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The dissertation aims at developing means to integrate conservation and development in biosphere reserves in Madagascar. Despite a multitude of concepts such as UNESCO biosphere reserves, Integrated Conservation and Development Projects and community-based natural resource management, gaps between conservation and development remain to exist. In a qualitative case study in Mananara-Nord and Sahamalaza Iles-Radama Biosphere Reserves in Madagascar data was collected on biosphere reserve management, local use of natural resources and socio-cultural aspects that influence natural resource use. Furthermore, natural values local people associate with the forest were investigated. Analysis revealed that management capacities constitute a limiting factor in biosphere reserve management. Collaboration between management, local people and international organisations fosters the achievement of both conservation and development. However, collaboration is only possible if (i) clear rules are formulated and (ii) partners have a vision in common. Based on the theory of social capital, newly introduced and locally existent rules/institutions having an influence on the use of natural resource were categorized in bonding, linking and bridging social capital. Furthermore, the perception of natural values was classified in instrumental and non-instrumental values and assigned to ecosystem services identifying the importance of nature for human well-being. With the capabilities approach Amartya Sen defined human well-being as the achievement of those capabilities a person considers valuable. This includes aspects that assure livelihoods on the one hand and aspects that are conducive to well-being on the other, thus both being relevant for development. In the dissertation capabilities are based on both instrumental and non-instrumental natural values and consequently offer an opportunity to demonstrate and characterise the relationship between nature and human well-being. Social and natural values provide orientation for a biosphere reserve management. The category bonding social capital (social values) describes local socio-cultural aspects in communities and their importance for collaborative processes. Natural values provide the management with guiding principles to foster nature conservation and to integrate locally existent capabilities. Supporting and furthering these capabilities enables the development of new capabilities of all concerned persons. The dissertation demonstrates various possibilities to build bridges between (i) nature conservation and development, (ii) natural and social sciences, (iii) formal regulations and local socio-cultural aspects and (iv) diverse actors. Implementation of a social monitoring is recommended together with local stewards and Malagasy students to collect information about the perception of natural and social values and use them as guiding principles for biosphere reserves. Collaboration with national and international scientific institutions can foster this process.
Background
Although chronic kidney disease (CKD) is highly prevalent in the general population, little research has been conducted on CKD management in ambulatory care.
Objective was to assess management and quality of care by evaluating CKD coding in ambulatory care, patient diagnosis awareness, frequency of monitoring and whether appropriate patients are referred to nephrology.
Methods
Clinical data from the population-based cohort Study of Health in Pomerania (SHIP-START) were matched with claims data of the Association of Statutory Health Insurance Physicians. Quality of care was evaluated according international and German recommendations.
Results
Data from 1778 participants (56% female, mean age 59 years) were analysed. 10% had eGFR < 60 ml/min/1.73m2 (mean age 74 years), 15% had albuminuria. 21% had CKD as defined by KDIGO. 20% of these were coded and 7% self-reported having CKD. Coding increased with GFR stage (G3a 20%, G3b 61%, G4 75%, G5 100%). Serum creatinine and urinary dip stick testing were billed in the majority of all participants regardless of renal function. Testing frequency partially surpassed recommendations. Nephrology consultation was billed in few cases with stage G3b-G4.
Conclusion
CKD coding increased with stage and was performed reliably in stages ≥ G4, while CKD awareness was low. Adherence to monitoring and referral criteria varied, depending on the applicability of monitoring criteria. For assessing quality of care, consent on monitoring, patient education, referral criteria and coordination of care needs to be established, accounting for patient related factors, including age and comorbidity.
Trial registration
This study was prospectively registered as DRKS00009812 in the German Clinical Trials Register (DRKS).