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Questions and concerns involving creatine supplementation and kidney damage/renal dysfunction are common. In terms of pervasive misinformation in the sport nutrition arena, the notion that creatine supplementation leads to kidney damage/renal dysfunction is perhaps second only to the myth that protein supplementation and high habitual protein intake causes kidney damage. Today, after > 20 years of research which demonstrates no adverse effects from recommended dosages of creatine supplements on kidney health, unfortunately, this concern persists. While the origin is unknown, the connection between creatine supplementation and kidney damage/renal dysfunction could be traced back to two things: a poor understanding of creatine and creatinine metabolism and a case study published in 1998.
The study discovered, in each healthcare arena investigated, a crowded HRH space with a wide range of public, private, formal and informal providers of varying levels of competence and a diverse richness of initiatives, shaped by the easy commodification of health and an unregulated market. The weak regulatory framework and capacity to regulate, combined with limited information regarding those not on the state payroll, allowed non-state providers to flourish, if not materially then at least numerically.
The disconnection between modest service needs (constrained by financial factors) and vigorous supply of health professionals was recognisable in all settings. Despite the underlying uncertainties about the true size of each workforce, time series pointed unambiguously towards a sustained growth, particularly in relation to the DR Congo and the Occupied Palestinian Territories, both endowed with large health training capacity. This trend has been recognised also in other healthcare arenas, such as in Angola [26]. Counter-intuitively, an expanding workforce looks like a recurring feature of the diminished state, which relinquishes its grip on supply, employment and professional practice. The profit prospects of healthcare activities, within a suffering domestic economy, attract both workers and entrepreneurs.
In the six healthcare arenas examined, professional associations were found to exist to differing degrees, sometimes if only to demand a tax from new entrants to the market but rarely, if ever, to provide professional support.
Strengthening the role of any putative state to take on its enabling role and establish governance mechanisms will be a protracted, incremental exercise, one likely to take decades to reach a basic level of functioning [46-49], with no guarantee that it will happen [11]. In each of the case studies, the fragility of governance structures is not new; rather, it is chronic and stubborn to international interventions. Even if a state-based governance structure registers progress, it will relate only to a modest portion of the healthcare market. And publicly employed health workers will remain subject to market pressures determined outside the public sphere. Thus, a focus on building the capacity of the state on its own is unlikely to result in tangible improvements. Our analysis suggests that conceptualising the HRH arena at the national level and focussing on the public health sector is, to an extent, misleading and provides a parody of reality. A more useful conceptualisation may be to look at local healthcare provision arrangements in their diversity including formal and informal as well as private and public elements [50]. This would provide a more holistic understanding of the HRH resources available to enhance the quality of health care and enable a piecing together of a system from the reality of what is, rather than on the illusion of what is not, drawn from a focus on idealised patterns [5,38,40,50-52]. This more comprehensive analysis of HRH will allow for the development of strategies to support and develop existing resources, promoting adaptive responses to existing dynamics [5].
The challenge, then, for the international community is to find ways to effectively engage with the system as a whole [53], essentially looking afresh at the healthcare arena and searching out all actors, working out new ways to engage with them. In other words, it means recognising the state as merely one actor and finding ways to at first recognise and then encompass all others. It means that donors and international organisations need to learn to work in different ways and extend their analysis beyond the notion of a state-led health system, accepting that in fragile and conflict-affected environments the healthcare space is fuzzy, fluid and fragmented. It also means accepting risk as an intrinsic part of change which provides opportunity for learning and adaptation. To minimise risk, interventions need to be incremental, combining strategic intent and structured intervention, while at the same time building in flexibility for adaptation to take into account emergence and complexity [54]. Such an approach will also require a highly flexible financing system that can support local providers and essential service delivery in the immediate term while building capacity in the longer term [42].
To conclude, our research highlights the need to recognise that public health authorities are only one of many actors in the health field and that reversal of fragility is a long-term commitment and demands a form of engagement which deliberately aims to harness the strengths of the diverse actors that provide health services. It requires a shift from a reductionist, predictable and linear view of health systems to one which acknowledges the complex character of health care in severely distressed environments. Crucially, improving HRH in fragile and conflict-affected areas requires researchers and policy makers to embrace the inclusive WHO definition of the health system. As compelling and easy as it is to focus on the public sector, this provides a caricature of reality. A more holistic scrutiny of the sections composing the healthcare arena and of their interactions will provide a more coherent understanding of the HRH dynamics in fragile and conflict-affected states. Importantly, it will allow identification of windows of opportunity for novel and experimental interventions. The approach will not be risk-free and demands tolerance for ambiguity and uncertainty around the likely effectiveness of interventions. The dividends will be realised, however, through the harnessing of the HRH active on the ground and the practices they adopt to survive. Meaningful interventions oriented to public goods must cover the whole market and not only its formal public arm. The next research agenda should aim at exploring the complex and dynamic structures of supply and demand in the HRH market in under-governed healthcare arenas, in order to identify existing or emergent systems of governance and to work with them to improve population health outcomes.
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Stewardship is a neglected function in most health systems [18]. Murray & Frenck (2000) have described health system stewardship as involving three key aspects "setting, implementing and monitoring the rules for the health system; assuring a level playing field for all actors in the system; and defining strategic directors for the health system as a whole". Currently there is no one metric to measure health stewardship at the national level, we used the Corruption Index as a measure of national governance and a proxy for health system stewardship because the general functioning of the government can strongly influence stewardship and regulation. Corruption is broadly defined by Transparency International as the misuse of public office for private gain [19]. As a result, our findings are limited to corruption within the public sphere although we do acknowledge that corruption is present in the private and non-governmental arena. In our study we have found that the more corrupt a government is perceived to be (i.e. lower CPI score) the stronger the association with increased rates of infant, child and maternal mortality.
Body appreciation might serve as a protective factor for developing eating disorders and is associated with participation in physical activity. Less is known about whether various arenas for physical activity may be linked to body appreciation. Therefore, the current study sought to (1) identify potential associations between physical activity level and arenas for physical activity, connectedness with nature, self-compassion, and body appreciation in adults, and (2) explore physical activity level and arenas, connectedness with nature, and self-compassion as explanatory factors for body appreciation.
The percentage of participants who engaged in various physical activity arenas were 98.5% for nature, 57.5% for fitness centers, and 43.0% for organized sports. Small, positive associations were found between body appreciation and the frequency of using fitness centers and nature as physical activity arenas. Self-compassion, connectedness with nature, and frequency of using fitness centers and nature as physical activity arenas explained 39% of the variance in body appreciation.
The importance of both fitness centers and nature as arenas for physical activity to explain body appreciation was surprising and might reflect different use of fitness centers among adults compared to younger age groups.
Physical activity at fitness centers and in nature were positively associated with body appreciation in adults. Self-compassion, connectedness with nature, and using fitness centers and nature as arenas for physical activity, were found to explain variation in body appreciation in adults.
Physical activity helps us feel good about ourselves and appreciate our bodies. However, less is known about the extent to which different arenas for physical activity are related to body appreciation. Therefore, 360 adults from Norway completed a survey with questions about their physical activity level, use of nature, fitness centers, and organized sports as arenas for physical activity, and measures linked to connectedness with nature, self-compassion, and body appreciation. We found an association between body appreciation and performing physical activity at fitness centers and in nature. Physical activity at these two arenas together with self-compassion and connectedness with nature explained body appreciation in these adults. Future studies should focus on the adolescent population, where the level of body appreciation tend to be lower and where organized sports, in addition to fitness centers, constitute an even more commonly used physical activity arena. 2b1af7f3a8