Social Investment Data Resource (SIDR) – to support a key government initiative called Target 120 (T120). T120 delivers targeted early interventions to young offenders and their families to reduce the likelihood of re-offending. Main AimThe SIDR brings together de-identified data from across government to be used for actuarial assessment and social investment analytics to assess long-term costs and benefits of T120 interventions. MethodsSIDR adopts a distributed linkage model where linkage workload is shared between the Department of Health Data Linkage Branch who curate WA Data Linkage System (WADLS) and the CDL. Design elements of the model included a common spine (embedded into the infrastructure of both groups), methods for leveraging quality from WADLS, and inclusion of family relationships data from the WA Family Connections database. The linkage model uses a combination of traditional and privacy-preserving record linkage (PPRL) methods. PPRL does not require release of personal identifiers; instead, data is irreversibly hashed prior to release for probabilistic linkage. The resultant SIDR repository has been designed to be securely and strictly managed. Access is by authorised, approved users only. ResultsUse of a distributed linkage model, coupled with traditional and PPRL methods, is an innovative yet pragmatic way of delivering data linkage services to a large, cross-sectoral research project. PPRL methods enable inclusion of otherwise excluded datasets in the project. Sharing of workload harnesses linkage capacity and capabilities across the state. The SIDR includes health data, education records, justice, child protection, disability and housing data. ConclusionSIDR provides a resource for whole-of-government policy development, service evaluation, academic research and social investment analytics for T120 and beyond. The SIDR distributed linkage model has potential for adaptation and use elsewhere.

India is home to almost one-third of the world's population that survive without adequate sanitation facilities. Bremen Overseas Research and Development Association (BORDA) in collaboration with the Consortium for DEWATS Dissemination (CDD) Society, has developed for the last 10 years, integrated solution packages for the provision of basic urban sanitation facilities. The customised packages include all or part of key sanitation elements like: toilets, decentralised wastewater treatment systems (DEWATS), health and hygiene education, solid waste management, drainage system, stakeholder participation measures. Over the last decade, with the support of its network partners CDD Society has been successful in delivering around 400 sanitation systems in South Asia. Due to the rapid growth of its population, India may require 1.3 million sanitation systems alone in the coming years. One of the key issues in meeting this huge target is the lack of trained professionals and implementing agencies. To upscale the efforts in delivering basic needs services in the sanitation sector, the Basic Needs Services (BNS) Network has started the establishment of a capacity building institution for decentralised sanitation solutions called Centre for Advanced Sanitation Solutions (CASS). CASS aims at providing the entire range of knowledge and skills required for the implementation of integrated sanitation solutions such as technical know-how for designing toilets, decentralised wastewater treatment systems (DEWATS), drainage systems, solid waste management and drinking water source protection; social support measures include health and hygiene education, community-based participatory planning tools as well as project management related aspects. For town and city managers, CASS will offer planning support for city and town-wide sanitation programmes. Furthermore, sanitation related R&D activities, knowledge management and exhibition is offered under CASS's ‘One-Stop-Shop’ concept; all components of sanitation are provided under one roof. This paper presents the basic components of the capacity building strategy developed by CDD/BORDA focusing on target groups, development of knowledge units (training module) and the didactical approach.

Land use disturbances are having enormous adverse impacts on the biodiversity and integrity of natural and managed ecosystems around the world. Adverse impacts on biodiversity are compromising ecosystem services and processes, reducing ecosystem resilience, and leading to unpredictable ecosystem responses to environmental change. The Metagenomics-Based Ecosystem Biomonitoring Project (EcoBiomics) focuses on the urgent need to better understand the extent and significance of ongoing changes to biodiversity in the soil and aquatic ecosystems that sustain essential ecosystem services upon which Canadians and the Canadian economy depend. This project uniquely recognizes that a breadth of scientific expertise from within the Canadian government is required to undertake this research, which is spread across relevant departments and agencies with Biodiversity portfolios. It involves over 50 participants (researchers, technicians, bioinformaticians, software developers, managers and students, etc.) contributing to many smaller projects in several locations across Canada organized by themes. The objectives of this project include: Develop standard soil and water methods and a federal Bioinformatics Platform to harmonize analyses of metabarcoding, metagenomics and metatranscriptomics data across federal departments/agencies; Establish genomic observatories and comprehensive biodiversity baselines for assessing future changes to water and soil biodiversity at long-term environmental monitoring sites in Canada; Develop new knowledge to improve water quality and soil health by comprehensively characterizing aquatic microbiomes, soil microbiomes, and invertebrate zoobiomes, and testing hypotheses to enhance environmental assessment, monitoring, and remediation activities. Develop standard soil and water methods and a federal Bioinformatics Platform to harmonize analyses of metabarcoding, metagenomics and metatranscriptomics data across federal departments/agencies; Establish genomic observatories and comprehensive biodiversity baselines for assessing future changes to water and soil biodiversity at long-term environmental monitoring sites in Canada; Develop new knowledge to improve water quality and soil health by comprehensively characterizing aquatic microbiomes, soil microbiomes, and invertebrate zoobiomes, and testing hypotheses to enhance environmental assessment, monitoring, and remediation activities. Our poster will focus primarily on the challenges associated with the first objective. Genomic technologies are revolutionizing biodiversity assessment in soil and aquatic ecosystems, and they now offer the only practical way to comprehensively characterize this enormous biodiversity. These technologies and associated tools allow us to obtain comprehensive baseline biodiversity data that are essential to support evidence-based decision-making. However, a strong focus of this project is to enable environmental assessment, monitoring, and remediation activities by a multitude of potential end users and thus standardized protocols and processes must be determined and shared. For the data generated, several procedures were defined. A minimum metadata profile related to the sampling event is required for all projects, which follows existing standards including the DarwinCore (https://dwc.tdwg.org). Sample preparation was also standardized based primarily on protocols developed in earlier projects that were validated for use in Ecobiomics, for example the Earth Microbiome Project (http://www.earthmicrobiome.org). The procedures for DNA extraction through sequencing largely followed the Minimum Information about “X” Sequence (MIxS) standard (gensc.org/mixs). This data is all input into an in-house custom-built software package, Sequence Database (SeqDB) used by all participants across the entire project, which is made available centrally via a federal high-performance computing centre. SeqDB not only stores the metadata and data generated but also maintains provenance based on defined workflows for metabarcoding, shotgun metagenomics, and other “omics” pipelines. It also supports project management through various metrics and visualizations. We will document some of the challenges to standardizing data and workflows in large multi-domain and multi-department project like Ecobiomics and the need for further standard development to truly support data sharing and integration across a highly diverse ecosystem of genomic observatories globally.

ObjectiveThe purpose of this project is to demonstrate the progress in development of a standardized public health (PH) emergency preparedness and response data ontology (terminology) through collaboration between the Centers for Disease Control and Prevention (CDC), Division of Emergency Operations (DEO), and the Logical Observation Identifiers Names and Codes (LOINC) system.IntroductionThe U.S. Department of Homeland Security National Incident Management System (NIMS) establishes a common framework and common terminology that allows diverse incident management and support organizations to work together across a wide variety of functions and hazard scenarios1. Using common terminology helps avoid confusion and enhances interoperability, particularly in fast-moving public health (PH) emergency responses. In addition, common terminology allows diverse incident management and support organizations to work together across a wide variety of functions and scenarios1. LOINC is one of a suite of designated standards for the electronic exchange of public health and clinical information. Implementation of LOINC facilitates improvement of semantic interoperability, including unified terminology2. More than 68,100 registered users from 172 countries use LOINC to move interoperable data seamlessly between systems3. The CDC Division of Emergency Operations (DEO) leads development of standardized PH emergency preparedness and response terminology to improve effective and interoperable communications between national and international partners. Realizing the scale of LOINC support and implementation across the global public health arena, CDC DEO collaborates with LOINC to further enhance and harmonize the current PH emergency response terminology and to attain critical PH emergency management and preparedness and response requirements.MethodsDEO analyzed 87,863 LOINC terms that were included in LOINC version 2.64, released on 06/15/20183. Access to this LOINC version was obtained through the Regenstrief LOINC Mapping Assistant (RELMA). RELMA is a Windows-based LOINC utility developed by the Regenstrief Institute (Indiapolis, USA) for searching the LOINC database and mapping local codes to LOINC codes4. The relevance of LOINC terminology to PH emergency preparedness and response was assessed through evaluating existing LOINC terminology against terminology specified by the World Health Organization PH Emergency Operation Centers (EOC). The following functions were evaluated: 1) Managing and Commanding; 2) Operating; 3) Planning/Intelligence; 4) Logistics and 5) Finance/Administration5. LOINC terminology was also evaluated against the CDC PH EOC Minimum Data Set (MDS)6 that contains 315 standardized terms. Analysis of fully specified LOINC terms was conducted through assessment of such LOINC term parts (attributes) as the code, name (component), system, method and class. Recommendations of gaps and enhancements were coordinated with LOINC management for inclusion of the new terminology in the release of version 2.65 .ResultsA new LOINC method, “CDC.EOC”, is under development. Currently, the “emergency management incident” terminology presented by LOINC is limited by such characteristics as event type, event location and event name and requires amplification regarding to PH operations (i.e., communication, logistics etc.).As a result of this investigation, emergency management terms are now being classified according to the type of incident or event (i.e., hurricane, outbreak, etc.) under LOINC code 80394-0. Similarly laboratory and clinical terms are being classified under a provisional LOINC code (89724-9). Two panels were created: 1) The emergency medical systems from the National Emergency Medical Services Information System (NEMSIS) was added under the NEMSIS.Panel (n= 177 terms) and 2) the Data Elements for Emergency Departments Systems (DEEDS) panel (n = 152 terms) was added with two subpanels: Attach.ED and Panel.ED.Assessing existing LOINC taxonomy and codification, DEO is working with the LOINC management team on evaluating additional options for reconciliation the PH emergency preparedness and response common information exchange reference model and LOINC standard. This process aims to further improve semantic interoperability of PH emergency preparedness and response information.ConclusionsThe LOINC terminology standardization is essential for improving PH preparedness and response data exchange and semantic interoperability. Collaboration with the Regenstrief Institute (LOINC) allows CDC to meet the terminology needs of PH emergency management and defines new opportunities for reconciliation data exchange between NIMS partners. This collaborative effort incorporates critically needed PH emergency and preparedness terminology and hierarchical structure in the LOINC standard.References1.FEMA National Incident Management System. Third Edition, October 2017. At: https://www.fema.gov/media-library-data/1508151197225-ced8c60378c3936adb92c1a3ee6f6564/FINAL_NIMS_2017.pdf2. US National Library of Medicine. Logical Observation Identifiers Names and Codes (LOINC). At: https://www.nlm.nih.gov/research/umls/loinc_main.html3. LOINC. The international standard for identifying health measurements, observations, and documents. At: https://loinc.org/4. RELMA-the Reginstrief Institute LOINC Mapping Assistant. At: https://loinc.org/relma/5.WHO. Framework for a Public Health Emergency Operations Centre. Interim document. November, 2015. At: http://www.who.int/ihr/publications/9789241565134_eng/en/6. CDC. Public Health Information Network Vocabulary Access and Distribution System (PHIN VADS). Minimum Data Set for PH Emergency Operations Center. At: https://phinvads.cdc.gov/vads/SearchVocab.action

Disability management (DM) is quite a fresh idea to Mainland China (Mainland). The government has thus turned to professionals from outside Mainland, i.e. Hong Kong (HK). Nevertheless, since HK is under ‘one country, two systems’ policy, it has developed an approach differing from that of Mainland. A DM pilot study was jointly conducted by the Guangdong Provincial Work Injury Rehabilitation Center (GPWIRC) and the Hong Kong Workers’ Health Centre (HKWHC) to review the developments of DM reform in China and HK. In China, the foundation of DM approach is the work injury insurance system. Under this system, GPWIRC established her services to provide work injury prevention and occupational rehabilitation as a pilot study in early 2000s. Following this pilot project, GPWIRC further develops work and social rehabilitation and work injury prevention in the context of the labor insurance system. While in HK, mainly NGOs, insurance companies and some public organizations contribute to the promotion of DM approach. On the other hand, the study also reveals similar challenges that Mainland and HK are currently facing in the development of DM, such as professional's training in local rehabilitation, the underdeveloped reimbursement system and etc.. The aforementioned pilot study shows that DM's principles are accepted at a national level and some specific public organizations in China context. There thus is a research need to study the current DM development situation in the private sector. By doing so, an ongoing study, namely “Demographic change and private sector disability management in Australia, Canada, China and Switzerland. A comparative study” launched in Nov. 2013. Through this research, questions of process and procedure of the DM system used in the company, benefits gained and drawbacks encountered by the companies, and the strengths and weaknesses in the current DM systems will be answered. Other than that, data will also be collected from the employees’ perspective on their job satisfaction, physical and mental health, employee morale and workplace attendance and etc.. The primary result is expected in 2016.

IntroductionIn July 1997, the Mackay campus of Central Queensland University hosted a conference with the theme Regional Australia: Visions of Mackay. It was the first academic conference to be held at the young campus, and its aim was to provide an opportunity for academics, business people, government officials, and other interested parties to discuss their visions for the development of Mackay, a regional community of 75,000 people situated on the Central Queensland coast (Danaher). I delivered a presentation at that conference and authored a chapter in the book that emerged from its proceedings. The chapter entitled “Mackay Online” explored the potential impact that the Internet could have on the Mackay region, particularly in the areas of regional business, education, health, and entertainment (Pace). Two decades later, how does the reality compare with that vision?Broadband BluesAt the time of the Visions of Mackay conference, public commercial use of the Internet was in its infancy. Many Internet services and technologies that users take for granted today were uncommon or non-existent then. Examples include online video, video-conferencing, Voice over Internet Protocol (VoIP), blogs, social media, peer-to-peer file sharing, payment gateways, content management systems, wireless data communications, smartphones, mobile applications, and tablet computers. In 1997, most users connected to the Internet using slow dial-up modems with speeds ranging from 28.8 Kbps to 33.6 Kbps. 56 Kbps modems had just become available. Lamenting these slow data transmission speeds, I looked forward to a time when widespread availability of high-bandwidth networks would allow the Internet’s services to “expand to include electronic commerce, home entertainment and desktop video-conferencing” (Pace 103). Although that future eventually arrived, I incorrectly anticipated how it would arrive.In 1997, Optus and Telstra were engaged in the rollout of hybrid fibre coaxial (HFC) networks in Sydney, Melbourne, and Brisbane for the Optus Vision and Foxtel pay TV services (Meredith). These HFC networks had a large amount of unused bandwidth, which both Telstra and Optus planned to use to provide broadband Internet services. Telstra's Big Pond Cable broadband service was already available to approximately one million households in Sydney and Melbourne (Taylor), and Optus was considering extending its cable network into regional Australia through partnerships with smaller regional telecommunications companies (Lewis). These promising developments seemed to point the way forward to a future high-bandwidth network, but that was not the case. A short time after the Visions of Mackay conference, Telstra and Optus ceased the rollout of their HFC networks in response to the invention of Asynchronous Digital Subscriber Line (ADSL), a technology that increases the bandwidth of copper wire and enables Internet connections of up to 6 Mbps over the existing phone network. ADSL was significantly faster than a dial-up service, it was broadly available to homes and businesses across the country, and it did not require enormous investment in infrastructure. However, ADSL could not offer speeds anywhere near the 27 Mbps of the HFC networks. When it came to broadband provision, Australia seemed destined to continue playing catch-up with the rest of the world. According to data from the Organisation for Economic Cooperation and Development (OECD), in 2009 Australia ranked 18th in the world for broadband penetration, with 24.1 percent of Australians having a fixed-line broadband subscription. Statistics like these eventually prompted the federal government to commit to the deployment of a National Broadband Network (NBN). In 2009, the Kevin Rudd Government announced that the NBN would combine fibre-to-the-premises (FTTP), fixed wireless, and satellite technologies to deliver Internet speeds of up to 100 Mbps to 90 percent of Australian homes, schools, and workplaces (Rudd).The rollout of the NBN in Mackay commenced in 2013 and continued, suburb by suburb, until its completion in 2017 (Frost, “Mackay”; Garvey). The rollout was anything but smooth. After a change of government in 2013, the NBN was redesigned to reduce costs. A mixed copper/optical technology known as fibre-to-the-node (FTTN) replaced FTTP as the preferred approach for providing most NBN connections. The resulting connection speeds were significantly slower than the 100 Mbps that was originally proposed. Many Mackay premises could only achieve a maximum speed of 40 Mbps, which led to some overcharging by Internet service providers, and subsequent compensation for failing to deliver services they had promised (“Optus”). Some Mackay residents even complained that their new NBN connections were slower than their former ADSL connections. NBN Co representatives claimed that the problems were due to “service providers not buying enough space in the network to provide the service they had promised to customers” (“Telcos”). Unsurprisingly, the number of complaints about the NBN that were lodged with the Telecommunications Industry Ombudsman skyrocketed during the last six months of 2017. Queensland complaints increased by approximately 40 percent when compared with the same period during the previous year (“Qld”).Despite the challenges presented by infrastructure limitations, the rollout of the NBN was a boost for the Mackay region. For some rural residents, it meant having reliable Internet access for the first time. Frost, for example, reports on the experiences of a Mackay couple who could not get an ADSL service at their rural home because it was too far away from the nearest telephone exchange. Unreliable 3G mobile broadband was the only option for operating their air-conditioning business. All of that changed with the arrival of the NBN. “It’s so fast we can run a number of things at the same time”, the couple reported (“NBN”).Networking the NationOne factor that contributed to the uptake of Internet services in the Mackay region after the Visions of Mackay conference was the Australian Government’s Networking the Nation (NTN) program. When the national telecommunications carrier Telstra was partially privatised in 1997, and further sold in 1999, proceeds from the sale were used to fund an ambitious communications infrastructure program named Networking the Nation (Department of Communications, Information Technology and the Arts). The program funded projects that improved the availability, accessibility, affordability, and use of communications facilities and services throughout regional Australia. Eligibility for funding was limited to not-for-profit organisations, including local councils, regional development organisations, community groups, local government associations, and state and territory governments.In 1998, the Mackay region received $930,000 in Networking the Nation funding for Mackay Regionlink, a project that aimed to provide equitable community access to online services, skills development for local residents, an affordable online presence for local business and community organisations, and increased external awareness of the Mackay region (Jewell et al.). One element of the project was a training program that provided basic Internet skills to 2,168 people across the region over a period of two years. A second element of the project involved the establishment of 20 public Internet access centres in locations throughout the region, such as libraries, community centres, and tourist information centres. The centres provided free Internet access to users and encouraged local participation and skill development. More than 9,200 users were recorded in these centres during the first year of the project, and the facilities remained active until 2006. A third element of the project was a regional web portal that provided a free easily-updated online presence for community organisations. The project aimed to have every business and community group in the Mackay region represented on the website, with hosting fees for the business web pages funding its ongoing operation and development. More than 6,000 organisations were listed on the site, and the project remained financially viable until 2005.The availability, affordability and use of communications facilities and services in Mackay increased significantly during the period of the Regionlink project. Changes in technology, services, markets, competition, and many other factors contributed to this increase, so it is difficult to ascertain the extent to which Mackay Regionlink fostered those outcomes. However, the large number of people who participated in the Regionlink training program and made use of the public Internet access centres, suggests that the project had a positive influence on digital literacy in the Mackay region.The Impact on BusinessThe Internet has transformed regional business for both consumers and business owners alike since the Visions of Mackay conference. When Mackay residents made a purchase in 1997, their choice of suppliers was limited to a few local businesses. Today they can shop online in a global market. Security concerns were initially a major obstacle to the growth of electronic commerce. Consumers were slow to adopt the Internet as a place for doing business, fearing that their credit card details would be vulnerable to hackers once they were placed online. After observing the efforts that finance and software companies were making to eliminate those obstacles, I anticipated that it would only be a matter of time before online transactions became commonplace:Consumers seeking a particular product will be able to quickly find the names of suitable suppliers around the world, compare their prices, and place an order with the one that can deliver the product at the cheapest price. (Pace 106)This expectation was soon fulfilled by the arrival of online payment systems such as PayPal in 1998, and online shopping services such as eBay in 1997. eBay is a global online auction and shopping website where individuals and businesses buy and sell goods and services worldwide. The eBay service is free to use for buyers, but sellers are charged modest fees when they make a sale. It exemplifies the notion of “friction-free capitalism” articulated by Gates (157).In 1997, regional Australian business owners were largely sceptical about the potential benefits the Internet could bring to their businesses. Only 11 percent of Australian businesses had some form of web presence, and less than 35 percent of those early adopters felt that their website was significant to their business (Department of Industry, Science and Tourism). Anticipating the significant opportunities that the Internet offered Mackay businesses to compete in new markets, I recommended that they work “towards the goal of providing products and services that meet the needs of international consumers as well as local ones” (107). In the two decades that have passed since that time, many Mackay businesses have been doing just that. One prime example is Big on Shoes (bigonshoes.com.au), a retailer of ladies’ shoes from sizes five to fifteen (Plane). Big on Shoes has physical shopfronts in Mackay and Moranbah, an online store that has been operating since 2009, and more than 12,000 followers on Facebook. This speciality store caters for women who have traditionally been unable to find shoes in their size. As the store’s customer base has grown within Australia and internationally, an unexpected transgender market has also emerged. In 2018 Big on Shoes was one of 30 regional businesses featured in the first Facebook and Instagram Annual Gift Guide, and it continues to build on its strengths (Cureton).The Impact on HealthThe growth of the Internet has improved the availability of specialist health services for people in the Mackay region. Traditionally, access to surgical services in Mackay has been much more limited than in metropolitan areas because of the shortage of specialists willing to practise in regional areas (Green). In 2003, a senior informant from the Royal Australasian College of Surgeons bluntly described the Central Queensland region from Mackay to Gladstone as “a black hole in terms of surgery” (Birrell et al. 15). In 1997 I anticipated that, although the Internet would never completely replace a visit to a local doctor or hospital, it would provide tools that improve the availability of specialist medical services for people living in regional areas. Using these tools, doctors would be able to “analyse medical images captured from patients living in remote locations” and “diagnose patients at a distance” (Pace 108).These expectations have been realised in the form of Queensland Health’s Telehealth initiative, which permits medical specialists in Brisbane and Townsville to conduct consultations with patients at the Mackay Base Hospital using video-conference technology. Telehealth reduces the need for patients to travel for specialist advice, and it provides health professionals with access to peer support. Averill (7), for example, reports on the experience of a breast cancer patient at the Mackay Base Hospital who was able to participate in a drug trial with a Townsville oncologist through the Telehealth network. Mackay health professionals organised the patient’s scans, administered blood tests, and checked her lymph nodes, blood pressure and weight. Townsville health professionals then used this information to advise the Mackay team about her ongoing treatment. The patient expressed appreciation that the service allowed her to avoid the lengthy round-trip to Townsville. Prior to being offered the Telehealth option, she had refused to participate in the trial because “the trip was just too much of a stumbling block” (Averill 7).The Impact on Media and EntertainmentThe field of media and entertainment is another aspect of regional life that has been reshaped by the Internet since the Visions of Mackay conference. Most of these changes have been equally apparent in both regional and metropolitan areas. Over the past decade, the way individuals consume media has been transformed by new online services offering user-generated video, video-on-demand, and catch-up TV. These developments were among the changes I anticipated in 1997:The convergence of television and the Internet will stimulate the creation of new services such as video-on-demand. Today television is a synchronous media—programs are usually viewed while they are being broadcast. When high-quality video can be transmitted over the information superhighway, users will be able to watch what they want, when and where they like. […] Newly released movies will continue to be rented, but probably not from stores. Instead, consumers will shop on the information superhighway for movies that can be delivered on demand.In the mid-2000s, free online video-sharing services such as YouTube and Vimeo began to emerge. These websites allow users to freely upload, view, share, comment on, and curate online videos. Subscription-based streaming services such as Netflix and Amazon Prime have also become increasingly popular since that time. These services offer online streaming of a library of films and television programs for a fee of less than 20 dollars per month. Computers, smart TVs, Blu-ray players, game consoles, mobile phones, tablets, and other devices provide a multitude of ways of accessing streaming services. Some of these devices cost less than 100 dollars, while higher-end electronic devices include the capability as a bundled feature. Netflix became available in Mackay at the time of its Australian launch in 2015. The growth of streaming services greatly reduced the demand for video rental shops in the region, and all closed down as a result. The last remaining video rental store in Mackay closed its doors in 2018 after trading for 26 years (“Last”).Some of the most dramatic transformations that have occurred the field of media and entertainment were not anticipated in 1997. The rise of mobile technology, including wireless data communications, smartphones, mobile applications, and tablet computers, was largely unforeseen at that time. Some Internet luminaries such as Vinton Cerf expected that mobile access to the Internet via laptop computers would become commonplace (Lange), but this view did not encompass the evolution of smartphones, and it was not widely held. Similarly, the rise of social media services and the impact they have had on the way people share content and communicate was generally unexpected. In some respects, these phenomena resemble the Black Swan events described by Nassim Nicholas Taleb (xvii)—surprising events with a major effect that are often inappropriately rationalised after the fact. They remind us of how difficult it is to predict the future media landscape by extrapolating from things we know, while failing to take into consideration what we do not know.The Challenge for MackayIn 1997, when exploring the potential impact that the Internet could have on the Mackay region, I identified a special challenge that the community faced if it wanted to be competitive in this new environment:The region has traditionally prospered from industries that control physical resources such as coal, sugar and tourism, but over the last two decades there has been a global ‘shift away from physical assets and towards information as the principal driver of wealth creation’ (Petre and Harrington 1996). The risk for Mackay is that its residents may be inclined to believe that wealth can only be created by means of industries that control physical assets. The community must realise that its value-added information is at least as precious as its abundant natural resources. (110)The Mackay region has not responded well to this challenge, as evidenced by measures such as the Knowledge City Index (KCI), a collection of six indicators that assess how well a city is positioned to grow and advance in today’s technology-driven, knowledge-based economy. A 2017 study used the KCI to conduct a comparative analysis of 25 Australian cities (Pratchett, Hu, Walsh, and Tuli). Mackay rated reasonably well in the areas of Income and Digital Access. But the city’s ratings were “very limited across all the other measures of the KCI”: Knowledge Capacity, Knowledge Mobility, Knowledge Industries and Smart Work (44).The need to be competitive in a technology-driven, knowledge-based economy is likely to become even more pressing in the years ahead. The 2017 World Energy Outlook Report estimated that China’s coal use is likely to have peaked in 2013 amid a rapid shift toward renewable energy, which means that demand for Mackay’s coal will continue to decline (International Energy Agency). The sugar industry is in crisis, finding itself unable to diversify its revenue base or increase production enough to offset falling global sugar prices (Rynne). The region’s biggest tourism drawcard, the Great Barrier Reef, continues to be degraded by mass coral bleaching events and ongoing threats posed by climate change and poor water quality (Great Barrier Reef Marine Park Authority). All of these developments have disturbing implications for Mackay’s regional economy and its reliance on coal, sugar, and tourism. Diversifying the local economy through the introduction of new knowledge industries would be one way of preparing the Mackay region for the impact of new technologies and the economic challenges that lie ahead.ReferencesAverill, Zizi. “Webcam Consultations.” Daily Mercury 22 Nov. 2018: 7.Birrell, Bob, Lesleyanne Hawthorne, and Virginia Rapson. The Outlook for Surgical Services in Australasia. Melbourne: Monash University Centre for Population and Urban Research, 2003.Cureton, Aidan. “Big Shoes, Big Ideas.” Daily Mercury 8 Dec. 2018: 12.Danaher, Geoff. Ed. Visions of Mackay: Conference Papers. Rockhampton: Central Queensland UP, 1998.Department of Communications, Information Technology and the Arts. Networking the Nation: Evaluation of Outcomes and Impacts. Canberra: Australian Government, 2005.Department of Industry, Science and Tourism. Electronic Commerce in Australia. Canberra: Australian Government, 1998.Frost, Pamela. “Mackay Is Up with Switch to Speed to NBN.” Daily Mercury 15 Aug. 2013: 8.———. “NBN Boost to Business.” Daily Mercury 29 Oct. 2013: 3.Gates, Bill. The Road Ahead. New York: Viking Penguin, 1995.Garvey, Cas. “NBN Rollout Hit, Miss in Mackay.” Daily Mercury 11 Jul. 2017: 6.Great Barrier Reef Marine Park Authority. Reef Blueprint: Great Barrier Reef Blueprint for Resilience. Townsville: Great Barrier Reef Marine Park Authority, 2017.Green, Anthony. “Surgical Services and Referrals in Rural and Remote Australia.” Medical Journal of Australia 177.2 (2002): 110–11.International Energy Agency. World Energy Outlook 2017. France: IEA Publications, 2017.Jewell, Roderick, Mary O’Flynn, Fiorella De Cindio, and Margaret Cameron. “RCM and MRL—A Reflection on Two Approaches to Constructing Communication Memory.” Constructing and Sharing Memory: Community Informatics, Identity and Empowerment. Eds. Larry Stillman and Graeme Johanson. Newcastle: Cambridge Scholars Publishing, 2007. 73–86.Lange, Larry. “The Internet: Where’s It All Going?” Information Week 17 Jul. 1995: 30.“Last Man Standing Shuts Doors after 26 Years of Trade.” Daily Mercury 28 Aug. 2018: 7.Lewis, Steve. “Optus Plans to Share Cost Burden.” Australian Financial Review 22 May 1997: 26.Meredith, Helen. “Time Short for Cable Modem.” Australian Financial Review 10 Apr. 1997: 42Nassim Nicholas Taleb. The Black Swan: The Impact of the Highly Improbable. New York: Random House, 2007.“Optus Offers Comp for Slow NBN.” Daily Mercury 10 Nov. 2017: 15.Organisation for Economic Cooperation and Development. “Fixed Broadband Subscriptions.” OECD Data, n.d. <https://data.oecd.org/broadband/fixed-broadband-subscriptions.htm>.Pace, Steven. “Mackay Online.” Visions of Mackay: Conference Papers. Ed. Geoff Danaher. Rockhampton: Central Queensland University Press, 1998. 111–19.Petre, Daniel and David Harrington. The Clever Country? Australia’s Digital Future. Sydney: Lansdown Publishing, 1996.Plane, Melanie. “A Shoe-In for Big Success.” Daily Mercury 9 Sep. 2017: 6.Pratchett, Lawrence, Richard Hu, Michael Walsh, and Sajeda Tuli. The Knowledge City Index: A Tale of 25 Cities in Australia. Canberra: University of Canberra neXus Research Centre, 2017.“Qld Customers NB-uN Happy Complaints about NBN Service Double in 12 Months.” Daily Mercury 17 Apr. 2018: 1.Rudd, Kevin. “Media Release: New National Broadband Network.” Parliament of Australia Press Release, 7 Apr. 2009 <https://parlinfo.aph.gov.au/parlInfo/search/display/display.w3p;query=Id:"media/pressrel/PS8T6">.Rynne, David. “Revitalising the Sugar Industry.” Sugar Policy Insights Feb. 2019: 2–3.Taylor, Emma. “A Dip in the Pond.” Sydney Morning Herald 16 Aug. 1997: 12.“Telcos and NBN Co in a Crisis.” Daily Mercury 27 Jul. 2017: 6.

The UP Manila Health Policy Development Hub recognizes the invaluable contribution of the participants in theseries of roundtable discussions listed below: RTD: Beyond Hospital Beds: Equity,quality, and service1. Ma. Esmeralda C. Silva, MPAf, MSPPM, PhD,Faculty, College of Public Health, UP Manila2. Leonardo R. Estacio, Jr., MCD, MPH, PhD, Dean,College of Arts and Sciences, UP Manila3. Michael Antonio F. Mendoza, DDM, MM, Faculty,College of Dentistry, UP Manila4. Hilton Y. Lam, MHA, PhD, Chair, UP Manila HealthPolicy Development Hub; Director, Institute of HealthPolicy and Development Studies, University of thePhilippines Manila5. Irma L. Asuncion, MHA, CESO III, Director IV,Bureau of Local Health Systems Development,Department of Health6. Renely Pangilinan-Tungol, MD, CFP, MPM-HSD,Municipal Health Officer, San Fernando, Pampanga7. Salome F. Arinduque, MD, Galing-Pook AwardeeRepresentative, Municipal Health Officer, San Felipe,Zambales8. Carmelita C. Canila, MD, MPH, Faculty, College ofPublic Health, University of the Philippines Manila9. Lester M. Tan, MD, MPH, Division Chief, Bureau ofLocal Health System Development, Department ofHealth10. Anthony Rosendo G. Faraon, MD, Vice President,Zuellig Family Foundation (ZFF)11. Albert Francis E. Domingo, MD, Consultant, HealthSystem strengthening through Public Policy andRegulation, World Health Organization12. Jesus Randy O. Cañal, MD, FPSO-HNS, AssociateDirector, Medical and Regulatory Affairs, AsianHospital and Medical Center13. Christian Edward L. Nuevo, Health Policy and SystemsResearch Fellow, Health Policy Development andPlanning Bureau, Department of Health14. Paolo Victor N. Medina, MD, Assistant Professor 4,College of Medicine, University of the PhilippinesManila15. Jose Rafael A. Marfori, MD, Special Assistant to theDirector, Philippine General Hospital16. Maria Teresa U. Bagaman, Committee Chair, PhilippineSociety for Quality, Inc.17. Maria Theresa G. Vera, MSc, MHA, CESO III, DirectorIV, Health Facility Development Bureau, Departmentof Health18. Ana Melissa F. Hilvano-Cabungcal, MD, AssistantAssociate Dean for Planning & Development, Collegeof Medicine, University of the Philippines Manila19. Fevi Rose C. Paro, Faculty, Department of Communityand Environmental Resource Planning, University ofthe Philippines Los Baños20. Maria Rosa C. Abad, MD, Medical Specialist III,Standard Development Division, Health Facilities andServices Regulation21. Yolanda R. Robles, RPh, PhD, Faculty, College ofPharmacy, University of the Philippines Manila22. Jaya P. Ebuen, RN, Development Manager Officer,CHDMM, Department of Health23. Josephine E. Cariaso, MA, RN, Assistant Professor,College of Nursing, University of the Philippines Manila24. Diana Van Daele, Programme Manager, CooperationSection, European Union25. Maria Paz de Sagun, Project Management Specialist,USAID26. Christopher Muñoz, Member, Yellow Warriors SocietyPhilippinesRTD: Health services and financingroles: Population based- andindividual-based1. Hilton Y. Lam, MHA, PhD, Chair, University of thePhilippines Manila Health Policy Development Hub;Director, Institute of Health Policy and DevelopmentStudies, University of the Philippines Manila2. Ma. Esmeralda C. Silva, MPAf, MSPPM, PhD,Faculty, College of Public Health, University of thePhilippines Manila3. Leonardo R. Estacio, Jr., MCD, MPH, PhD, Dean,College of Arts and Sciences, University of thePhilippines Manila4. Michael Antonio F. Mendoza, DDM, MM, Faculty,College of Dentistry, University of the PhilippinesManila5. Mario C. Villaverde, Undersecretary, Health Policyand Development Systems and Development Team,Department of Health6. Jaime Z. Galvez Tan, MD, Former Secretary, Department of Health7. Marvin C. Galvez, MD, OIC Division Chief, BenefitsDevelopment and Research Department, PhilippineHealth Insurance Corporation8. Alvin B. Caballes, MD, MPE, MPP, Faculty, Collegeof Medicine, University of the Philippines Manila9. Carlos D. Da Silva, Executive Director, Association ofMunicipal Health Maintenance Organization of thePhilippines, Inc.10. Anthony Rosendo G. Faraon, MD, Vice President,Zuellig Family Foundation (ZFF) 11. Albert Francis E. Domingo, MD, Consultant, HealthSystem strengthening through Public Policy andRegulation, World Health Organization12. Salome F. Arinduque, MD, Galing-Pook AwardeeRepresentative, Municipal Health Officer, San Felipe,Zambales13. Michael Ralph M. Abrigo, PhD, Research Fellow,Philippine Institute for Developmental Studies14. Oscar D. Tinio, MD, Committee Chair, Legislation,Philippine Medical Association15. Rogelio V. Dazo, Jr., MD, FPCOM, Legislation,Philippine Medical Association16. Ligaya V. Catadman, MM, Officer-in-charge, HealthPolicy Development and Planning Bureau, Department of Health17. Maria Fatima Garcia-Lorenzo, President, PhilippineAlliance of Patients Organization18. Tomasito P. Javate, Jr, Supervising Economic DevelopmentSpecialist, Health Nutrition and Population Division,National Economic and Development Authority19. Josefina Isidro-Lapena, MD, National Board ofDirector, Philippine Academy of Family Physicians20. Maria Eliza Ruiz-Aguila, MPhty, PhD, Dean, Collegeof Allied Medical Professions, University of thePhilippines Manila21. Ana Melissa F. Hilvano-Cabungcal, MD, AssistantAssociate Dean for Planning & Development, College ofMedicine, University of the Philippines Manila22. Maria Paz P. Corrales, MD, MHA, MPA, Director III,Department of Health-National Capital Region23. Karin Estepa Garcia, MD, Executive Secretary, PhilippineAcademy of Family Physicians24. Adeline A. Mesina, MD, Medical Specialist III,Philippine Health Insurance Corporation25. Glorey Ann P. Alde, RN, MPH, Research Fellow,Department of HealthRTD: Moving towards provincelevel integration throughUniversal Health Care Act1. Hilton Y. Lam, MHA, PhD, Chair, University of thePhilippines Manila Health Policy Development Hub;Director, Institute of Health Policy and DevelopmentStudies, University of the Philippines Manila2. Ma. Esmeralda C. Silva, MPAf, MSPPM, PhD,Faculty, College of Public Health, University of thePhilippines Manila3. Leonardo R. Estacio, Jr., MCD, MPH, PhD, Dean,College of Arts and Sciences, University of thePhilippines Manila4. Michael Antonio F. Mendoza, DDM, MM, Faculty,College of Dentistry, University of the PhilippinesManila5. Mario C. Villaverde, Undersecretary of Health, HealthPolicy and Development Systems and DevelopmentTeam, Department of Health6. Ferdinand A. Pecson, Undersecretary and ExecutiveDirector, Public Private Partnership Center7. Rosanna M. Buccahan, MD, Provincial Health Officer,Bataan Provincial Office8. Lester M. Tan, MD, Division Chief, Bureau of LocalHealth System Development, Department of Health9. Ernesto O. Domingo, MD, FPCP, FPSF, FormerChancellor, University of the Philippines Manila10. Albert Francis E. Domingo, MD, Consultant, HealthSystem strengthening through Public Policy andRegulation, World Health Organization11. Leslie Ann L. Luces, MD, Provincial Health Officer,Aklan12. Rene C. Catan, MD, Provincial Health Officer, Cebu13. Anthony Rosendo G. Faraon, MD, Vice President,Zuellig Family Foundation14. Jose Rafael A. Marfori, MD, Special Assistant to theDirector, Philippine General Hospital15. Jesus Randy O. Cañal, MD, FPSO-HNS, Consultant,Asian Hospital and Medical Center16. Ramon Paterno, MD, Member, Universal Health CareStudy Group, University of the Philippines Manila17. Mayor Eunice U. Babalcon, Mayor, Paranas, Samar18. Zorayda E. Leopando, MD, Former President,Philippine Academy of Family Physicians19. Madeleine de Rosas-Valera, MD, MScIH, SeniorTechnical Consultant, World Bank20. Arlene C. Sebastian, MD, Municipal Health Officer,Sta. Monica, Siargao Island, Mindanao21. Rizza Majella L. Herrera, MD, Acting Senior Manager,Accreditation Department, Philippine Health InsuranceCorporation22. Alvin B. Caballes, MD, MPE, MPP, Faculty, Collegeof Medicine, University of the Philippines Manila23. Pres. Policarpio B. Joves, MD, MPH, MOH, FPAFP,President, Philippine Academy of Family Physicians24. Leilanie A. Nicodemus, MD, Board of Director,Philippine Academy of Family Physicians25. Maria Paz P. Corrales, MD, MHA, MPA, Director III,National Capital Region Office, Department of Health26. Dir. Irma L. Asuncion, MD, MHA, CESO III, DirectorIV, Bureau of Local Health Systems Development,Department of Health27. Bernard B. Argamosa, MD, Mental Health Representative, National Center for Mental Health28. Flerida Chan, Chief, Poverty Reduction Section, JapanInternational Cooperation Agency29. Raul R. Alamis, Chief Health Program Officer, ServiceDelivery Network, Department of Health30. Mary Anne Milliscent B. Castro, Supervising HealthProgram Officer, Department of Health 31. Marikris Florenz N. Garcia, Project Manager, PublicPrivate Partnership Center32. Mary Grace G. Darunday, Supervising Budget andManagement Specialist, Budget and Management Bureaufor the Human Development Sector, Department ofBudget and Management33. Belinda Cater, Senior Budget and Management Specialist,Department of Budget and Management34. Sheryl N. Macalipay, LGU Officer IV, Bureau of LocalGovernment and Development, Department of Interiorand Local Government35. Kristel Faye M. Roderos, OTRP, Representative,College of Allied Medical Professions, University ofthe Philippines Manila36. Jeffrey I. Manalo, Director III, Policy Formulation,Project Evaluation and Monitoring Service, PublicPrivate Partnership Center37. Atty. Phebean Belle A. Ramos-Lacuna, Division Chief,Policy Formulation Division, Public Private PartnershipCenter38. Ricardo Benjamin D. Osorio, Planning Officer, PolicyFormulation, Project Evaluation and MonitoringService, Public Private Partnership Center39. Gladys Rabacal, Program Officer, Japan InternationalCooperation Agency40. Michael Angelo Baluyot, Nurse, Bataan Provincial Office41. Jonna Jane Javier Austria, Nurse, Bataan Provincial Office42. Heidee Buenaventura, MD, Associate Director, ZuelligFamily Foundation43. Dominique L. Monido, Policy Associate, Zuellig FamilyFoundation44. Rosa Nene De Lima-Estellana, RN, MD, Medical OfficerIII, Department of Interior and Local Government45. Ma Lourdes Sangalang-Yap, MD, FPCR, Medical OfficerIV, Department of Interior and Local Government46. Ana Melissa F. Hilvano-Cabungcal, MD, AssistantAssociate Dean for Planning & Development, College ofMedicine, University of the Philippines Manila47. Colleen T. Francisco, Representative, Department ofBudget and Management48. Kristine Galamgam, Representative, Department ofHealth49. Fides S. Basco, Officer-in-charge, Chief Budget andManagement Specialist, Development of Budget andManagementRTD: Health financing: Co-paymentsand Personnel1. Hilton Y. Lam, MHA, PhD, Chair, University of thePhilippines Manila Health Policy Development Hub;Director, Institute of Health Policy and DevelopmentStudies, University of the Philippines Manila2. Ma. Esmeralda C. Silva, MPAf, MSPPM, PhD,Faculty, College of Public Health, University of thePhilippines Manila3. Leonardo R. Estacio, Jr., MCD, MPH, PhD, Dean,College of Arts and Sciences, University of thePhilippines Manila4. Michael Antonio F. Mendoza, DDM, MM, Faculty,College of Dentistry, University of the Philippines Manila5. Ernesto O. Domingo, MD, Professor Emeritus,University of the Philippines Manila6. Irma L. Asuncion, MHA, CESO III, Director IV,Bureau of Local Health Systems Development,Department of Health7. Lester M. Tan, MD, MPH, Division Chief, Bureau ofLocal Health System Development, Department ofHealth8. Marvin C. Galvez, MD, OIC Division Chief, BenefitsDevelopment and Research Department, PhilippineHealth Insurance Corporation9. Adeline A. Mesina, MD, Medical Specialist III, BenefitsDepartment and Research Department, PhilippineHealth Insurance Corporation10. Carlos D. Da Silva, Executive Director, Association ofHealth Maintenance Organization of the Philippines,Inc.11. Ma. Margarita Lat-Luna, MD, Deputy Director, FiscalServices, Philippine General Hospital12. Waldemar V. Galindo, MD, Chief of Clinics, Ospital ngMaynila13. Albert Francis E. Domingo, MD, Consultant, HealthSystem strengthening through Public Policy andRegulation, World Health Organization14. Rogelio V. Dazo, Jr., MD, Member, Commission onLegislation, Philippine Medical Association15. Aileen R. Espina, MD, Board Member, PhilippineAcademy of Family Physicians16. Anthony R. Faraon, MD, Vice President, Zuellig FamilyFoundation17. Jesus Randy O. Cañal, Associate Director, Medical andRegulatory Affairs, Asian Hospital and Medical Center18. Jared Martin Clarianes, Technical Officer, Union of LocalAuthorities of the Philippines19. Leslie Ann L. Luces, MD, Provincial Health Officer,Aklan20. Rosa Nene De Lima-Estellana, MD, Medical OfficerIII, Department of the Interior and Local Government21. Ma. Lourdes Sangalang-Yap, MD, Medical Officer V,Department of the Interior and Local Government 22. Dominique L. Monido, Policy Associate, Zuellig FamilyFoundation23. Krisch Trine D. Ramos, MD, Medical Officer, PhilippineCharity Sweepstakes Office24. Larry R. Cedro, MD, Assistant General Manager, CharitySector, Philippine Charity Sweepstakes Office25. Margarita V. Hing, Officer in Charge, ManagementDivision, Financial Management Service Sector,Department of Health26. Dr. Carlo Irwin Panelo, Associate Professor, College ofMedicine, University of the Philippines Manila27. Dr. Angelita V. Larin, Faculty, College of Public Health,University of the Philippines Manila28. Dr. Abdel Jeffri A. Abdulla, Chair, RegionalizationProgram, University of the Philippines Manila29. Christopher S. Muñoz, Member, Philippine Alliance ofPatients Organization30. Gemma R. Macatangay, LGOO V, Department ofInterior and Local Government – Bureau of LocalGovernment Development31. Dr. Narisa Portia J. Sugay, Acting Vice President, QualityAssurance Group, Philippine Health InsuranceCorporation32. Maria Eliza R. Aguila, Dean, College of Allied MedicalProfessions, University of the Philippines Manila33. Angeli A. Comia, Manager, Zuellig Family Foundation34. Leo Alcantara, Union of Local Authorities of thePhilippines35. Dr. Zorayda E. Leopando, Former President, PhilippineAcademy of Family Physicians36. Dr. Emerito Jose Faraon, Faculty, College of PublicHealth, University of the Philippines Manila37. Dr. Carmelita C. Canila, Faculty, College of PublicHealth, University of the Philippines ManilaRTD: Moving towards third partyaccreditation for health facilities1. Hilton Y. Lam, MHA, PhD, Chair, University of thePhilippines Manila Health Policy Development Hub;Director, Institute of Health Policy and DevelopmentStudies, University of the Philippines Manila2. Ma. Esmeralda C. Silva, MPAf, MSPPM, PhD,Faculty, College of Public Health, University of thePhilippines Manila3. Leonardo R. Estacio, Jr., MCD, MPH, PhD, Dean,College of Arts and Sciences, University of thePhilippines Manila4. Michael Antonio F. Mendoza, DDM, MM, Faculty,College of Dentistry, University of the PhilippinesManila5. Rizza Majella L. Herrera, MD, Acting SeniorManager, Accreditation Department, Philippine HealthInsurance Corporation6. Bernadette C. Hogar-Manlapat, MD, FPBA, FPSA,FPSQua, MMPA, President and Board of Trustee,Philippine Society for Quality in Healthcare, Inc.7. Waldemar V. Galindo, MD, Chief of Clinics, Ospital ngMaynila8. Amor. F. Lahoz, Division Chief, Promotion andDocumentation Division, Department of Trade andIndustry – Philippine Accreditation Bureau9. Jenebert P. Opinion, Development Specialist, Department of Trade and Industry – Philippine AccreditationBureau10. Maria Linda G. Buhat, President, Association ofNursing Service Administrators of the Philippines, Inc.11. Bernardino A. Vicente, MD, FPPA, MHA, CESOIV, President, Philippine Tripartite Accreditation forHealth Facilities, Inc.12. Atty. Bu C. Castro, MD, Board Member, PhilippineHospital Association13. Cristina Lagao-Caalim, RN, MAN, MHA, ImmediatePast President and Board of Trustee, Philippine Societyfor Quality in Healthcare, Inc.14. Manuel E. Villegas Jr., MD, Vice Treasurer and Board ofTrustee, Philippine Society for Quality in Healthcare,Inc.15. Michelle A. Arban, Treasurer and Board of Trustee,Philippine Society for Quality in Healthcare, Inc.16. Joselito R. Chavez, MD, FPCP, FPCCP, FACCP,CESE, Deputy Executive Director, Medical Services,National Kidney and Transplant Institute17. Blesilda A. Gutierrez, CPA, MBA, Deputy ExecutiveDirector, Administrative Services, National Kidney andTransplant Institute18. Eulalia C. Magpusao, MD, Associate Director, Qualityand Patient Safety, St. Luke’s Medical Centre GlobalCity19. Clemencia D. Bondoc, MD, Auditor, Association ofMunicipal Health Officers of the Philippines20. Jesus Randy O. Cañal, MD, FPSO-HNS, AssociateDirector, Medical and Regulatory Affairs, Asian Hospitaland Medical Center21. Maria Fatima Garcia-Lorenzo, President, PhilippineAlliance of Patient Organizations22. Leilanie A. Nicodemus, MD, Board of Directors,Philippine Academy of Family Physicians23. Policarpio B. Joves Jr., MD, President, PhilippineAcademy of Family Physicians24. Kristel Faye Roderos, Faculty, College of Allied MedicalProfessions, University of the Philippines Manila25. Ana Melissa Hilvano-Cabungcal, MD, AssistantAssociate Dean, College of Medicine, University of thePhilippines Manila26. Christopher Malorre Calaquian, MD, Faculty, Collegeof Medicine, University of the Philippines Manila27. Emerito Jose C. Faraon, MD, Faculty, College ofPublic Health, University of the Philippines Manila 28. Carmelita Canila, Faculty, College of Public Health,University of the Philippines Manila29. Oscar D. Tinio, MD, Representative, Philippine MedicalAssociation30. Farrah Rocamora, Member, Philippine Society forQuality in Healthcare, IncRTD: RA 11036 (Mental Health Act):Addressing Mental Health Needs ofOverseas Filipino Workers1. Hilton Y. Lam, MHA, PhD, Chair, University of thePhilippines Manila Health Policy Development Hub;Director, Institute of Health Policy and DevelopmentStudies, University of the Philippines Manila2. Leonardo R. Estacio, Jr., MCD, MPH, PhD, UPManila Health Policy Development Hub; College ofArts and Sciences, UP Manila3. Ma. Esmeralda C. Silva, MPAf, MSPPM, PhD, UPManila Health Policy Development Hub; College ofPublic Health, UP Manila4. Michael Antonio F. Mendoza, DDM, UP ManilaHealth Policy Development Hub; College of Dentistry,UP Manila5. Frances Prescilla L. Cuevas, RN, MAN, Director,Essential Non-Communicable Diseases Division,Department of Health6. Maria Teresa D. De los Santos, Workers Education andMonitoring Division, Philippine Overseas EmploymentAdministration7. Andrelyn R. Gregorio, Policy Program and Development Office,Overseas Workers Welfare Administration8. Sally D. Bongalonta, MA, Institute of Family Life &Children Studies, Philippine Women’s University9. Consul Ferdinand P. Flores, Department of ForeignAffairs10. Jerome Alcantara, BLAS OPLE Policy Center andTraining Institute11. Andrea Luisa C. Anolin, Commission on FilipinoOverseas12. Bernard B. Argamosa, MD, DSBPP, National Centerfor Mental Health13. Agnes Joy L. Casino, MD, DSBPP, National Centerfor Mental Health14. Ryan Roberto E. Delos Reyes, Employment Promotionand Workers Welfare Division, Department of Laborand Employment15. Sheralee Bondad, Legal and International AffairsCluster, Department of Labor and Employment16. Rhodora A. Abano, Center for Migrant Advocacy17. Nina Evita Q. Guzman, Ugnayan at Tulong para saMaralitang Pamilya (UGAT) Foundation, Inc.18. Katrina S. Ching, Ugnayan at Tulong para sa MaralitangPamilya (UGAT) Foundation, Inc.RTD: (Bitter) Sweet Smile of Filipinos1. Dr. Hilton Y. Lam, Institute of Health Policy andDevelopment Studies, NIH2. Dr. Leonardo R. Estacio, Jr., College of Arts andSciences, UP Manila3. Dr. Ma. Esmeralda C. Silva, College of Public Health,UP Manila4. Dr. Michael Antonio F. Mendoza, College of Dentistry,UP Manila5. Dr. Ma. Susan T. Yanga-Mabunga, Department ofHealth Policy & Administration, UP Manila6. Dr. Danilo L. Magtanong, College of Dentistry, UPManila7. Dr. Alvin Munoz Laxamana, Philippine DentalAssociation8. Dr. Fina Lopez, Philippine Pediatric Dental Society, Inc9. Dr. Artemio Licos, Jr.,Department of Health NationalAssociation of Dentists10. Dr. Maria Jona D. Godoy, Professional RegulationCommission11. Ms. Anna Liza De Leon, Philippine Health InsuranceCorporation12. Ms. Nicole Sigmuend, GIZ Fit for School13. Ms. Lita Orbillo, Disease Prevention and Control Bureau14. Mr. Raymond Oxcena Akap sa Bata Philippines15. Dr. Jessica Rebueno-Santos, Department of CommunityDentistry, UP Manila16. Ms. Maria Olivine M. Contreras, Bureau of LocalGovernment Supervision, DILG17. Ms. Janel Christine Mendoza, Philippine DentalStudents Association18. Mr. Eric Raymund Yu, UP College of DentistryStudent Council19. Dr. Joy Memorando, Philippine Pediatric Society20. Dr. Sharon Alvarez, Philippine Association of DentalColleges

Our capacity to tell stories is a skill that can be considered both natural and learned. Storytelling and oral history are parts of all human societies, and we seek to understand ourselves and each other through our stories. Our individual and collective memories collide in our stories, and reconcile to construct what Kansteiner calls our "collectively shared representations of the past" (182). It is our personal narratives that are the building blocks to public understanding, and as Harter, Japp and Beck maintain in Narratives, Health and Healing, "narrative is a fundamental human way of giving meaning to experience" (3). Adding to this idea of narrative as way of illuminating meaning, Goodall posits narrative as also being a way of knowing and as a research methodology, stating "narrative provides us with a range of forms and styles for discovering meaning and communicating it to readers through stories. It is an epistemology" (13). This re-imaging and re-purposing of narrative and storytelling has the capacity to significantly influence and shift the ways in which cultural and social research is carried out. This emerging approach can also influence the ways we understand the experiences of marginalised groups, and consequently how we respond to issues around social inclusion through policy and community based solutions. For researchers personal stories and narratives have the capacity to illuminate the nuances of broad issues; this potential also means that seemingly intractable social problems are given a human face with which to engage. It is in this way that personal narratives energise public narratives and shape our ways of thinking and collective understandings (Harter et al. 4). This paper investigates a digital storytelling project conducted in late 2009 with a group of Forgotten Australians in the months leading up to the public apology in the Australian Parliament, and how the personal stories of the participants brought to life previous research about the marginalisation of individuals who had experienced out-of-home care as children. This paper also explores how the endemic, institutionalised abuse of a group of people was translated to the broader community and galvanised support through the impact of their personal stories. Digital Storytelling As a dynamic practice storytelling, in all its forms, must be nurtured and developed if it is to contribute to the lives of individuals and communities. The number of storytelling, and in particular digital storytelling, initiatives and projects in Australia has increased rapidly since the early 2000s, and are utilised by various public and community organisations for a variety of reasons. Digital technology has had a profound impact on the ability for "ordinary" people to tell their stories, and research has identified the potential of digital storytelling in these contexts to assist in the representation of multiple voices and viewpoints in society through inclusive processes of co-creation (cf. see Burgess; Hartley, Uses and "TV"; Klaebe and Burgess). The storytelling project that forms the basis for this paper used some traditional written storytelling practices but was mainly concerned with digital storytelling. Digital stories are generally a two to four minute multi-media story that uses photographs, film and drawings to convey a personal story which the author narrates in their own voice over the series of images. Much has been, and continues to be written, about digital storytelling as a site of participatory culture and as a means of improving digital literacy in pockets of the community traditionally absent in the realm of digital citizenship (cf. Hartley, Uses; Hartley and McWilliam; Burgess; Meadows; Lundby). As Hartley points out digital storytelling has become such a compelling medium in which to record stories in communities because it "fills a gap between everyday cultural practice and professional media" (Uses 122). As a means of creating narratives digital storytelling has proven to be a significant mode, due in part to its ability to reach a large number of people relatively easily. The rise of digital storytelling partially mirrors the broad shift towards more participatory online culture that privileges user generated content and ordinary voices over official content. The origins of digital storytelling lie in a response to the absence of "ordinary" voices in mainstream media and policy making and grew with the increasing affordability of digital technology. The potential for social inclusion and participation along with the promise of self-representation is implicit in the discourse surrounding digital storytelling. "The ability to express oneself in digital media and in the case of digital storytelling using digital video editing, has become a central literary for full participation in society" (Lambert 85). Social Inclusion in an Australian context is defined by the Australian Government as all Australians feeling valued and having "the opportunity to participate fully in the life of our society. Achieving this vision means that all Australians will have the resources, opportunities and capability to" learn, work, engage in the community and have a voice (Social Inclusion Unit). The aims articulated by Lambert in the previous paragraph and the philosophy of social inclusion and the belief that individual stories have the capacity to impact on national agendas and policy lay at the heart of the digital storytelling project outlined later in this paper. The Forgotten Australians As cohort the Forgotten Australians are defined as individuals who were removed from their families, or were orphaned or child immigrants from the United Kingdom. These children were placed in institutions where they suffered abuse or neglect between 1930 and 1970, and it is estimated that up approximately 500,000 children were placed in out of home care during this time. In November 2009 the Australian Parliament delivered a bi-partisan apology to the Forgotten Australians for the pain and suffering they experienced in church and state run institutions. The stories of the Forgotten Australians were beginning to make their way into the consciousness of the Australian public in the lead up to the apology through documentaries on the national broadcasting service and stories in the mainstream media. Like most large groups the demographic of the Forgotten Australians is diverse, within those who identify as part of this group are successful and well-known Australians, along with ordinary Australians many of whom have struggled significantly as a direct result of their childhood experiences. Those involved in this project were considered to be individuals who were quite profoundly marginalised in mainstream society. A number lived with mental illness, the majority lacked stable housing and all had been severely emotionally, physically and sexually abused during their time in State or Church run institutions as children. The apology to the Forgotten Australians was preceded many years of advocacy and activism by community groups and individuals. They utilised personal stories, the digitisation of records and as the apology drew closer a number of digital storytelling projects to bring the personal narratives into the public arena in the hope of affecting change. Stories from these projects were broadcast across a variety of platforms such as YouTube, the websites for the major advocacy groups and community organisations and more recently the National Library Australia website. The stories differed from site to site and served different functions depending on the place from which they were disseminated. Hildebrand identifies the role of YouTube as a site for the intersection of personal experience, popular culture and historical narratives, and, as such, a vehicle for cultural memory "allow[ing] users to seek out the media texts that have shaped them and that would otherwise be forgotten in 'objective' histories" (54). YouTube videos relevant to the Forgotten Australians ranged from locally made stories and documentation, news items and presentations recorded by major organisations, but uploaded by individuals, and also those posted by these institutions themselves. A notable feature of all of these contributions is their role in the representation of witnesses' stories. In the case of reports on Forgotten Australians from major news organisations the commentary they attracted was largely from those who identified as fellow forgotten Australians attesting to—and corroborating—the interviewees' stories. Whether they were posted by survivors themselves or by mainstream media or other institutions, they exhibited a unity around a particular will to memory: setting the record straight through testimony. Here, the clips and posts were characterised by the provision of information as evidence for the assertion of cultural trauma as a shared experience and focus of identification (Adkins et al. 15). Storytelling functions as one of our most powerful forms for experiencing, expressing, and enacting sorrow and pain...it is pivotal in the process of sense making, allowing individuals to cope with chaotic, equivocal, and confusing conditions of everyday life, including illness and suffering. (152) Advocacy and community groups such as CLAN were focused on creating a sense of community amongst survivors with no story or artefact too small or insignificant to be included, which differed slightly from the agenda of the National Library of Australia—the institution of public memory that has been most closely involved in recording and disseminating the stories of the Forgotten Australians. The Forgotten Australians and Former Child Migrants Oral History Project conducted by the National Library Australia was one of the recommendations of the two Senate Community Affairs References Committee reports following the Senate Inquiries and receives funding from the Commonwealth Department of Families, Housing, Community Services and Indigenous Affairs. According to the National Library Australia website, this oral history project will run for three years and aims to document a rounded history of the experiences of the children in institutional care and the lifelong impact of these experiences on their lives and their families. This project will also interview a selection of advocates, and allied professionals including welfare officers, employees of institutions and administrators. (Project Team) In many important ways the purposes served in this project were those of the governments—previous and present, which was to capture and keep the stories, memories, documents and artefacts, and to share the officially selected stories with the rest of the nation, and those stories would support and affirm the government's roadmap for moving on from the apology. These digital storytelling projects, to varying degrees and levels of impact, served to provide the public with the personal narratives behind the issue being presented in the media and by advocacy groups as a large scale issue concerning hundreds of thousands of victims. Although the sheer size of the numbers of children affected was confronting, it was the personal stories that created a momentum towards the public apology. The findings of both Senate Inquiries recommended a formal apology; however this did not occur until the individual experiences of the Forgotten Australians were translated and represented in narratives and, through this, the construction of a sense of cultural memory resulting in formal recognition. Many Australians were sceptical about the importance of a public apology to the Forgotten Australians, as they had been of the apology to the Stolen Generation in 2008. To be a genuine act of reconciliation an apology requires the act of listening as much as speaking, fittingly Prime Minister Rudd quoted predominantly from personal oral history testimonies that had been collected over the years and that were of public record, but had not been digitally accessible to all, as many stories now are in the Bringing Them Home report. The Case Study In August 2009 I was funded by the Australasian Centre for Interactive Design (ACID) to conduct a series of digital storytelling and writing workshops in conjunction with Micah Projects, a community building and social justice organisation based in Brisbane. Micah delivers services for people experiencing homelessness, runs programmes for young mothers and is responsible for the Historical Abuse Network which is a network servicing the Forgotten Australians. After some discussion with the CEO of Micah it was decided that the clients involved with the Historical Abuse Network would benefit most from this project. Many of the participants had been involved in the 2003 senate inquiry into the treatment of children in institutional care. In the intervening years they had told the story of their abuse many times in official contexts and provided statements of harm for the inquiry. However, for this project we wanted to encourage the participants to create stories that allowed them some agency in their own lives rather, to re-claim some of their story from the official framework of abuse, and to use digital storytelling as a tool for this. The participants were between 45 and 65 in age, and were divided equally between women and men. There were a number of complexities inherent in this project, some of which were specific to this particular cohort and some specific to all marginalised individuals and groups. The most significant problem arose out the expectation that the "authors" will bring with them photographs and keepsakes from their lives to use in the stories. Many of the participants did not have photographs of their childhoods or of their families; some did not know how old they were (in many institutions all birthdays were celebrated on a single day, and consequently most lost track of their age and birth date) or had not had contact with their biological family for decades and as a result had few keepsakes. These hallmarks of legitimate biography were absent from their pasts and their presents. The combination of these factors meant that for many the ability to create a coherent narrative about their life or to feel ownership over their life had been seriously compromised. However, it became apparent that by using sounds and images in the digital story the technology was able to create a materiality out of memory for the participants. As it became clearer that the foundation of the stories was memory rather than a narrative arc, the more it became imperative to embrace the fragmentation, inconsistency and incoherence of the memories, and to incorporate these aspects into the digital stories. Instead of being easy to follow or emotionally satisfying narratives, some of the stories had much more in common with what is referred to in psychology and health frameworks as "chaos narratives". A chaos narrative has a sense of disconnected events characterised by a lack of closure and the presence of day-to-day uncertainty (Harter 4). Often such stories seem too incoherent to be told and too painful to be heard by others, as was certainly the case with some of the stories created for this project. Conclusion The Finding a Voice digital storytelling project led by Professor Jo Tacchi aligns with the aims of this project in its social innovation, and the role of storytelling and voice as having the genuine potential to impact on the understanding of poverty and disadvantage. Tacchi states that it "is an approach that allows those who are living in conditions that might constitute 'poverty' to tell those who are not what this experience is like, in their own words. Such an approach might challenge our 'expert' conceptions of poverty itself" (170), and confront mainstream or approved versions of social issues. Carabas posits that the agency embedded in the narrative act reforms or reframes the meanings of events through counter narratives and the act of telling transformed personal and social suffering. Those who had been objects of other's reports started to tell their own stories and rewrite official history in the first person singular (154). For the Forgotten Australians, those involved in this project and in similar ones the opportunity to tell their stories in their own words allowed them to push past the detached, impersonal representation of their experiences. Instead they could re-position the debate to being about individuals and the effect of government policy on their lives, and in doing so agitate for a formal apology. Storytelling and narrative as a research methodology, and as a way of knowing, is continuing to be refined by social and cultural researchers and by community organisations. Despite the emerging and nebulous nature of this field one thing is clear: our human desire to tell stories has the ability to be harnessed to build narratives which create understanding and insight and consequently demand that as communities and nations we respond to injustice and disadvantage accordingly. References Adkins, Barbara, Donna Hancox, and Helen Klaebe. 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