scholarly journals Exploring the macro-level, meso-level and micro-level barriers and facilitators to the provision of good quality early inflammatory arthritis (EIA) care in England and Wales

RMD Open ◽  
2021 ◽  
Vol 7 (3) ◽  
pp. e001616
Author(s):  
Magdalena Zasada ◽  
Mark Yates ◽  
Nicola Ayers ◽  
Zoë Ide ◽  
Sam Norton ◽  
...  
Keyword(s):  
Inflammatory Arthritis ◽  
Care Quality ◽  
Barriers And Facilitators ◽  
Macro Level ◽  
Healthcare Team ◽  
England And Wales ◽  
Meso Level ◽  
Early Inflammatory Arthritis ◽  
Micro Level

BackgroundEvidence from a national clinical audit of early inflammatory arthritis (EIA) shows considerable variability between hospitals in performance, unexplained by controlling for case-mix.ObjectiveTo explore the macro-level, meso-level and micro-level barriers and facilitators to the provision of good quality EIA care.MethodsA qualitative study within 16 purposively sampled rheumatology units across England and Wales. Quality was assessed in relation to 11 quality indicators based on clinical opinion, evidence and variability observed in the data. Data from semi-structured interviews with staff (1–5 from each unit, 56 in total) and an online questionnaire (n=14/16 units) were integrated and analysed using the framework method for thematic analysis using a combined inductive and deductive approach (underpinned by an evidence-based framework of healthcare team effectiveness), and constant comparison of data within and between units and its relationship with the quality criteria.FindingsQuality of care was influenced by an interplay between macro, meso and micro domains. The macro (eg, shared care arrangements and relationships with general practitioners) and meso (eg, managerial support and physical infrastructure) factors were found to act as crucial enablers of and barriers to higher quality service provision at the micro (team) level. These organisational factors directly influenced team structure and function, and thereby EIA care quality.ConclusionsVariability in quality of EIA care is associated with an interplay between macro, meso and micro service features. Tackling macro and meso barriers is likely to have a significant impact on quality of EIA service, and ultimately patient experience and outcomes.

Barriers and Facilitators to Acceptance of Mental Illness

2016 ◽  
pp. 52-65
Author(s):  
Lauren Mizock ◽  
Zlatka Russinova
Keyword(s):  
Mental Illness ◽  
Serious Mental Illness ◽  
Barriers And Facilitators ◽  
Macro Level ◽  
Meso Level ◽  
Clinical Strategies ◽  
Research Interviews ◽  
Societal Level ◽  
Micro Level

A number of barriers and facilitators have been theorized to impact the process of accepting serious mental illness. This chapter discusses the identified barriers and facilitators to acceptance of mental illness, using excerpts from research interviews with participants with serious mental illness. Barriers and facilitators are described as occurring at the micro level (cognitive, emotional, behavioral, identity-related), meso level (relational), and macro level (cultural, systemic). The ability of practitioners and clinicians to support change with individual clients at the micro and meso levels is discussed. The need for acceptance of mental illness on a societal level is also explored. A clinical strategies list, discussion questions, activities, the “Barriers and Facilitators to Acceptance Worksheet,” and diagrams are also included.

scholarly journals Young Children’s Belonging in Finnish Educational Settings: an Intersectional Analysis

2021 ◽  
Author(s):  
Anna-Maija Puroila ◽  
Jaana Juutinen ◽  
Elina Viljamaa ◽  
Riikka Sirkko ◽  
Taina Kyrönlampi ◽  
...  
Keyword(s):  
Educational Policy ◽  
Educational Programs ◽  
Macro Level ◽  
Educational Settings ◽  
Policy Documents ◽  
Meso Level ◽  
Continuity And Change ◽  
Positional Power ◽  
Micro Level ◽  
Similarities And Differences

AbstractThe study draws on a relational and intersectional approach to young children’s belonging in Finnish educational settings. Belonging is conceptualized as a multilevel, dynamic, and relationally constructed phenomenon. The aim of the study is to explore how children’s belonging is shaped in the intersections between macro-, meso-, and micro-levels of young children’s education in Finland. The data consist of educational policy documents and ethnographic material generated in educational programs for children aged birth to 8 years. A situational mapping framework is used to analyze and interpret the data across and within systems levels (macro-level; meso-level; and micro-level). The findings show that the landscape in which children’s belonging is shaped and the intersections across and within the levels are characterized by the tensions between similarities and differences, majority and minorities, continuity and change, authority and agency. Language used, practices enacted, and positional power emerge as the (re)sources through which children’s (un)belonging is actively produced.

scholarly journals POS0959 DIAGNOSTIC DELAY IN AXIAL SPONDYLOARTHRITIS: RESULTS FROM THE NATIONAL EARLY INFLAMMATORY ARTHRITIS AUDIT

2021 ◽  
Vol 80 (Suppl 1) ◽  
pp. 744.1-744
Author(s):  
M. Russell ◽  
F. Coath ◽  
M. Yates ◽  
K. Bechman ◽  
S. Norton ◽  
...  
Keyword(s):  
Inflammatory Arthritis ◽  
Clinical Characteristics ◽  
Axial Spondyloarthritis ◽  
Diagnostic Delay ◽  
British Society ◽  
Standards Of Care ◽  
Symptom Duration ◽  
Research Support ◽  
England And Wales ◽  
Early Inflammatory Arthritis

Background:Diagnostic delay is a significant problem in axial spondyloarthritis (axSpA), and there is a growing body of evidence showing that delayed axSpA diagnosis is associated with worse clinical, humanistic and economic outcomes.1 International guidelines have been published to inform referral pathways and improve standards of care for patients with axSpA.2,3Objectives:To describe the sociodemographic and clinical characteristics of newly-referred patients with axSpA in England and Wales in the National Early Inflammatory Arthritis Audit (NEIAA), with rheumatoid arthritis (RA) and mechanical back pain (MBP) as comparators.Methods:The NEIAA captures data on all new patients over the age of 16 referred with suspected inflammatory arthritis to rheumatology departments in England and Wales.4 We describe baseline sociodemographic and clinical characteristics of axSpA patients (n=784) recruited to the NEIAA between May 2018 and March 2020, compared with RA (n=9,270) and MBP (n=370) during the same period.Results:Symptom duration prior to initial rheumatology assessment was significantly longer in axSpA than RA patients (p<0.001), and non-significantly longer in axSpA than MBP patients (p=0.062): 79.7% of axSpA patients had symptom durations of >6 months, compared to 33.7% of RA patients and 76.0% of MBP patients; 32.6% of axSpA patients had symptom durations of >5 years, compared to 3.5% of RA patients and 24.6% of MBP patients (Figure 1A). Following referral, median time to initial rheumatology assessment was longer for axSpA than RA patients (36 vs. 24 days; p<0.001), and similar to MBP patients (39 days; p=0.30). The proportion of axSpA patients assessed within 3 weeks of referral increased from 26.7% in May 2018 to 34.7% in March 2020; compared to an increase from 38.2% to 54.5% for RA patients (Figure 1B). A large majority of axSpA referrals originated from primary care (72.4%) or musculoskeletal triage services (14.1%), with relatively few referrals from gastroenterology (1.9%), ophthalmology (1.4%) or dermatology (0.4%).Of the subset of patients with peripheral arthritis requiring EIA pathway follow-up, fewer axSpA than RA patients had disease education provided (77.5% vs. 97.8%; p<0.001), and RA patients reported a better understanding of their condition (p<0.001). HAQ-DI scores were lower at baseline in axSpA EIA patients than RA EIA patients (0.8 vs 1.1, respectively; p=0.004), whereas baseline Musculoskeletal Health Questionnaire (MSK-HQ) scores were similar (25 vs. 24, respectively; p=0.49). The burden of disease was substantial across the 14 domains comprising MSK-HQ in both axSpA and RA (Figure 1C).Conclusion:We have shown that diagnostic delay remains a major challenge in axSpA, despite improved disease understanding and updated referral guidelines. Patient education is an unmet need in axSpA, highlighting the need for specialist clinics. MSK-HQ scores demonstrated that the functional impact of axSpA is no less than for RA, whereas HAQ-DI may underrepresent disability in axSpA.References:[1]Yi E, Ahuja A, Rajput T, George AT, Park Y. Clinical, economic, and humanistic burden associated with delayed diagnosis of axial spondyloarthritis: a systematic review. Rheumatol Ther. 2020;7:65-87.[2]NICE. Spondyloarthritis in over 16s: diagnosis and management. 2017.[3]van der Heijde D, Ramiro S, Landewe R, et al. 2016 update of the ASAS-EULAR management recommendations for axial spondyloarthritis. Ann Rheum Dis. 2017;76(6):978-91.[4]British Society for Rheumatology. National Early Inflammatory Arthritis Audit (NEIAA) Second Annual Report. 2021.Acknowledgements:The National Early Inflammatory Arthritis Audit is commissioned by the Healthcare Quality Improvement Partnership, funded by NHS England and Improvement, and the Welsh Government, and carried out by the British Society for Rheumatology, King’s College London and Net Solving.Disclosure of Interests:Mark Russell Grant/research support from: UCB, Pfizer, Fiona Coath: None declared, Mark Yates Grant/research support from: UCB, Abbvie, Katie Bechman: None declared, Sam Norton: None declared, James Galloway Grant/research support from: Abbvie, Celgene, Chugai, Gilead, Janssen, Lilly, Pfizer, Roche, UCB, Jo Ledingham: None declared, Raj Sengupta Grant/research support from: AbbVie, Biogen, Celgene, Lilly, MSD, Novartis, Pfizer, Roche, UCB, Karl Gaffney Grant/research support from: AbbVie, Biogen, Cellgene, Celltrion, Janssen, Lilly, Novartis, Pfizer, Roche, UCB.

The prospects for pluralism in contract theory

Legal Studies ◽  
2021 ◽  
pp. 1-20
Author(s):  
Zhong Xing Tan
Keyword(s):  
Contract Theory ◽  
Practical Reasoning ◽  
Contemporary Literature ◽  
Contract Law ◽  
Macro Level ◽  
Meso Level ◽  
Specific Performance ◽  
Micro Level

Abstract This paper explores the promise of pluralism in the realm of contract law. I begin by identifying and rejecting conceptual strategies adopted by monistic and dualistic approaches. Turning towards pluralism, I evaluate three versions in contemporary literature: pluralism across contracting spheres and types, pluralism through consensus and convergence, and pluralism through localised values-balancing and practical reasoning. I suggest embracing some pluralism about contract pluralism, by using these models to construct a framework of ‘meta-pluralism’, where at the macro-level, we are concerned with plural spheres of contracting activity; at the meso-level, a variety of trans-substantive interpretive concepts that receive some measure of juristic consensus; and at the micro-level, practical reasoning through particularistic analysis of case-specific considerations. I illustrate the meta-pluralistic framework through a case study on the varieties of specific performance, and explain how the proposed pluralistic framework enriches our understanding of the nature of contract.

The Meaning of Property in Things

2020 ◽  
pp. 3-21
Author(s):  
Bart J. Wilson
Keyword(s):  
Property Rights ◽  
Homo Sapiens ◽  
Physical World ◽  
Macro Level ◽  
Human Society ◽  
Ordinary People ◽  
Social Scientists ◽  
Meso Level ◽  
Micro Level ◽  
Central Claim

The central claim of the book is that property is a universal and uniquely human custom. Contra cultural relativists, every human society has property tools, utensils, and ornaments. Contra biologists, only Homo sapiens has property in things other than food, mates, and territories. Contra philosophers and legal scholars, the bedrock of property is custom, not rights. Contra social scientists and ordinary people, property is indeed a custom and not something that must be instituted by government. Property operates at the three levels. At the micro-level core of property is an organism that perceives the physical world through its body. The meso-level of property is the community within which the organism resides. At the macro-level of property are the institutions that unite strangers of different communities through the modern democratic concept of rights. Whereas the custom of property is ancient, moral, and universal to all people, property rights are modern, amoral, and majoritarian.

Value co-creation through actor embeddedness and actor engagement

2019 ◽  
Vol 37 (3) ◽  
pp. 271-283 ◽  
Author(s):  
Anees Wajid ◽  
Muhammad Mustafa Raziq ◽  
Omer Farooq Malik ◽  
Shahab Alam Malik ◽  
Nabila Khurshid
Keyword(s):  
Design Methodology ◽  
Conceptual Models ◽  
Perceived Value ◽  
Marketing Research ◽  
Macro Level ◽  
Content Type ◽  
Creation Process ◽  
Meso Level ◽  
Micro Level ◽  
Service Ecosystem

Purpose It is argued that the service-dominant (S-D) view of the value co-creation concept is mainly of a macro nature and is difficult to examine empirically. In this regard, marketing research using the micro-foundation theory proposes some conceptual models, through which relationships (involving value co-creation) at a micro/meso level may be studied. The purpose of this paper is to add to such exchanges regarding value co-creation and conceptualize the link of embeddedness of an actor (in a service-ecosystem) to their engagement in the value co-creation process. Design/methodology/approach The authors draw on the S-D logic and the value co-creation concept and make propositions with regard to two micro-foundational concepts: actor engagement and actor embeddedness. Findings The authors show that actor embeddedness can be considered as an antecedent of actor engagement, which leads to value co-creation at a macro level and perceived value in context at the micro level. Originality/value The authors fill some gaps in literature with regard to S-D logic and value co-creation by combining two micro-foundational concepts: actor engagement and actor embeddedness and propose how through these, some macro-level outcomes such as value co-creation and resource integration may be determined.

Meeting the Challenges in Evaluating Mobile Learning

2011 ◽  
pp. 178-194 ◽  
Author(s):  
Giasemi Vavoula ◽  
Mike Sharples
Keyword(s):  
Mobile Learning ◽  
Mobile Technology ◽  
Cultural Context ◽  
Learning Experience ◽  
Learning Processes ◽  
Macro Level ◽  
Learning In Context ◽  
Meso Level ◽  
Micro Level ◽  
Context Of Learning

We propose six challenges in evaluating mobile learning: capturing and analysing learning in context and across contexts, measuring mobile learning processes and outcomes, respecting learner/participant privacy, assessing mobile technology utility and usability, considering the wider organisational and socio-cultural context of learning, and assessing in/formality. A three-level framework for evaluating mobile learning is proposed, comprising a micro level concerned with usability, a meso level concerned with the learning experience, and a macro level concerned with integration within existing educational and organisational contexts. The article concludes with a discussion of how the framework meets the evaluation challenges and with suggestions for further extensions.

Englishization of Croatian higher education

2021 ◽  
Author(s):  
Branka Drljača Margić
Keyword(s):  
Higher Education ◽  
Macro Level ◽  
Quality Of Education ◽  
Perceived Benefits ◽  
The Status ◽  
English Medium Instruction ◽  
Micro Level ◽  
The University

The perceived benefits of English-medium instruction (EMI), such as greater competitiveness of universities, are the reasons why meso- and macro-level stakeholders in Croatian higher education (HE) seek to implement it. Nevertheless, the overall adoption of EMI has been rather slow, resulting in only 3% of study programmes in English. Such a small number has sparked no public or scholarly resistance to this aspect of Englishization. On the micro level, however, the introduction of EMI has provoked a range of different reactions, from favourable attitudes to concerns over the quality of education and the status of Croatian in academia. Evidence for these views were gleaned from the studies conducted at the University of Rijeka, Croatia.

Structural Sexism and Health in the United States: A New Perspective on Health Inequality and the Gender System

2019 ◽  
Vol 84 (3) ◽  
pp. 486-516 ◽  
Author(s):  
Patricia Homan
Keyword(s):  
Health Outcomes ◽  
Physical Health ◽  
Gender Inequality ◽  
Health Inequality ◽  
State Level ◽  
The United States ◽  
Macro Level ◽  
Future Research ◽  
Meso Level ◽  
Micro Level

In this article, I build a new line of health inequality research that parallels the emerging structural racism literature. I develop theory and measurement for the concept of structural sexism and examine its relationship to health outcomes. Consistent with contemporary theories of gender as a multilevel social system, I conceptualize and measure structural sexism as systematic gender inequality at the macro level (U.S. state), meso level (marital dyad), and micro level (individual). I use U.S. state-level administrative data linked to geocoded data from the NLSY79, as well as measures of inter-spousal inequality and individual views on women’s roles as predictors of physical health outcomes in random-effects models for men and women. Results show that among women, exposure to more sexism at the macro and meso levels is associated with more chronic conditions, worse self-rated health, and worse physical functioning. Among men, macro-level structural sexism is also associated with worse health. However, greater meso-level structural sexism is associated with better health among men. At the micro level, internalized sexism is not related to physical health among either women or men. I close by outlining how future research on gender inequality and health can be furthered using a structural sexism perspective.

Bridging Levels of Public Administration: How Macro Shapes Meso and Micro

2019 ◽  
Vol 52 (4) ◽  
pp. 631-656 ◽  
Author(s):  
Alasdair Roberts
Keyword(s):  
Public Administration ◽  
American History ◽  
The State ◽  
Macro Level ◽  
Levels Of Analysis ◽  
Meso Level ◽  
State Institutions ◽  
Micro Level ◽  
The Relationship

Scholars in public administration now recognize three levels of analysis: macro, meso, and micro. But there is uncertainty about the relationship between levels and concern about a “schism” in research. However, linkages between levels can be demonstrated easily. At the macro-level, leaders develop an overall strategy for pursuing national priorities, which determines the broad architecture of the state. Institutions must be built, renovated, or managed to give effect to these strategies: This is the meso-level of public administration. Overall, strategies also shape the micro-level relationship between people who rule and people who are ruled. This is done by categorizing people—as subjects or citizens, for example—and by redefining categories. Macro-level strategies evolve, with consequences for the agenda at the meso- and micro-levels. Experience at lower levels also shapes strategy at the macro-level. The interaction among levels is illustrated by comparison of three eras in modern American history.

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