Search

BackgroundEconomic compensation interventions may help support higher voluntary medical male circumcision (VMMC) coverage in priority sub-Saharan African countries. To inform World Health Organization guidelines, we conducted a systematic review of economic compensation interventions to increase VMMC uptake.MethodsEconomic compensation interventions were defined as providing money or in-kind compensation, reimbursement for associated costs (e.g. travel, lost wages), or lottery entry. We searched five electronic databases and four scientific conferences for studies examining the impact of such interventions on VMMC uptake, HIV testing and safer-sex/risk-reduction counseling uptake within VMMC, community expectations about compensation, and potential coercion. We screened citations, extracted data, and assessed risk of bias in duplicate. We conducted random-effects meta-analysis. We also reviewed studies examining acceptability, values/preferences, costs, and feasibility.ResultsOf 2484 citations identified, five randomized controlled trials (RCTs) and three non-randomized controlled trials met our eligibility criteria. Studies took place in Kenya, Malawi, South Africa, Tanzania, Uganda, Zambia, and Zimbabwe. Meta-analysis of four RCTs showed significant impact of any economic compensation on VMMC uptake (relative risk: 5.23, 95% CI: 3.13 to 8.76). RCTs of food/transport vouchers and conditional cash transfers generally showed increases in VMMC uptake, but lotteries, subsidized VMMC, and receiving a gift appeared somewhat less effective. Three non-randomized trials showed mixed impact. Six additional studies suggested economic compensation interventions were generally acceptable, valued for addressing key barriers, and motivating to men. However, some participants felt they were insufficiently motivating or necessary; one study suggested they might raise community suspicions. One study from South Africa found a program cost of US$91 per additional circumcision and US$450-$1350 per HIV infection averted.ConclusionsEconomic compensation interventions, particularly transport/food vouchers, positively impacted VMMC uptake among adult men and were generally acceptable to potential clients. Carefully selected economic interventions may be a useful targeted strategy to enhance VMMC coverage.

BackgroundVoluntary medical male circumcision (VMMC) remains an essential component of combination HIV prevention services, particularly in priority countries in sub-Saharan Africa. As VMMC programs seek to maximize impact and efficiency, and to support World Health Organization guidance, specific uptake-enhancing strategies are critical to identify.MethodsWe systematically reviewed the literature to evaluate the impact of service delivery interventions (e.g., facility layout, service co-location, mobile outreach) on VMMC uptake among adolescent and adult men. For the main effectiveness review, we searched for publications or conference abstracts that measured VMMC uptake or uptake of HIV testing or risk reduction counselling within VMMC services. We synthesized data by coding categories and outcomes. We also reviewed studies assessing acceptability, values/preferences, costs, and feasibility.ResultsFour randomized controlled trials and five observational studies were included in the effectiveness review. Studies took place in South Africa, Tanzania, Uganda, Zambia, and Zimbabwe. They assessed a range of service delivery innovations, including community-, school-, and facility-based interventions. Overall, interventions increased VMMC uptake; some successfully improved uptake among age-specific subpopulations, but urban-rural stratification showed no clear trends. Interventions that increased adult men's uptake included mobile services (compared to static facilities), home-based testing with active referral follow-up, and facility-based HIV testing with enhanced comprehensive sexual education. Six acceptability studies suggested interventions were generally perceived to help men choose to get circumcised. Eleven cost studies suggested interventions create economies-of-scale and efficiencies. Three studies suggested such interventions were feasible, improving facility preparedness, service quality and quantity, and efficiencies.ConclusionsInnovative changes in male-centered VMMC services can improve adult men's and adolescent boys' VMMC uptake. Limited evidence on interventions that enhance access and acceptability show promising results, but evidence gaps persist due to inconsistent intervention definition and delivery, due in part to contextual relevance and limited age disaggregation.

The term 'Aboriginal' in this text has been used when referring to Aboriginal peoples living on the Anangu Pitjantjatjara Yankunytjatjara (APY) Lands. The term 'Aboriginal and Torres Strait Islander' has been used when referring to the broader community. Background: This project investigated how cultural immersion in remote Aboriginal communities influenced medical students' career intentions. Methodology: An academic GP registrar (AB) interviewed 15 medical students who participated in the Adelaide Medical Students' Society Anangu Pitjantjatjara Yankunytjatjara (APY) Exchange. This program was coordinated by medical student volunteers in collaboration with the Ngaanyatjarra Pitjantjatjara Yankunytjatjara Women's Council (NPYWC). The following questions were specifically addressed: 'How does being a guest in a remote Aboriginal community influence medical students' attitudes towards Aboriginal and Torres Strait Islander health care?' and 'Does exposure to Aboriginal communities increase medical students' willingness to pursue careers in Aboriginal and Torres Strait Islander health, rural and remote medicine and/or general practice?'. Results: Interest in Aboriginal and Torres Strait Islander health care increased from 73% of participants pre-trip to 100% post-trip, in rural and remote medicine from 40% to 100%, and in general practice from 33% to 67%. The experience also challenged pre-conceptions and increased understanding of the bio-psycho-socio-spiritual aspects of Aboriginal health. Conclusion: Being a guest in remote Aboriginal communities enhanced students' personal and professional motivation to work in Aboriginal and Torres Strait Islander health, remote health and general practice. There is limited evidence regarding the most effective ways to engage medical students in rural and remote health care, particularly in settings with a large Aboriginal and Torres Strait Islander population. This project found that immersion trips positively influenced career intentions of medical students towards working in Aboriginal and Torres Strait Islander health care, rural and remote health and general practice. The findings suggest that investment in such experiences could significantly change workforce engagement in these under-resourced areas of health care. [ABSTRACT FROM AUTHOR]

HIV testing has been promoted as a key HIV prevention strategy in low-resource settings, despite studies showing variable impact on risk behavior. We sought to examine rates of HIV testing and the association between testing and sexual risk behaviors in Kisumu, Kenya. Participants were interviewed about HIV testing and sexual risk behaviors. They then underwent HIV serologic testing. We found that 47% of women and 36% of men reported prior testing. Two-thirds of participants who tested HIV-positive in this study reported no prior HIV test. Women who had undergone recent testing were less likely to report high-risk behaviors than women who had never been tested; this was not seen among men. Although rates of HIV testing were higher than seen in previous studies, the majority of HIV-infected people were unaware of their status. Efforts should be made to increase HIV testing among this population.

This article demonstrates the explanatory power of an expanded policy stream, as part of Kingdon's Multiple Streams Framework. Product substitutes, corporate social responsibility, the global economy, and the market maverick rationalize the incentives under which regulators, consumers, businesses, and environmental NGOs interact to explain the formation of two landmark voluntary programs on mercury and arsenic use, respectively. Arsenic and mercury are ranked first and third, respectively, on the US Environmental Protection Agency's priority list of hazardous substances. In both cases, the existence of a product substitute that performed on par with the original product but generated less negative environmental impact motivated the private sector to go beyond compliance in their environmental management. Notwithstanding, the push and pull of variables in the problem, politics, and policy streams, and the interplay of diverse actors led to the emergence of diverse forms of voluntary programs. In the mercury case, an industry association steered the technocratic process of the chlor-alkali industry's voluntary stewardship program, which led to marginal reductions in toxic chemical use, as part of the global phase-out of mercury already under way. By contrast, in the arsenic case, an environmental activist campaign successfully compelled the pressure-treated wood industry to concede to a voluntary cancelation of chromated copper arsenate, an arsenic compound, in residential uses. Subsequently, arsenic use fell to levels not seen since the 1920s. In both cases, strong coalition building—the former by businesses and the latter by environmental NGOs—combined with a fragmented or nonexistent opposing side shaped the final form of each voluntary program. [ABSTRACT FROM AUTHOR]

Voluntary environmental programs have the potential to impact not only participants but also nonparticipants, through, for example, the dissemination of information about abatement technologies, thereby creating spillover effects. Standard program evaluation techniques do not accurately estimate program impacts in such cases. This paper presents a theoretical and empirical analysis of spillovers in a voluntary environmental program (VEP). The theoretical model identifies the key distinction between the impact of participation and the impact of the program, as well as the nature of the bias that results from failure to incorporate spillover effects. It also motivates the inclusion of spillovers in both the participation and outcome equations of the empirical model. Using data from EPA's 33/50 Program, we show that failure to account for spillovers can lead to significant underestimation of program impacts. [ABSTRACT FROM AUTHOR]

BackgroundThe Botswana government recently implemented a policy of routine or "opt-out" HIV testing in response to the high prevalence of HIV infection, estimated at 37% of adults.Methods and findingsWe conducted a cross-sectional, population-based study of 1,268 adults from five districts in Botswana to assess knowledge of and attitudes toward routine testing, correlates of HIV testing, and barriers and facilitators to testing, 11 months after the introduction of this policy. Most participants (81%) reported being extremely or very much in favor of routine testing. The majority believed that this policy would decrease barriers to testing (89%), HIV-related stigma (60%), and violence toward women (55%), and would increase access to antiretroviral treatment (93%). At the same time, 43% of participants believed that routine testing would lead people to avoid going to the doctor for fear of testing, and 14% believed that this policy could increase gender-based violence related to testing. The prevalence of self-reported HIV testing was 48%. Adjusted correlates of testing included female gender (AOR = 1.5, 95% CI = 1.1-1.9), higher education (AOR = 2.0, 95% CI = 1.5-2.7), more frequent healthcare visits (AOR = 1.9, 95% CI = 1.3-2.7), perceived access to HIV testing (AOR = 1.6, 95% CI = 1.1-2.5), and inconsistent condom use (AOR = 1.6, 95% CI = 1.2-2.1). Individuals with stigmatizing attitudes toward people living with HIV and AIDS were less likely to have been tested for HIV/AIDS (AOR = 0.7, 95% CI = 0.5-0.9) or to have heard of routine testing (AOR = 0.59, 95% CI = 0.45-0.76). While experiences with voluntary and routine testing overall were positive, 68% felt that they could not refuse the HIV test. Key barriers to testing included fear of learning one's status (49%), lack of perceived HIV risk (43%), and fear of having to change sexual practices with a positive HIV test (33%).ConclusionsRoutine testing appears to be widely supported and may reduce barriers to testing in Botswana. As routine testing is adopted elsewhere, measures should be implemented to assure true informed consent and human rights safeguards, including protection from HIV-related discrimination and protection of women against partner violence related to testing.

In this paper, I conduct one of the first evaluations of a voluntary management program that features an independent verification mechanism to determine whether it is achieving its ultimate objectives. Using a sample of thousands of manufacturing facilities across the United States, I find evidence that the ISO 14001 Environmental Management System Standard has attracted companies with superior environmental performance, and that adoption leads to further performance improvement. This contrasts sharply with findings from prior evaluations of voluntary management programs that lacked verification mechanisms. This suggests that independent verification mechanisms such as certification may be necessary for voluntary management programs to mitigate information asymmetries surrounding difficult-to-observe management practices. Implications are discussed for the industry-associations, government agencies, and the non-governmental organizations that design these programs, the companies that are investing resources to adopt these programs, and those that are relying on them as a credible signal of superior management practices. The substantial variation in magnitude and significance of the results across comparison groups and performance metrics highlights the need for researchers to conduct robustness tests when evaluating voluntary management programs.

Objective: Intimate partner violence (IPV) affects 1 in 4 American women, and physical child abuse is reported to occur in 10-67 % of homes with IPV. Routine evaluation of physical abuse in IPV-exposed children is neither widespread nor informed by clinical guidelines. Thus, the true frequency of detectable injuries in IPV-exposed children remains unknown. The purpose of this study was to examine the frequency of injuries in children <3-years-old reported for IPV to a regional child protective services (CPS) office., Methods: In this prospective observational study, we reviewed encounters of children whose caregivers agreed to an evaluation for injuries (physical exam and imaging, if indicated) from July 2019-June 2022. Children were included if: 1) a CPS investigator referred a child for evaluation for injuries ("non-acute" evaluation) or 2) a child presented immediately after an IPV incident ("acute" evaluation)., Results: Of 326 children <3-years-old reported to the CPS office after IPV exposure, 90 (27.6 %) were evaluated: 81(90 %) presented for a non-acute evaluation, and 21(23 %) were reported to have sustained trauma during the IPV event. Of the 90 children evaluated, 3 (3.3 %, 95 % CI 0.7-9.4) were found to have cutaneous injuries, fractures, and/or intracranial findings. Each was <6-months old and had an "acute" evaluation., Conclusion: In this study of children reported to CPS for IPV exposure, a small percentage was found to have injuries. A multi-center study that examines the frequency of and factors that increase the risk of abusive injuries in IPV-exposed children may ensure that testing targets children at highest risk., Competing Interests: Declaration of competing interest Andrea G. Asnes reports that the Department of Pediatrics receives payment for her expert testimony in child abuse cases and that she receives grants from the State of Connecticut to support the Yale Child Abuse Programs. John M. Leventhal reports that the Yale Department of Pediatrics receives payment for his case review and expert testimony in child abuse cases., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Background: Surgical voluntary medical male circumcision (VMMC) is a safe procedure; however, maintaining quality standards at scale, particularly during scale-up, is a challenge making ongoing quality management (QM) efforts essential. This study describes program quality measured by rates of adverse events (AEs) over four years of VMMC implementation in Namibia, compares AE rates over time, and discusses QM processes that contextualize AE trends and illustrate improvements in quality as the program matured. The International Training and Education Center for Health (I-TECH) assisted the Namibian Ministry of Health and Social Services (MoHSS) in expanding VMMC in three regions among boys and men over 10 years of age between January 2015 and September 2019., Methods: A comprehensive package of QM strategies was implemented by multi-disciplinary onsite teams with support from national and international technical advisors. Retrospective routine MoHSS data from the VMMC register, client forms, and monthly AE reports were collected during implementation in the three regions to assess the impact of QM interventions on AEs and to calculate the proportion of clients who experienced AEs over time. The proportion of clients who experienced an AE over time was compared using a Cochran-Armitage test for trend., Results: Between January 2015 and September 2019, 40,336 clients underwent VMMC and 593 (1.5%) clients experienced a post-operative AE in the three supported regions. The AE rate was highest in the first quarter of clinical service delivery in each region (January-March 2015 in Oshana and Zambezi, October-December 2017 in //Kharas) but declined over the implementation period as the program matured. This observed trend between program maturity and declining AE rates over time was significant (p < 0.001) when compared using a Cochran-Armitage test for trend., Conclusions: As the I-TECH-supported VMMC program matured, QM measures were introduced and routinized, and clinical quality improved over time with the rate of AEs decreasing significantly over the implementation period. Applying systematic and continuous QM processes and approaches across the continuum of VMMC services and considering local context can contribute to increased clinical safety. QM measures that are established in more mature program sites can be quickly adopted to respond to quality issues in program expansion sites., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Voluntary medical male circumcision (VMMC) is an HIV prevention intervention that has predominantly targeted adolescent and young men, aged 10-24 years. In 2020, the age eligibility for VMMC shifted from 10 to 15 years of age. This report describes the VMMC client age distribution from 2018 to 2021, at the site, national, and regional levels, among 15 countries in southern and eastern Africa. Overall, in 2018 and 2019, the highest proportion of VMMCs were performed among 10-14-year-olds (45.6% and 41.2%, respectively). In 2020 and 2021, the 15-19-year age group accounted for the highest proportion (37.2% and 50.4%, respectively) of VMMCs performed across all age groups. Similarly, in 2021 at the site level, 68.1% of VMMC sites conducted the majority of circumcisions among men aged 15-24 years. This analysis highlights that adolescent boys and young men are the primary recipients of VMMC receiving an important lifetime reduction in HIV risk.

As the primary means for growth and development over the past two centuries, industry has played a central role in generating our current Anthropocene. The increasing impacts of climate change bring industry to the fore as the largest emitter of greenhouse gases and as a potential manufacturer of transformational technologies and infrastructure. While energy efficiency improvements are driving industrial sector emissions and cost reductions, additional switching away from fossil fuels and capture of carbon emissions is needed for climate stabilization. [ABSTRACT FROM AUTHOR]

This article examines the motivations for firms in India to participate in voluntary environmental programs (VEPs) using a unique data set of cement, power and steel industry for the year 2012. It examines the effects of regulatory, societal, market and internal factors in influencing voluntary environmental behavior. To this objective we estimate both, ordinal (Ordered Probit) and cardinal (Poisson) models. We find that the firm size, its location, export orientation, and intangible valuation have a positive and significant relationship with the number of VEPs undertaken by the firm. The MNC status of the firm has no impact while the debt equity ratio and average age of the firm has negative impact on the adoption of VEPs. [ABSTRACT FROM AUTHOR]

The traditional model of taking single actions when components reach their end of life or provide inadequate service has enabled the residential sector to gradually improve its energy efficiency over time. However, to achieve the large potential reductions in energy consumption and greenhouse gas emissions in residential buildings, a deeper systematic approach is required. The house as a system approach to energy retrofits emphasizes that for the greatest improvements in energy performance, multiple retrofit actions must be taken, and the order is important. This was the core concept in the Canadian residential energy efficiency programs, EnerGuide for Houses (1998-2006) and ecoEnergy (2007-2012). In this study, a systematic analysis of a large dataset that documents 19,552 residential energy evaluations conducted by a single agency in Waterloo, Canada, allows for a more nuanced description of how well the energy retrofit actions taken by participants followed the house as a system approach. The findings are encouraging in that participants did respond to the multiple recommendations given to them by energy advisors. In particular, a higher number of recommendations were associated with households arranging follow-up evaluations and taking more action under the performance-based grant program. However, the results also illustrate that participants frequently did not attend to the retrofits in the combinations associated with the house as a system approach. Insulation to reduce heat losses should have been the first priority in the systemic approach, but was often not upgraded, and the extent or depth of the upgrade was often less than what had been recommended. Furnaces and windows, which should have been upgraded in combination with or after the building envelope, were often upgraded as singular actions, demonstrating the persistence of the traditional model in some households. Time-limited grants do not appear compatible with encouraging the house as a system approach; it appears that staged approaches and careful attention to the building envelope retrofits would allow these programs to promote the house as a system approach to encourage deep retrofits and achieve low-carbon housing. [ABSTRACT FROM AUTHOR]

How does strength of domestic NGOs influence participation in the Covenants of Mayors program? Launched by the European Commission in 2008, this program invites local and regional authorities to voluntarily commit to implementing EU climate change and energy policies. We focus on the transitional countries of Eastern Europe and Eurasia to examine whether the strength of their domestic NGOs correlates with cities’ decisions to participate in this transnational program. To operationalize NGO strength, we suggest thinking of it as a stock variable that cumulates over time, instead of a single-year, flow variable. With country year as the unit of analysis, we examine the percentage of urban population covered by the Covenant across a panel of 26 transitional economies for the period 2008–2014. We find that the key variable of interest, cumulative NGO strength, is a statistically significant predictor of program participation, even after controlling for domestic and international factors, including the salience of international NGOs and the years since the country began the formal process to join the European Union. [ABSTRACT FROM PUBLISHER]

This article focuses on the Global 500, which are the world’s largest companies by revenue, to examine the factors and dynamics internal to companies that motivate some corporations, but not others, to engage in transnational climate governance. Empirical results based on multilevel mixed-effects analyses, which separately identify the relative weight of firm and country-level factors, suggest that the likelihood that a firm participates in transnational climate governance (TCG) is higher when there exists a “policy supporter” who champions sustainability policies and when a company adopts explicit sustainability practices, such as the incorporation of ESG (Environmental, Social and Governance) principles. Voluntary climate action and carbon disclosure are more likely to take place when a company has a large asset base and certifies with the ISO 14001 environmental management standard. Moreover, the level of civil liberties that corporations enjoy in their respective country of origin is associated with participation in TCG. A decomposition of the variance indicates that firm-level factors account for a majority of the variance in TCG participation. This study has implications for climate change governance and policies, which have increasingly focused on concrete climate solutions and innovations by nonstate and substate actors. [ABSTRACT FROM PUBLISHER]

Ideally, the benefits of public health interventions should outweigh any associated harms, burdens, and adverse unintended consequences. The intended benefit of voluntary medical male circumcision (VMMC) programs in eastern and southern Africa (ESA) is the reduction of HIV infections. We review the literature for evidence of reductions in HIV incidence, evaluate the extent to which decreases in HIV incidence can be reasonably attributed to VMMC programs, and summarize social harms and ethical concerns associated with these programs. Review findings suggest that HIV incidence had been declining across ESA since before the large-scale rollout of VMMC as a public health intervention, and that this decline may be due to the combined effects of HIV prevention and treatment interventions, such as expanded antiretroviral therapy. The independent effect of VMMC programs in reducing HIV infections at the population level remains unknown. On the other hand, VMMC-associated evidence is increasing for the existence of negative social impacts such as stigmatization and/or discrimination, and ethically problematic practices, including lack of informed consent. We conclude that the relationship between the benefits and burdens of VMMC programs may be more unfavorable than what has been commonly suggested by proponents of global VMMC campaigns., (© 2021. The Author(s), under exclusive licence to Springer Nature Limited.)

To explain why regulators continue to implement voluntary emission reduction programs (VP), this study presents a model with multiple polluting firms, a trade association, a regulator, and a legislator who sets a mandatory standard and is politically influenced by the trade association, a representative of the polluting firms. We show that the regulator can implement a voluntary program, which generates less social cost and more aggregate abatement than a mandatory standard. We also find that assigning the greatest importance to the abatement rates of individual firms generates the highest level of social welfare if the damage due to individual firms' emissions does not depend on other firms' emissions. However, the importance of the participation rate will increase relatively to the abatement rate as the damage due to individual firms' emissions becomes more sensitive to other firms' emissions. [ABSTRACT FROM AUTHOR]

O estudo acompanhou a rotina de um ensaio clínico de vacinas experimentais anti-HIV no Rio de Janeiro, Brasil, focalizando os processos de recrutamento, seleção e seguimento dos voluntários. Utilizaram-se técnicas de observação da rotina do centro de pesquisas e entrevistas a profissionais e voluntários. Os resultados evidenciaram que o ensaio é uma atividade coletiva, em que constantes negociações são necessárias entre o que é exigido pelo protocolo e o que precisa, pode ou deve ser adaptado para que ele funcione, em função de situações como: tempo prolongado de aprovação do estudo pelas instâncias regulatórias, dificuldades no recrutamento de voluntários, até problemas maiores como a descontinuidade das vacinações (ocorrida no protocolo estudado). Discute-se como a aplicação do protocolo transborda o script técnico-científico, transformando-se em um objeto fronteiriço entre mundos sociais diferentes. O protocolo é adaptado segundo uma ordem local, de acordo com a dinâmica das relações sociais, não podendo desconsiderar-se a constante inter-relação entre ciência, sociedade, técnica e política.This study monitored the protocol of a clinical trial for experimental anti-HIV vaccines in Rio de Janeiro, Brazil, focusing on the recruitment, selection, and follow-up of volunteers. The techniques included observation of the research center's routine and interviews with health professionals and volunteers. The results show that the trial is a collective activity, in which constant negotiations are needed between the protocol requirements and what can, should, or must be adapted in order for it to work, as a function of: prolonged time before the trial's approval by the regulatory bodies, difficulties in recruiting volunteers, and even larger problems like discontinuity in the vaccines (which occurred in a specific protocol). The article discusses how the protocol's application extends beyond the technical and scientific "script", transforming it into a boundary object between different social worlds. The protocol is adapted according to a local order, based on the dynamics of social relations and the constant interrelationship between science, society, technique, and politics.

In 2007, voluntary medical male circumcision (VMMC) was endorsed by the World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS after it was found to be associated with approximately a 60% reduction in the risk for female-to-male transmission of HIV (1). As a result of this endorsement, the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), through partnerships with U.S. government agencies, including CDC, the U.S. Department of Defense, and the U.S. Agency for International Development, started supporting VMMCs performed in prioritized countries in southern and eastern Africa. During 2010-2016, CDC supported 5,880,372 VMMCs in 12 countries (2,3). During 2017-2021, CDC supported 8,497,297 VMMCs performed in 13 countries. In 2020, the number of VMMCs performed declined 31.8% compared with the number in 2019, primarily because of COVID-19-related disruptions to VMMC service delivery. PEPFAR 2017-2021 Monitoring, Evaluation, and Reporting data were used to provide an update and describe CDC's contribution to the scale-up of the VMMC program, which is important to meeting the 2025 Joint United Nations Programme on HIV/AIDS (UNAIDS) target of 90% of males aged 15-59 years having access to VMMC services in prioritized countries to help end the AIDS epidemic by 2030 (4)., Competing Interests: All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.

Incident reporting systems are often used without a structured review process, limiting their utility to learn from defects and compromising their impact on improving the healthcare system. The objective of this study is to describe the experience of implementing a Comprehensive Management System (CMS) for incident reports in the ICU. A physician-led multidisciplinary Incident Report Committee was created to review, analyse and manage the department incident reports. New protocols, policies and procedures, and other patient safety interventions were developed as a result. Information was disseminated to staff through multiple avenues. We compared the pre- and post-intervention periods for the impact on the number of incident reports, level of harm, time needed to close reports and reporting individuals. A total of 1719 incidents were studied. ICUrelated incident reports increased from 20 to 36 incidents per 1000 patient days (P=0.01). After implementing the CMS, there was an increase in reporting 'no harm' from 14.2 to 28.1 incidents per 1000 patient days (P <0.001). There was a significant decrease in the time needed to close incident report after implementing the CMS (median of 70 days [Q1-Q3: 26-212] versus 13 days [Q1-Q3: 6-25, P<0.001]). A physician-led multidisciplinary CMS resulted in significant improvement in the output of the incident reporting system. This may be important to enhance the effectiveness of incident reporting systems in highlighting system defects, increasing learning opportunities and improving patient safety. [ABSTRACT FROM AUTHOR]

This analysis extends previous work on green insurance by proposing a mechanism that offers a stronger adoption incentive and is applicable to heterogeneous populations and non-binary adoption decisions. Endogenous learning about the new technology is incorporated, and empirically calibrated simulation results are presented for the case of reduced-phosphorus dairy diets. Results show that the mechanism has a significant impact on behavior and may incur no net cost for the regulator when an insurance premium is charged. Conditions under which a green payment mechanism may be preferable to green insurance also are discussed.