The capability approach in rehabilitation: developing capability care

PURPOSE

To develop a multidisciplinary outpatient rehabilitation intervention for people with neuromuscular diseases (NMD) based on the capability approach: capability care for persons with NMD.

MATERIALS AND METHODS

The development process is described using a framework of actions for intervention development. It has been an iterative process consisting of a design phase based on theoretical insights and project group discussions, and a refine phase involving input from relevant stakeholders.

RESULTS

Multidisciplinary efforts have resulted in the development of capability care for rehabilitation of persons with NMD. It can focus both on facilitating and achieving functionings (beings and doings), as well as looking for alternative functionings that fulfil the same underlying value, thereby contributing to the persons' well-being. To facilitate a conversation on broader aspects that impact on well-being, persons with NMD receive a preparation letter and healthcare professionals are provided with guiding questions and practical tools to use.

CONCLUSIONS

We have shown that it is possible to develop a healthcare intervention based on the capability approach. We hope that rehabilitation professionals will be encouraged to use capability care and that other medical professionals will be inspired to develop capability care in their respective fields.

REGISTRATION

Registered at trialregister.nl NL8946.

Measurement of food poverty (shoku no hinkon) as capability deprivation in high-income countries: operationalisation with single mothers in Japan

Existing food insecurity instruments are focused largely on the financial constraints associated with acquiring sufficient amounts of food. This narrow focus has resulted in underestimating the true prevalence of food poverty, particularly in high-income countries. Food poverty needs to be defined as capability deprivation, extending from the nutritional to the temporal, spatial, qualitative and affective aspects of eating. In this article, the Alkire-Foster counting approach is evaluated and an alternative method for measuring such multidi-mensional food poverty is proposed. The method is demonstrated by using evidence from interviews with 53 single mothers, the most high-risk social group in Japan. On the basis of an operational definition of food deprivation and poverty cut-offs, 16 mothers (30%) were identified as living in food poverty, followed by a qualitative analysis of their deprivation profiles. The results show that the economically-poor were highly likely to fall into food poverty, but that food poverty also occurred without economic deprivation, notably among the mental or physical illness carriers and long-hour workers. This multidimensional and decomposable measurement tool is effective for identifying food-poor populations not reflected in traditional food insecurity measurement instruments.

A new sexual wellbeing paradigm grounded in capability approach concepts of human flourishing and social justice

Over the last twenty years, there has been a growing interest in measuring sexual wellbeing, including by a WHO/UNFPA working group in 2007, which sought clarity on key dimensions and asked for indicators of these to be devised. However, there remains a lack of conceptual clarity surrounding the concept of sexual wellbeing, which may create variation in what is being assessed and to what we are referring. This paper proposes one way in which to achieve conceptual clarity might be through the utilisation of a Capability Approach, thereby posing a new set of normative questions about what sexual wellbeing is. The central argument in this paper is for researchers, theorists and practitioners to focus more fully on a person's freedom to achieve sexual wellbeing within a particular social and cultural context. We suggest the kinds of data that might need to be captured to operationalise and measure such an understanding. By offering new critical insights, we hope to drive forward empirical and methodological development in the evaluation of sexual wellbeing.

Physical-Literacy-Enriched Physical Education: A Capabilities Perspective

(1) Background: Physical literacy is increasing in popularity across the world as a concept central to the promotion of lifelong engagement in physical activity across a multitude of sectors. The education sector has embraced physical literacy as a concept worthy of focus. Physical literacy literature is bold in its claim that physical literacy should be the foundation of physical education. The objective of this paper was to understand the value of physical literacy as the goal of physical education through the lens of the capability approach; (2) Positioning: This research adopted a post-qualitative sensibility whereby knowledge is decentered, favoring the inseparability of ethics, ontology, and knowledge (ethico-onto-epistemology); (3) Discussion: Throughout the discussion, traditional humanist examples are extended to include post-humanism perspectives to offer a more holistic and ecological appreciation of the relationship between capabilities, physical literacy, and physical education, using the ten capabilities of life, bodily health, bodily integrity, senses, imagination and thought, emotions, practical reason, affiliation, other species, play, and control over one's environment; (4) Conclusions: The paper concludes with the recommendation that the capabilities approach offers a valuable framework for the continued justification of physical-literacy-enriched physical education, which, when aligned, can help to shape the opportunities provided for children and young people in support of their holistic development and lifelong engagement in physical activity.

Sustainable employability and work engagement: a three-wave study

Introduction

The recent concept of sustainable employability (SE), which refers to being able and enabled to achieve valuable work goals, has lately attracted substantial attention in many developed countries. Although limited cross-sectional studies found that SE in the form of capability set was positively associated with work outcomes, why and through which mechanism SE is related to crucial work outcomes remains still unexplored. Therefore, the present three-wave study aimed to (1) investigate the SE-work outcomes linkage over time, and (2) uncover the psychological pathway between SE and two work outcomes (i.e., task performance and job satisfaction) by proposing work engagement as a mediator.

Methods

To test the mediation process, we approached CentERdata to collect data among a representative sample of 287 Dutch workers. We used a three-wave design with approximately a 2-month time lag.

Results

The results of bootstrap-based path modeling indicated that SE was a significant predictor of task performance but not job satisfaction over time. Work engagement mediated the relationships between SE and (a) task performance and (b) job satisfaction.

Discussion

These findings suggest that organizations may foster workers' task performance and job satisfaction by configuring a work context that fosters SE-allowing workers to be able and be enabled to achieve important work goals.

Rethinking device abandonment: a capability approach focused model

It is estimated that approximately 97 million people in the world have complex communication needs and may benefit from alternative and augmentative communication (AAC). Although AAC is considered an evidenced-based intervention, device abandonment remains common, and researchers have attempted to analyze the causes of people abandoning devices. These devices have been prescribed following extensive assessment and often a protracted period of negotiation with a funding body. In this paper, we present the process of AAC prescription using a new model called the Communication Capability Approach by adding the Capability Approach from Amartya Sen to the widely used Participation Model. This allows clinicians to see individual daily decision-making as a valid choice of the individual. We propose reframing the concept of device abandonment as the person and their family making a choice to use a full range of multimodal communication to meet their own needs. This changes the tone of the narrative to viewing the person using AAC as competent and able to exercise self-determination and agency in this decision rather than as abandoning the device. AAC choices can be made on a day-to-day basis, according to the context of use so that people do not abandon devices but rather use whichever mode of communication is appropriate to the context.

Toward a Practice Framework for Throughcare Reintegration Programs

Practice frameworks for programs supporting people to transition between prison and community are a critical resource for service agencies, researchers and policy makers. Although reintegration programs are often commissioned with reference to Risk-Needs-Responsivity and the Good Lives Model, these frameworks lack specificity for practical program design. Following recent meta-theoretical guidelines, we articulate a practice framework for reintegration programs over three levels: (1) principles and values; (2) knowledge related assumptions; and (3) intervention guidelines. Level 1 is drawn from the capability approach, which frames the goal of increasing the substantive freedom of individuals. Level 2 is drawn from desistance theory, which grounds claims that sustained cessation of offending is enabled by changes in people's self-labels and narrative, relationships with friends and family, access to resources, and community participation. Level 3 is drawn from throughcare service design and structures practice into seven domains. This framework has potential to reduce rates of reincarceration.

Promoting Equity in Health Care through Human Flourishing, Justice, and Solidarity

In this article, we develop a non-rights-based argument based on beneficence (i.e., the welfare of individuals and communities) and justice as the disposition to act justly to promote equity in health care resource allocation. To this end, we structured our analysis according to the following main sections. The first section examines the work of Amartya Sen and his equality of capabilities approach and outlines a framework of health care as a fundamental human need. In the subsequent section, we provide a definition of health equity based on the moral imperative to guarantee that every individual ought to have the freedom to pursue health goals and well-being. In the later part of the article, we outline a non-right approach to health care based on three pillars: (1) human flourishing, (2) justice as a disposition not a process, and (3) solidarity.

Bringing classes back into poverty discussions

The 1980s saw a shift in the emphasis of discourse on poverty from production relations to consumption relations, with levels of consumption and purchasing power used to define poverty. Based on this concept, much of the research establishes absolute poverty lines or develops relative indicators to distinguish between "poor" and "non-poor." This paper makes the case that such poverty measurement, while useful for assessing trends over the long term or taking into account relative dynamics, distorts our knowledge of poverty by hiding its root causes and results in overly optimistic interpretations. These discussions also decontextualize poverty from its political and economic context by uncritically accepting and promoting neoliberal regime. Moreover, the article questions the meaning of the "eradication of poverty" and suggests that the nominal rise in PPP income obscures historical capitalist accumulation processes (such as dispossession, proletarianization and depeasantization). As a result, the study suggests to recenter the analysis on the material causes of poverty, which are rooted in the functioning of the capitalist system, its antagonistic character, and the class-based contradictions of production itself.

What does a "good life" mean for people living with dementia? A protocol for a think-aloud study informing the value of care

Introduction

Economic evaluation currently focuses almost exclusively on the maximization of health, using the Quality-Adjusted Life-Year (QALY) framework with instruments such as the EQ-5D, with a limited number of health-focused dimensions providing the assessment of health benefit. This evaluative framework is likely to be insufficient for setting priorities in dementia care because of its exclusive concern with health. Data are also often collected from the perspective of a proxy, limiting the voice of those living with dementia in decision-making. This protocol describes a research project that aims to gather the perspectives of people living with dementia, their insights, and preferences for assessing their quality of life to inform economic evaluation outcome measurement and design with a goal of creating a more robust evidence base for the value of healthcare services. Specifically, this study will elucidate what a "good life" means to people living with dementia and how well instruments currently used in economic evaluation meet this description. This project will further test the acceptability of capability wellbeing instruments as self-report instruments and compare them to generic and dementia-specific preference-based instruments.

Methods and analysis

People living with dementia, diagnosed, or waiting to receive a formal diagnosis and with the capacity to participate in research, will be invited to participate in an hour "think aloud" interview. Participants will be purposefully selected to cover a range of dementia diagnoses, age, and sex, recruited through the integrated care, geriatric, and post-diagnostic clinics at St James' and Tallaght University Hospitals and dementia support groups in the Ireland. During the interview, participants will be invited to reflect on a "good life" and "think aloud" while completing four economic quality of life instruments with a perspective that goes beyond health (AD-5D/QOL-AD, AQOL-4D, ICECAP-O, ICECAP-SCM). An interviewer will then probe areas of difficulty when completing the instruments in a semi-structured way. The analysis will identify the frequency of errors in comprehension, retrieval, judgment, and response from verbatim transcripts. Qualitative data will be analyzed using constant comparison.

Ethics

The St James's Hospital and Tallaght University Hospital Joint Research Ethics Committee approved the study (Approval Date: 11 April 2022).

The agency of fertility plans

Fertility plans are a prominent area for agency research, and are a clear example of a misalignment between resources and agency capacity. We relied both on the idea of conversion factors of the Capability Approach and the pragmatist tradition of temporal-oriented agency to propose a framework for the study of fertility agency as the conversion process of resources into plans and behavior. We outlined said framework by using a unique dataset on fertility plans composed of open and closed questions from an Italian sample. Economic factors and imaginaries related to children and family represented the vast majority of (hindering and enabling) conversion factors. The notion of conversion factors is crucial for disentangling the network of heterogeneous elements involved in fertility agency: it allows focus to be shifted from structural factors related to social position and psychological characteristics to more situated elements that enable agency capacity.

Mobile Health in China: Well Integrated or a New Divide?

The application of mobile health holds promises of achieving greater accessibility in the evolving health care sector. The active engagement of private actors drives its growth, while the challenges that exist between health care privatization and equitable access are a concern. This article selects the private internet hospital in China as a case study. It indicates that a market-oriented regulatory mechanism of private mobile health will contribute little to improving health equity from the perspectives of egalitarians and libertarians. By integrating the capability approach and the right to health, it is claimed that mobile health is a means of accessing health care for everyone, where substantive accessibility should be emphasized. With this view, this article provides policy recommendations that reinforce private sector engagement for mobile health, recognizing liberty, equity, and collective responsibility in the Chinese context.

Objection or Obstacle: Applying Amartya Sen's Capability Approach to the Conscientious Refusal of Emergency Contraception

The conscientious refusal to dispense emergency contraception (EC) is legally protected in fourteen states. While the ethical dimensions of these objections have been explored within moral and feminist philosophy, conscientious refusal to the over-the-counter sale of EC has not been significantly studied through an egalitarian lens, especially with attention to the existing reproductive healthcare landscape in which these refusals occur. This article argues, through Amartya Sen's capability approach, that conscientious refusal to EC creates a burdensome inequality for people wishing to prevent pregnancy that manifests within a background of historical injustices, elevating its importance in our weighing of capabilities.

Community Participation and Multidimensional Child Growth: Evidence from the Vietnam Young Lives Study

Background

Community participation has the potential to improve the effects of interventions and reduce inequalities in child growth. Multidimensional indicators capture such effects and inequalities.

Objectives

The objective of this study was to measure the association between multidimensional child growth and community participation in 2 nutrition-sensitive interventions.

Methods

A Multidimensional Index of Child Growth was calculated with the 5-y-old cohort of the Vietnam Young Lives Survey. Young Lives is a unique dataset that has information on community participation in the design and implementation stages of 2 interventions: a health and a water, sanitation, and hygiene (WASH) intervention. Community participation during the interventions was recorded retrospectively with interviews at the household level. Ordinary least-squares and quantile regressions were estimated using data on 240 children. A Multidimensional Index of Child Advantage, sex, and location (urban/rural) were included as control covariates.

Results

A positive association (post hoc statistical power = 0.859) was estimated for community participation during the design stage of the WASH intervention, particularly for the most deprived children (P < 0.05). Negative effects were estimated for the health intervention during the design stage (P < 0.05) and no significant effects were found for community participation during the implementation stage of the interventions. Instead of the physical dimension, the significant associations in the design stage were related to the nonphysical dimension of child growth. Inequalities in multidimensional growth were found for children living in rural areas, but not for girls.

Conclusions

The association between community participation and multidimensional child growth is indicative of the importance of community participation during the design phase of interventions, in particular for the nonphysical dimensions of child growth related to social and psychological factors. The benefits of participation were greater for urban children compared with rural children, which deserves further attention.

Data justice and data solidarity

Datafication shapes and gradually transforms societies. Given this impact, issues of justice around data-driven practices have received more and more attention in recent years as shown, for example, by various reports and guidelines on artificial intelligence and data ethics. In this article, we elaborate on and defend two claims. First, these discourses on justice tend to center primarily around conceptions of fairness. We argue that justice in connection with datafication relates to, but ultimately encompasses more than, solely fairness. Second, although it is an important project to clarify what justice in connection with datafication encompasses, we argue that attention toward attitudes and practices of data solidarity have so far been largely overlooked. They are, however, indispensable as a catalytic element to advance toward data justice in practice.

New technologies such as big data, machine learning, and artificial intelligence are rapidly generating new opportunities and challenges for various social practices. At the same time, they raise important ethical questions. For example, for whom will these opportunities and advantages result in benefits, and who bears the burdens? A fundamental issue is which individuals and groups with their respective claims and particularities are involved and affected by the use of ever-increasing amounts of data and the inferences drawn from them. To navigate this terrain, reference is often made to the notion of justice. Such reference can be helpful to the extent that we are clear about what justice entails and what it takes to get there. In this article, we argue that justice requires us to make visible the claims of those left out, excluded, or disadvantaged in and around the use of data. To this end, we put forward the concept of data solidarity and examine its interplay with data justice.

Development and Poverty Dynamics in Severe Mental Illness: A Modified Capability Approach in the Chinese Context

Albeit poverty reduction has been listed as an overarching objective in many countries’ development plans, little is known about how development could shape poverty dynamics in disadvantaged groups. Guided by a modified capability framework, this study aimed to explore the long-term experiences of poverty dynamics in severe mental illness. Semi-structured interviews were carried out with 20 caregivers who provided care for persons with severe mental illness in Chengdu, China. Their perceptions on development, the illness, and social security were addressed. Content analysis was employed to analyze data. Participants experienced an overall improvement of life quality due to changes on urban infrastructure and transformed lifestyle. However, they were more disadvantaged while facing ability-based opportunities. These families were hindered from transferring opportunities into incomes. Negative impacts of the illness were also reflected in multiple stigma and conversion difficulties. Additionally, the high threshold for payment made those inclusive social security policies not inclusive for them. Poverty associated with severe mental illness was unlikely to be alleviated automatically within the process of development. Social isolation and high caregiving burden had aggravated poverty for those disadvantaged families. Poverty alleviation should be closely linked to the improvement in social policies in China.

The need for adolescents' agency in salutogenic approaches shaping physical activity in schools

Physical activity (PA) contributes to health throughout life. In particular, young people can benefit from this. Schools can play a key role in providing learning conditions to experience meaningful PAs aimed at inspiring students to lifelong PA. In this article, we argue the need for a salutogenic approach in schools focussing on respecting and enhancing adolescents' agency with regard to their PA. This approach entails listening to adolescents' perspectives and inviting them to participate in actively designing and carrying out PA as a prerequisite for their inclusive engagement. We unpack the concept of agency by drawing on insights from the Capability Approach. This provides input for the integration of agency in health promoting schools and salutogenic approaches, to enhance PA-related agency. Finally, we outline a research agenda to, eventually, create opportunities for students in schools to expand their PA-related agency. Lay Summary Physical activity (PA) contributes to health throughout life. Schools can play a key role in fostering meaningful PA experiences to inspire students to lifelong PA. This requires schools to focus on students' personal aspirations, providing them with the space to develop their autonomy and find opportunities to decide and act upon expanding their agency with respect to the physically active lifestyles they deem meaningful.

'We may be long in the tooth, but it makes us tough': exploring stillness for older adults during the COVID-19 lockdowns

Following the outbreak of the SARS-CoV-2 across the world in 2020, millions of people were reduced in their mobility to hinder the spread of the disease. The lockdown was particularly difficult for older adults, who were deemed 'vulnerable' because many felt unsafe leaving the house and often forced to self-isolate. In this paper, we interpret the lockdowns as a period of prolonged stillness: breaks from everyday practices, including withdrawnness, inefficiency, and retreat. We extend ideas of stillness by integrating the capability approach, which shows how the opportunities and challenges that arise from moments of stillness are dependent on a combination of individual agency and the role of structural or contextual factors. Using the accounts of thirty-eight older adults in the Netherlands and England, we show how the COVID-19 lockdowns established and encouraged different types of stillness which had differing impacts upon the older adults' lives. The effect of the prolonged stillness on these different areas of everyday life is based on individual agency and contextual factors, such as choosing to volunteer or having an adequate internet connection. Thus, our findings contribute to discussions around active ageing and demonstrate that slowing down, and spending more time at home, can provide respite from an otherwise active everyday life.

Typical school-to-work transitions of young adults with disabilities in Germany - a cohort study of recipients of vocational rehabilitation services after leaving school in 2008

PURPOSE

In Germany, vocational rehabilitation (VR) for young people with disabilities (YPWD) aims to counteract disadvantages on the training and labour markets. However, the school-to-work transitions (STWT) among YPWD are underexplored. This study investigates to what extent and for whom VR provides an institutional bridge into employment.

MATERIALS AND METHODS

Based on representative administrative data of the German Federal Employment Agency, young people in VR are observed for 6.5 years after completing lower or intermediate secondary education in 2008. Using optimal matching and cluster analysis, six typical STWT trajectories are identified.

RESULTS

Most of the YPWD completed company-external vocational training, some undertook regular in-firm training. These forms of training often lead to regular employment, albeit with a delay for some. Other young people are guided from training in sheltered workshops into sheltered employment. Another group exhibits problematic STWTs in which recurring unemployment and (non-training) programmes fail to lead to training or employment.

CONCLUSIONS

VR combined with in-firm or company-external vocational training can facilitate the STWTs of people with disabilities. However, individuals from poor families are less likely to benefit from VR. Similarly, restricted capabilities and problematic STWTs are observed when young people drop out of VR due to poor cooperation.Implications for rehabilitationVocational training often is a prerequisite for labour market entry; however, if the structural conditions on the local labour market are unfavourable, young people with disabilities do not take up employment.Training within sheltered workshops often leads to highly institutionalised trajectories that should be reconsidered to permit greater permeability into the regular labour market.As young people with problematic STWT more often come from poor households, they should be targeted to a greater extent in the context of VR counselling.

Challenges in developing capability measures for children and young people for use in the economic evaluation of health and care interventions

Methods for measuring outcomes suitable for economic evaluations of health and care interventions have primarily focused on adults. The validity of such methods for children and young people is questionable in areas including the outcome domains measured and how they are measured and valued, with most existing measures narrowly focusing on health. Novel methods for assessing benefits beyond health by focusing on a person's capability have also concentrated on adults to date. This paper aims to set out the rationale for capability measures in children and young people. It argues for the need to expand the evaluative space beyond health functioning towards broader capabilities, with children and young people playing an integral role in capability measure development. Drawing from existing literature, specific challenges related to the identification, measurement, and valuation of capabilities in children and young people are also discussed. Finally, the practical implications for conducting economic evaluation when measuring and valuing capabilities at different stages across the life-course are illustrated. We develop an alternative framework based on conceiving capabilities as evolving across the life-course. This framework may also be helpful in thinking about how to model health outcomes across the life-course.

Patient capability: Justice and grassroots healthcare delivery in China

The current reform of China's healthcare system focuses mainly on two dimensions: the promotion of primary healthcare and the improvement of quality of grassroots healthcare (GH). Specifically, the reforms are aimed at meeting the needs of patients in the grassroots areas (PGAs) through the provision of universal healthcare and hierarchical diagnosis and treatment (HDT). In practice, however, disparities in health outcomes between the grassroots and upper levels persist. The gaps between increased health coverage and heightened barriers to accessing quality medical care in the grassroots areas are growing ever larger. What explains this paradox is the limited capability of PGAs to transform healthcare resources into better health-seeking behaviors and health outcomes, resulting in injustice that is built into the system, which is neither ethical nor fair. Using Amartya Sen's capability approach (CA) to explore issues of justice in relation to China's GH system and its performance, we suggest that an institutional structure, one that focuses on promoting universal coverage in the grassroots areas, although necessary, is by itself insufficient in promoting justice and equality in accessing healthcare. Institutional disparities in the healthcare system and China's household registration policy, constructed according to the rural-urban divide, have also produced injustices. We argue that greater attention should be given to meeting the medical needs of PGAs and empowering them with greater choice, permitting them a higher level of freedom and agency, and thus remedying the problems that we describe. We conclude with policy recommendations aimed at improving justice within the system.

The capability approach as a bridging framework across health promotion settings: theoretical and empirical considerations

Health promotion research has increasingly called for transdisciplinary approaches. Such calls ask for bridging frameworks that define comprehensive sets of health determinants and appropriately conceptualize the roles of population groups as well as other relevant actor groups in the co-production of health. This article aims to present the seminal capability approach by Sen and Nussbaum as a potentially suitable framework for such bridging endeavors to guide health promotion research. It highlights domains of the capability approach that appear to be particularly relevant to bridging diverse disciplines and settings. Such domains particularly refer to the agency of decisive actor groups (population groups, professionals, policymakers and researchers) as well as to the differentiation of personal, social and environmental conversion factors that disciplines define within their specific epistemologies and ontologies. The article uses empirical examples from a German research consortium that aimed to promote physical activity in five different settings while fostering cooperation and conceptual alignment between several academic disciplines and sub-disciplines to highlight benefits and challenges of using the capability approach as a bridging framework for transdisciplinary health promotion. We conclude that the capability approach might serve as bridging framework to guide future transdisciplinary research if partners involved continuously exchange to develop a shared understanding of the issues to be researched.

At the limits of "capability": The sexual and reproductive health of women migrant workers in Malaysia

Despite the centrality of sexual and reproductive health (SRH) to UN Sustainable Development Goals (SDGs), women migrant workers in Malaysia face an environment inimical to their SRH needs. Drawing on qualitative case study material, we present the first empirical application of the capability approach (CA) to explore the reproductive health needs of women migrant workers in a developing country, offering an original analysis of the capability for SRH of these women. Specifically, we explore the resources available to them; their opportunities and freedoms ("capabilities"); and factors that mediate transformation of resources into capability sets ("conversion factors"). While SRH information and health care are notionally available, women migrant workers face multiple challenges in converting resources into functionings, constraining the achievement of capability for SRH. Challenges include language barriers, personal beliefs, power relations between workers and employers and the consequences of current migration policy. We consider the scale of the challenges facing these women in securing SRH rights, the difficulties of operationalising the CA within such a setting, and the implications of our findings for the adequacy of the CA in supporting marginalised populations.

Perceived changes in capability during the COVID-19 pandemic: A Swedish cross-sectional study from June 2020

AIMS

Measures against COVID-19 potentially impact quality of life in different ways. The capability approach by Amartya Sen with a broad and consistent framework for measuring quality of life is suited to capture the various consequences. We aimed to examine (a) whether individuals experienced change in 10 capability dimensions during the first half of 2020, (b) which dimensions were affected most, and (c) whether changes were unequally distributed in terms of gender, education, income, geography, housing, living situation and place of birth.

METHODS

We assessed self-reported capability change in Sweden in 10 capability dimensions in a cross-sectional online survey among 500 participants on a five-item Likert scale. We analysed the distribution of answers by comparing the balance of positive and negative perceived changes and used mixed effects logistic regression to examine associations with background characteristics of the participants.

RESULTS

Reported perceived negative changes outweighed positive changes, and a higher proportion stated negative perceived changes if they also stated having low capability in the same dimension. In the capabilities of financial situation, political resources and health, the proportions of perceived negative change were highest. Odds for perceived negative change compared to no or positive change were higher for lower incomes, living in smaller municipalities compared to living in medium-sized municipalities, being born outside Europe, living in the south of Sweden, and renting instead of owning housing.

CONCLUSIONS

Self-reported negative capability change, and associated inequalities related to socioeconomic position, place of birth and regional residence should be of concern for policymakers.

Challenging the association between health literacy and health: the role of conversion factors

Previous studies have found substantial correlations between health literacy and various health outcomes. However, the role of social and personal factors in those links remains understudied. Applying a moderation approach, we assume that these factors function as conversion factors on the associations between health literacy and health outcomes. Consequently, we test if associations between health literacy and health outcomes are stronger among young male adults who score high in conversion factors compared to those who score low. Cross-sectional data from the Young Adult Survey Switzerland were used for the analyses (n = 9339, age = 18-25). Multiple logistic regression analyses were applied to estimate associations between health literacy and health. Moderator analyses with three conversion factors and five health outcomes were conducted. For each health outcome at least one conversion factor moderated the association between health literacy and health according to the hypothesis. Although strength and form of the moderation effect differ across analyses, generally stronger associations were found among groups with beneficial social or personal factors. The present findings support the hypothesis that conversion factors play a crucial role in the associations between health literacy and health. The findings, thus, point towards a potential risk of linear health literacy approaches that assume equal benefits from increased health literacy. Individuals with beneficial social and personal factors (those already privileged) may enjoy greater health benefits from interventions improving health literacy.

Using Everyday Technology Independently When Living with Forgetfulness: Experiences of Older Adults in Barcelona

Older adults living with forgetfulness encounter difficulties when engaging with changing and dynamic everyday technology (ET). The capability to use ET is important for independence in later life and is affected by the contextual and individual characteristics of older adults. Using the capability approach as a theoretical lens, this phenomenological study aims to explore the experiences of older adults living with forgetfulness, in order to identify contextual and individual factors that facilitate the use of ET in everyday life. A qualitative methodology was used to interview 16 community-dwelling older adults participating in memory and technology workshops at local community centres in Barcelona. Findings show that motivation and openness to learning played a facilitating role in our participants’ use of ET. The presence of social support in the form of “technology experts” and community centres offering learning opportunities were also enhancing factors that encourage independence when engaging with ET. In conclusion, our study demonstrates the importance of expanding intergenerational ET learning opportunities, through the creation of age-friendly spaces.

Who's afraid of perfectionist moral enhancement? A reply to Sparrow

Robert Sparrow recently argued that state-driven moral bioenhancement is morally problematic because it inevitably invites moral perfectionism. While sharing Sparrow's worry about state-driven moral bioenhancement, I argue that his anti-perfectionism argument is too strong to offer useful normative guidance. That is, if we reject state-driven moral bioenhancement because it cannot remain neutral between different conceptions of the good, we might have to conclude that all forms of moral enhancement programs ought not be made compulsory, including the least controversial and most popular state-driven program: compulsory (moral) education. In this paper, I argue that, instead, the spirit of Sparrow's worry should be recast in the language of the capability approach-an approach that strives to enhance people's capabilities to develop their own conceptions of the good by restricting itself from endorsing thick conceptions of the good. The distinction made regarding thick and thin conceptions of the good helps to capture sentiments against state-driven bioenhancement programs without falling prey to the issues I raise against Sparrow's anti-perfectionist arguments.

"When I Breastfeed, It Feels as if my Soul Leaves the Body": Maternal Capabilities for Healthy Child Growth in Rural Southeastern Tanzania

The burden of childhood stunting in Tanzania is persistently high, even in high food-producing regions. This calls for a paradigm shift in Child Growth Monitoring (CGM) to a multi-dimensional approach that also includes the contextual information of an individual child and her/his caregivers. To contribute to the further development of CGM to reflect local contexts, we engaged the Capability Framework for Child Growth (CFCG) to identify maternal capabilities for ensuring healthy child growth. Ethnographic fieldwork was conducted in Southeastern Tanzania using in-depth interviews, key informant interviews, participant observation, and focus group discussions with caregivers for under-fives. Three maternal capabilities for healthy child growth emerged: (1) being able to feed children, (2) being able to control and make decisions on farm products and income, and (3) being able to ensure access to medical care. Mothers’ capability to feed children was challenged by being overburdened by farm and domestic work, and gendered patterns in childcare. Patriarchal cultural norms restricted women’s control of farm products and decision-making on household purchases. The CFCG could give direction to the paradigm shift needed for child growth monitoring, as it goes beyond biometric measures, and considers mothers’ real opportunities for achieving healthy child growth.

Maternal and Child Survival in Haor Region in Bangladesh. An Analysis of Fathers' Capabilities to Save the Future

Maternal and child survival is a major public health problem in haor areas in Bangladesh. Fathers feel responsible as expressed by their capability "to save the future". Using the Capability Framework for Child Growth, we aimed to identify what contextual factors underlie a father's real opportunities to secure a safe delivery, including social norms and beliefs. Parents from households having children less than two years old were asked to participate in two rounds of qualitative research. In total, 25 focus group discussions and eight in-depth interviews were conducted. Late admission to health facilities emerged as the overarching disabling factor for fathers' capability to save the lives of mothers and children. Poor communication about the mother's health condition between spouses and fear for caesarean birth were underlying this late admission. In addition, inadequate advice by local doctors, underdeveloped infrastructure, and seasonal extremities contributed to late admission to health care facilities. The participants indicated that mother's autonomy in haor to seek health care is a constraint. This capability analysis points towards relevant interventions. In addition to the need for an improved health infrastructure, programs to improve maternal and child survival in haor could focus on the gendered household responsibilities and poor communication between spouses.

Capabilities for Physical Activity by Turkish- and Russian-Speaking Immigrants Aged 65 Years and Older in Germany: A Qualitative Study

This study builds upon Sen's seminal capability approach to analyze the interplay of individual and structural factors for immigrants' physical activity (PA) in old age. The authors conducted software-assisted thematic analysis of group interviews with Turkish- and Russian-speaking immigrants aged 65 years and older in Germany (n = 19). The authors present how interviewees perceive diverse resources, environmental, social, and individual factors that shape their capabilities for PA. Age-related health literacy, family support, and access rules to sport opportunities shape both groups' capabilities for PA. Turkish interviewees' continuous bilocation and Russian interviewees' past experience with PA as workplace exercise are two major differences between those groups. Results indicate that capabilities are ambiguous-managed and shaped by individuals, which makes more static terms like barriers and options less helpful for an analysis. Systematically applying the capability approach in intervention research would allow to analyze interaction and to ultimately better reach underserved groups like immigrants 65 years and older.

Happy with Your Capabilities? Valuing ICECAP-O and ICECAP-A States Based on Experienced Utility Using Subjective Well-Being Data

Background. The ICECAP-O and the ICECAP-A are validated capability well-being instruments. To be used in economic evaluations, multidimensional instruments require weighting of the distinguished well-being states. These weights are usually obtained through ex ante preference elicitation (i.e., decision utility) but could also be based on experienced utility. Objective. This article describes the development of value sets for ICECAP-O and ICECAP-A based on experienced utility and compares them with current decision utility weights. Methods. Data from 2 cross-sectional samples corresponding to the target groups of ICECAP-O and ICECAP-A were used in 2 separate analyses. The utility impacts of ICECAP-O and ICECAP-A levels were assessed through regression models using a composite measure of subjective well-being as a proxy for experienced utility. The observed utility impacts were rescaled to match the 0 to 1 range of the existing value set. Results. The calculated experienced utility values were similar to the decision utility weights for some of the ICECAP dimensions but deviated for others. The largest differences were found for weights of the ICECAP-O dimension enjoyment and the ICECAP-A dimensions attachment and autonomy. Conclusions. The results suggest a different weighting of ICECAP-O and ICECAP-A levels if experienced utility is used instead of decision utility.

Response process validity of three patient reported outcome measures for people requiring kidney care: a think-aloud study using the EQ-5D-5L, ICECAP-A and ICECAP-O

OBJECTIVES

To determine the response process validity, feasibility of completion, acceptability and preferences for three patient-reported outcome measures that could be used in economic evaluation-the EQ-5D-5L, ICECAP-A and ICECAP-O-in people requiring kidney care.

DESIGN

Participants were asked to 'think-aloud' while completing the EQ-5D-5L, ICECAP-A and ICECAP-O, followed by a semistructured interview. Five raters identified errors or struggles in completing the measures from the think-aloud component of the transcripts. Patient preferences for measures were extracted from the semistructured interview.

SETTING

Eligible patients were identified through a large UK secondary care renal centre.

PARTICIPANTS

In total, 30 participants were included in the study, consisting of patients attending renal outpatients for chronic kidney disease (n=18), with a functioning kidney transplant (n=6) and receiving haemodialysis (n=6).

RESULTS

Participants had few errors and struggles in completing the EQ-5D-5L (11% error rate, 3% struggle rate), ICECAP-A (2% error rate, 2% struggle rate) and ICECAP-O (4% error rate, 3% struggle rate). The main errors with the EQ-5D-5L were judgements that did not comply with the 'your health today' instruction. Comprehension errors were most prominent on ICECAP-O. Judgement errors were the only errors reported on ICECAP-A. Although the EQ-5D-5L had slightly more errors and struggles, it was the measure most preferred, with participants able to make a clearer link with EQ-5D-5L and their health condition.

CONCLUSIONS

The EQ-5D-5L, ICECAP-A and ICECAP-O are feasible for people requiring kidney care to complete and can be included in studies conducting economic evaluations of kidney care interventions. Further research is required to assess how health (eg, EQ-5D) and capability (eg, ICECAP) measures can be included in an economic evaluation simultaneously, as well as what ICECAP measure(s) to include when patient groups straddle the age ranges for ICECAP-A (18 years and older) and ICECAP-O (65 years and older).

Embryonic Regulation and Research: What Is the Status of Human Germline Genome Editing in Australia?

This article considers the status of human germline genome editing in Australia. Through an analysis of the current State, Territory and Commonwealth legal and ethical regulatory frameworks, and incorporating the capability approach to health justice proposed by Martha Nussbaum and Amartya Sen, the article argues that heritable alterations using CRISPR/Cas9 technology in a clinical context are inevitable in Australia, so the law needs to respond adequately to these scientific advances. The article concludes that human germline genome editing is currently not, and should not, be lawful in Australia, except for research purposes.

Assessing the Multiple Dimensions of Poverty. Data Mining Approaches to the 2004-14 Health and Demographic Surveillance System in Cuatro Santos, Nicaragua

We identified clusters of multiple dimensions of poverty according to the capability approach theory by applying data mining approaches to the Cuatro Santos Health and Demographic Surveillance database, Nicaragua. Four municipalities in northern Nicaragua constitute the Cuatro Santos area, with 25,893 inhabitants in 5,966 households (2014). A local process analyzing poverty-related problems, prioritizing suggested actions, was initiated in 1997 and generated a community action plan 2002–2015. Interventions were school breakfasts, environmental protection, water and sanitation, preventive healthcare, home gardening, microcredit, technical training, university education stipends, and use of the Internet. In 2004, a survey of basic health and demographic information was performed in the whole population, followed by surveillance updates in 2007, 2009, and 2014 linking households and individuals. Information included the house material (floor, walls) and services (water, sanitation, electricity) as well as demographic data (birth, deaths, migration). Data on participation in interventions, food security, household assets, and women's self-rated health were collected in 2014. A K-means algorithm was used to cluster the household data (56 variables) in six clusters. The poverty ranking of household clusters using the unsatisfied basic needs index variables changed when including variables describing basic capabilities. The households in the fairly rich cluster with assets such as motorbikes and computers were described as modern. Those in the fairly poor cluster, having different degrees of food insecurity, were labeled vulnerable. Poor and poorest clusters of households were traditional, e.g., in using horses for transport. Results displayed a society transforming from traditional to modern, where the forerunners were not the richest but educated, had more working members in household, had fewer children, and were food secure. Those lagging were the poor, traditional, and food insecure. The approach may be useful for an improved understanding of poverty and to direct local policy and interventions.

Capability of deaf children with a cochlear implant

INTRODUCTION

The main idea underlying this paper is that impairments such as deafness are particularly relevant to the extent that they lead to deprivation of capability. Likewise, the impact of healthcare services such as cochlear implants and subsequent rehabilitation can best be inferred from the extent that they protect or restore capability of those affected.

METHODS

To explore children's post-implant capabilities, we tested two newly developed digital, adaptive child self-report and parent-report questionnaires in 19 deaf children (aged 8-12 years) and their parents during rehabilitation, as well as in 23 age peers with normal hearing.

RESULTS

Despite the impressive speech-language results that were recorded with cochlear implants, the post-implant capabilities of the deaf children we evaluated differed from those of their hearing peers, with the cochlear implant group appearing particularly disadvantaged in areas such as accessing information, communication, social participation, and participation in school.

CONCLUSION

Deaf children with cochlear implants who are performing well on linguistic and auditory tests can still experience serious limitations in desired functioning. Our findings suggest that a capability approach may reveal aspects of what is being achieved through rehabilitation that might otherwise remain unnoticed, and that could help to further improve the well-being of our patients.IMPLICATIONS FOR REHABILITATIONOverall, children with cochlear implants appeared disadvantaged in certain capability areas, like accessing information, communication, social participation, and participation in school.It may be worthwhile to also ascertain capabilities in these children, representing a domain not covered by clinical measures, tapping directly into areas that are valuable to the patient.

A Proposal for a Comprehensive Human-Animal Approach of Evaluation for Animal-Assisted Interventions

Background: An important field of human–animal interactions is animal-assisted interventions (AAIs), which refers to research on human–animal interactions in order to promote or facilitate health or education in humans. Very few studies among the rich literature on AAIs seem to include aspects of animal welfare and/or animal ethics. Also, very few studies on AAIs have a comprehensive human–animal approach that studies animals, humans, and the relations between them at the same time. This paper tries to argue for and present a possible comprehensive human–animal approach to evaluate AAIs. Methods: A combination of the species and role approach proposed by Lerner, the capability approach proposed by Nussbaum, and a modified comprehensive human–animal approach to evaluate AAIs proposed by Lerner and Silfverberg was philosophically analyzed. Results: This paper shows that the combination is the modified role and species version of the capabilities approach, and by following it one could do a comprehensive human–animal approach of an evaluation of AAIs. Conclusion: Although the aim was reached for horses and animal-assisted therapy, further work needs to be done for all species suggested in the IAHAIO (International Association of Human–Animal Interaction Organizations) White Paper as well as for all branches of AAIs in order to establish this comprehensive human–animal approach.

Estimating conversion rates: A new empirical strategy with an application to health care in Italy

This study proposes a new empirical strategy for assessing how "efficient" different individuals and groups are in converting their available resources into achievements. Following the capabilities approach, pioneered by Amartya Sen, we employ the concept of "conversion rates" to capture the efficiency of the link from resources to achievements. The methodology is both simpler and more conceptually precise than previous options, this offering the potential to support significant expanded work in this area. The proposed methodology is then tested in relation to health care in Italy. The findings suggest that investments in education may carry particular health benefits for women, which public resources are particularly important for the elderly, and that single individuals pose special challenges because they benefit less from all types of resources than married couples. The results thus highlight significant heterogeneities in the abilities of different groups to convert public, private, and nonfinancial resources into health, and we conclude by noting the possible consequences for health care and public policies.

Qualitative and quantitative interpretations of the least restrictive means

Within healthcare ethics and public health ethics, it has been the custom that medical and public health interventions should adhere to the principle of the least restrictive means. This principle holds that public health measures should interfere with the autonomous freedom of individuals to the least possible or necessary extent. This paper contributes to the discussion on how best to conceptualize what counts as the least restrictive means. I argue that we should adopt a novel, qualitative interpretation of what counts as the least restrictive means. Based on the multidimensional framework of the capability approach, the qualitative interpretation holds that the least restrictive means should be measured in terms of whether it restricts certain normatively valuable freedoms. I contrast this interpretation with quantitative interpretations that measure how much, or the extent to which, a public health measure interferes with the freedom of individuals.

Do capability and functioning differ? A study of U.K. survey responses

A core feature of the capability approach is that a person's capabilities (what they are able to do and be in their life) can differ from their functionings (what they actually do and are in their life). However, the degree to which capability and functioning differ in practice is unclear. This paper investigates this issue, focusing on capability and functioning differences (CFD) across different aspects of life and different individuals. In the study, the ICECAP-A capability questionnaire was modified to measure both functionings and capabilities and was completed by U.K.-based convenience sample of 943 people. Around one third of people reported CFD in at least one area of their life, most commonly in terms of their "achievement." People were more likely to report CFD when they had a degree-level education and when they had impaired health. An additional finding was that capability varied more with education whereas functioning varied more with health status. This finding needs further examination, but it suggests that the choice of evaluative space may influence how priorities are set for public spending.

Development of a measure (ICECAP-Close Person Measure) through qualitative methods to capture the benefits of end-of-life care to those close to the dying for use in economic evaluation

BACKGROUND

End-of-life care affects both the patient and those close to them. Typically, those close to the patient are not considered within economic evaluation, which may lead to the omission of important benefits resulting from end-of-life care.

AIM

To develop an outcome measure suitable for use in economic evaluation that captures the benefits of end-of-life care to those close to the dying.

DESIGN

To develop the descriptive system for the outcome measure, in-depth qualitative interviews were conducted with the participants and constant comparative analysis methods were used to develop a descriptive system for the measure.

PARTICIPANTS

Twenty-seven individuals bereaved within the last 2 years or with a close-person currently receiving end-of-life care were purposively recruited into the study. Participants were recruited through newsletters, adverts, snowball sampling and a local hospice.

RESULTS

Twenty-seven individuals were recruited. A measure of capability with six attributes, each with five levels, was developed based on themes arising from the analysis. Attributes comprise the following: good communication with services, privacy and space to be with the loved one, emotional support, practical support, being able to prepare and cope and being free from emotional distress related to the condition of the decedent.

CONCLUSION

This measure is designed to capture the benefits of end-of-life care to close-persons for use in economic evaluation. Further research should value the measure and develop methods for incorporating outcomes for close-persons into economic evaluation.

Chapter 1. Beyond the reification of vulnerability, thinking vulnerability as the subject capability

In this introduction I will draw an overview of theories associated with the notion of care from feminist studies to clinical theory by articulating the concept of vulnerability to that of capability in Amartya Sen and showing the roots of capability theory in Aristotle and anti-utilitarian theories.

The Capability Approach: A Critical Review of Its Application in Health Economics

The capability approach is an approach to assessing well-being developed by Amartya Sen. Interest in this approach has resulted in several attempts to develop questionnaires to measure and value capability at an individual level in health economics. This commentary critically reviews the ability of these questionnaires to measure and value capability. It is argued that the method used in the questionnaires to measure capability will result in a capability set that is an inaccurate description of the individual's true capability set. The measured capability set will either represent only one combination and ignore the value of choice in the capability set, or represent one combination that is not actually achievable by the individual. In addition, existing methods of valuing capability may be inadequate because they do not consider that capability is a set. It may be practically more feasible to measure and value capability approximately rather than directly. Suggestions are made on how to measure and value an approximation to capability, but further research is required to implement the suggestions.

The family accompaniment of persons with dementia seen through the lens of the capability approach

Using the capability approach initially developed by A Sen as a theoretical framework, this paper analyses both what people with dementia and their families do in response to difficulties in their daily life brought about by the disease, and the reasons they give for acting as they do. Individual and collective interviews and ethnographic observations with 15 persons with dementia and one or more of their family members were conducted. Follow-up interviews were possible for nine families. Results highlight a great diversity in ways of doing things and in accompaniment by family members. Daily adjustments are often hidden or minimized, at least at the onset of the dementia. Later, they become more frequent, repetitive and indispensable but remain influenced by the social and gender roles that existed prior to the illness. The inventiveness of families, in a context marked by various kinds of constraints, is primarily motivated by their desire to maintain the apparently intact abilities of the person with dementia but especially to preserve forms of liberty and what counted for the person, what that person valued before the disease. There are some ways of living with dementia, even when accompanied, which may long remain preferable to others, which better answer to the past and present aspirations of persons with dementia and the purposes of the accompanying persons. It is thus essential that health professionals, as well as society in general, recognize and address this issue.

Personalised Medicine and Scarce Resources: A Discussion of Ethical Chances and Challenges from the Perspective of the Capability Approach

In the aftermath of the economic crisis that started in 2008, resources have become scarcer than ever in some countries, also in health care. Priority setting and rationalisation of existing resources also affect pharmaceutical innovations, including those that would contribute to what is called personalised medicine. In this paper, we will highlight the ethical issues surrounding rationalisation and its impact on personalised medicine through the lens of the capability approach. Thereby, challenges to and opportunities for personalised medicine will be examined, assessing how they affect patients' 'real options' to access innovative therapies. In our focus on the 'first challenge: citizens and patients' of the so-called Strategic Research and Innovation Agenda, the strength of the capability approach becomes particularly apparent in identifying what different values are at stake in this context.

The Economic Crisis and Its Ethical Relevance for Public Health in Europe - an Analysis in the Perspective of the Capability Approach

Policy responses to the economic crisis have manifest consequences to European population health and health systems. The aim of this article is to assess, by using the capability approach advanced by Sen, the ethical dimension of trade-offs made in health policy due to austerity measures. From a capability approach point of view, austerity measures such as reducing resources for health care, further deregulating the health care market or moving towards privatisation are ethically challenging since they limit opportunities and capabilities for individuals of a population. Public policies should thus aim to guarantee sufficient capabilities (options to access health care and possibilities to make healthy choices) for its populations. Prioritising those in need is a notion the capability approach particularly focuses on in its goal of supporting those with the least capabilities.

Practical Opportunities for Healthy Diet and Physical Activity: Relationship to Intentions, Behaviors, and Body Mass Index

PURPOSE

Current strategies for improving diet and activity patterns focus on encouraging patients to make better choices, but they meet with limited success. Because the choices people make depend on the choices they have, we examined how practical opportunities for diet and physical activity shape behavioral intentions and achieved behaviors.

METHODS

Participants included 746 adults who visited 8 large primary care practices in the Residency Research Network of Texas in 2012. We used structural equation models to confirm factor structures for a previously validated measure of practical opportunities, and then modeled achieved diet (Starting the Conversation - Diet questionnaire), physical activity (International Physical Activity Questionnaire), and BMI as a function of opportunities (classified as either resources or conversion factors that influence use of resources), behavioral intentions, and demographic covariates.

RESULTS

In path models, resources (P <.001) and conversion factors (P = .005) predicted behavioral intentions for activity. Conversion factors (P <.001), but not resources, predicted diet intentions. Both activity resources (P = .01) and conversion factors (P <.001) were positively associated with weekly activity minutes. Diet conversion factors (P <.001), but not diet resources (P = .08), were positively associated with diet quality. The same patterns were observed for body mass index (BMI). Socioeconomic gradients in resources and conversion factors were evident.

CONCLUSIONS

Individuals' feasible opportunities for healthy diet and activity have clinically meaningful associations with intentions, achieved behaviors, and BMI. Assessing opportunities as part of health behavior management could lead to more effective, efficient, and compassionate interventions.

Using the capability approach to understand the determinants of subjective well-being among community-dwelling older people in New Zealand

BACKGROUND

as the longevity of the population increases, attention has turned to quality of life of older people as a component of healthy ageing. The objective of this study was to use Welch Saleeby's model of the capability approach to explore the determinants of subjective well-being among older people.

METHODS

this analysis used data from a sample of older people, aged 50-87, from 2012 wave of the New Zealand Longitudinal Study of Ageing (NZLSA) (n = 2,793). Structural equation modelling was used to examine the relationships between the commodities (number of chronic conditions reported, physical and mental health), and personal and environmental factors (economic living standard and discrimination), on the capabilities of older people to achieve well-being.

RESULTS

the findings supported Welch Saleeby's model. Capabilities mediated the relationship between commodities and well-being, indicating that increasing the range of real opportunities available to older people is a key step in increasing well-being. Age and gender were also found to be significant moderators of these relationships. The relationship between economic living standards and well-being was weakest for the oldest participants, but experiences of discrimination had a stronger effect on well-being in this age group.

CONCLUSION

Welch Saleeby's model of the capability approach provides a useful framework for advancing the ethics of care as it highlights the multidimensional nature of well-being in later life. Focusing on expanding capabilities for older people enables policymakers and practitioners to understand the resources and supports required to enable well-being in the context of health challenges.

Ideas of Perfection and the Ethics of Human Enhancement

Whatever ethical stance one takes in the debate regarding the ethics of human enhancement, one or more reference points are required to assess its morality. Some have suggested looking at the bioethical notions of safety, justice, and/or autonomy to find such reference points. Others, arguing that those notions are limited with respect to assessing the morality of human enhancement, have turned to human nature, human authenticity, or human dignity as reference points, thereby introducing some perfectionist assumptions into the debate. In this article, we ask which perfectionist assumptions should be used in this debate. After a critique of views that are problematic, we take a positive approach, suggesting some perfectionist elements that can lend guidance to the practice of human enhancement, based on the work of Martha Nussbaum's Capability Approach. We suggest that the central capabilities can be used to define the human aspect of human enhancement and thereby allow a moral evaluation of enhancement interventions. These central capabilities can be maximized harmoniously to postulate what an ideal human would look like. Ultimately, the aim of this article is twofold. First, it seeks to make explicit the perfectionist assumptions found in the debate and eliminate those that are problematic. Second, the paper clarifies an element that is often neglected in the debate about human enhancement, the view of the ideal human towards which human enhancement should strive. Here, we suggest that some central capabilities that are essential for an ideal human being can be maximized harmoniously and can therefore serve as possible reference points to guide human enhancement.

Malaria Control in Amerindian Communities of Venezuela : Strengthening Ecohealth Practice Throughout Conservation Science and Capability Approach

Adaptive management and ecohealth frameworks were developed for malaria elimination in Amerindian riparian communities of Venezuela. These frameworks were developed as a strategy to capture, organize, and communicate connections among key factors related to local malaria complex systems. Important causal relationships between social, economic, and environmental stressors which are determinant of malaria were identified at different levels and assumptions that guide interventions are offered, based on available scientific knowledge and input from stakeholders. Drawing on our experience of action research committed to the health of Amerindian populations and conservation of areas with biodiversity value, the authors provide lessons to strengthen the practice of an ecohealth approach. First, conservation targets were considered as a way to achieve sustainable human well-being rather than as a consequence of well-being. Second, the effectiveness and sustainability of technical solutions generally proposed for malaria control depend largely on individual knowledge, attitudes, and practices. Hence, it is necessary to look at the real opportunities of choices that Amerindian people have for attaining a life without malaria, and therefore pay attention to local capabilities, needs, and freedom to choose. The ecohealth approach can benefit from the capability approach, and we explain why.

Test-retest reliability of capability measurement in the UK general population

Although philosophically attractive, it may be difficult, in practice, to measure individuals' capabilities (what they are able to do in their lives) as opposed to their functionings (what they actually do). To examine whether capability information could be reliably self-reported, we administered a measure of self-reported capability (the Investigating Choice Experiments Capability Measure for Adults, ICECAP-A) on two occasions, 2 weeks apart, alongside a self-reported health measure (the EuroQol Five Dimensional Questionnaire with 3 levels, EQ-5D-3L). We found that respondents were able to report capabilities with a moderate level of consistency, although somewhat less reliably than their health status. The more socially orientated nature of some of the capability questions may account for the difference.