Chronic pain among older adults and its impact on satisfaction with social participation: development and validation of the "Instrument to Assess Older Adults' Social Participation". A descriptive quantitative study

BACKGROUND

We aimed to develop and validate a practical instrument to assess older adults' satisfaction with their social participation (SP).

DESIGN AND SETTING

This methodological validation study was conducted at a public higher education institution.

METHODS

A two-phase study was designed, developed, and validated to assess older adults' satisfaction with their SP. In the first phase, we conceptualized SP and developed an "instrument to assess older adults' satisfaction with their SP (IAPSI)," as approved by a committee of specialists, pre-tested, and partially validated. Second, we determined the IAPSI's reproducibility using Cronbach's alpha to measure internal consistency, Pearson's and Spearman's coefficients to measure correlations, the Bland-Altman plot and intraclass correlation coefficient (ICC) to measure reproducibility. We also generated a receiver operating characteristic (ROC) curve.

RESULTS

102 older adults (mean age, 87.29) participated in the first phase. Moderate internal consistency (Cronbach's alpha 0.7) and significant moderate correlations with quality of life by World Health Organization Quality of Life (WHOQOL)-bref and by WHOQOL-old social domains (Pearson's coefficients 0.54 and 0.64, respectively; P < 0.001) were found. The ROC curve indicated an IAPSI score of 17 as the threshold for the impact of pain on satisfaction with SP (83.3% sensitivity and 88.9% specificity, P < 0.001). In the second phase, 56 older adults (between 81 and 90 years old) participated. We found adequate intra- and inter-observer reproducibility for the IAPSI (ICC 0.96 and 0.78, respectively).

CONCLUSION

We have developed a practical instrument with appropriate psychometric properties to assess older adults' satisfaction with their SP.

An examination of the social perceptions and vaping preferences of young electronic nicotine delivery system users

Background

Little research has been conducted on social aspects and preferences of electronic nicotine delivery system (ENDS) use among young ENDS users, and none have examined differences in these aspects and preferences by gender and tobacco use status.

Methods

A total of 558 young regular vapers (ages 16-24; vaped at least once a week for the last 3 months) from Nova Scotia were recruited to complete a demographic and vaping questionnaire. A 2 x 3 study design was used to compare participants on social aspects and vaping preferences based on gender (male or female) and tobacco use status (never, former, or current smoker). Chi-square tests were used to determine significant differences, and Bonferroni tests were used to assess over- and under-representation within significant variables.

Results

Current tobacco-using male vapers had a higher frequency of experiencing pressure to vape from friends and current employment as compared to females. Former and never tobacco-using male vapers had a higher frequency of parental awareness of their vaping behavior than females. Former tobacco-using female vapers had a higher frequency of being influenced to vape by others they know on social media than males. Both never and former tobacco-using females reported a higher frequency of exposure to vaping content on social media than males. Never tobacco-using female vapers preferred vape pen devices relative to males.

Conclusions

Important gender differences by tobacco use status exist and demonstrate differential patterns of social influence for ENDS use and their experiences within this demographic.

COVID-19 conscience tracing: mapping the moral distances of coronavirus

One of the many problems posed by the collective effort to tackle COVID-19 is non-compliance with restrictions. Some people would like to obey restrictions but cannot due to their job or other life circumstances; others are not good at following rules that restrict their liberty, even if the potential consequences of doing so are repeatedly made very clear to them. Among this group are a minority who simply do not care about the consequences of their actions. But many others fail to accurately perceive the harms that they might be causing. One of the main reasons for this is that the harms done by transmitting COVID-19 to someone else are morally distant from the agent, particularly in cases where infection is asymptomatic. In this paper, I describe seven different aspects of moral distance in the context of COVID-19, explore how they affect (lack of) motivation to obey restrictions, and suggest several ways in which such moral distance can be reduced - primarily through enhanced-contact tracing that makes it clear to individuals and the public precisely who they could be harming and how.

Health Technology Assessment for In Silico Medicine: Social, Ethical and Legal Aspects

The application of in silico medicine is constantly growing in the prevention, diagnosis, and treatment of diseases. These technologies allow us to support medical decisions and self-management and reduce, refine, and partially replace real studies of medical technologies. In silico medicine may challenge some key principles: transparency and fairness of data usage; data privacy and protection across platforms and systems; data availability and quality; data integration and interoperability; intellectual property; data sharing; equal accessibility for persons and populations. Several social, ethical, and legal issues may consequently arise from its adoption. In this work, we provide an overview of these issues along with some practical suggestions for their assessment from a health technology assessment perspective. We performed a narrative review with a search on MEDLINE/Pubmed, ISI Web of Knowledge, Scopus, and Google Scholar. The following key aspects emerge as general reflections with an impact on the operational level: cultural resistance, level of expertise of users, degree of patient involvement, infrastructural requirements, risks for health, respect of several patients’ rights, potential discriminations for access and use of the technology, and intellectual property of innovations. Our analysis shows that several challenges still need to be debated to allow in silico medicine to express all its potential in healthcare processes.

One Health Action against Human Fascioliasis in the Bolivian Altiplano: Food, Water, Housing, Behavioural Traditions, Social Aspects, and Livestock Management Linked to Disease Transmission and Infection Sources

The Northern Bolivian Altiplano is the fascioliasis endemic area with the reported highest human prevalence and intensities. A multidisciplinary One Health initiative was implemented to decrease infection/reinfection rates detected by periodic monitoring between the ongoing yearly preventive chemotherapy campaigns. Within a One Health axis, the information obtained throughout 35 years of field work on transmission foci and affected rural schools and communities/villages is analysed. Aspects linked to human infection risk are quantified, including: (1) geographical extent of the endemic area, its dynamics, municipalities affected, and its high strategic importance; (2) human population at risk, community development and mortality rates, with emphasis on problems in infancy and gender; (3) characteristics of the freshwater collections inhabited by lymnaeid snail vectors and constituting transmission foci; (4) food infection sources, including population surveys with questionnaire and reference to the most risky edible plant species; (5) water infection sources; (6) household characteristics; (7) knowledge of the inhabitants on Fasciola hepatica and the disease; (8) behavioural, traditional, social, and religious aspects; (9) livestock management. This is the widest and deepest study of this kind ever performed. Results highlight prevention and control difficulties where inhabitants follow century-old behaviours, traditions, and beliefs. Intervention priorities are proposed and discussed.

The Person's Care Requires a Sex and Gender Approach

There is an urgent need to optimize pharmacology therapy with a consideration of high interindividual variability and economic costs. A sex-gender approach (which considers men, women, and people of diverse gender identities) and the assessment of differences in sex and gender promote global health, avoiding systematic errors that generate results with low validity. Care for people should consider the single individual and his or her past and present life experiences, as well as his or her relationship with care providers. Therefore, intersectoral and interdisciplinary studies are urgently required. It is desirable to create teams made up of men and women to meet the needs of both. Finally, it is also necessary to build an alliance among regulatory and ethic authorities, statistics, informatics, the healthcare system and providers, researchers, the pharmaceutical and diagnostic industries, decision makers, and patients to overcome the gender gap in medicine and to take real care of a person in an appropriate manner.

Quality of Life in Individuals with Diabetic Foot Syndrome

BACKGROUND AND OBJECTIVE

Diabetic foot syndrome (DFS) is a common long-term complication of diabetes mellitus. DFS has recently been associated with adverse effects that could further impair the quality of life of diabetic patients, and increase the social and economic burden, morbidity, and premature mortality of the disease. The main physio-pathological basis of DFS is due to diabetesinduced neuropathy and angiopathy in the lower limbs and feet. Patients diagnosed with DFS must significantly modify their daily habits in order to cope with signs and symptoms of DFS and this can alter their quality of life. The objective of this review is to summarize the evidence regarding the economic, physical and social limitations which can affect the quality of life (QoL) in patients with DFS, the effects of ulcers and amputations on QoL outcomes.

RESULTS

Different aspects related to DFS such as physical alterations, psychological complaints and even disorders, socio-economic difficulties can affect the quality of life of these patients. However, the QoL related to low socio-economic factors gave mixed results and physical activity, education and type of footwear can influence the outcomes. There is a general gender-dependent higher prevalence of DFS in men, although it depends on the geographical area. DFS often co-occurs with other diabetes-induced complications (retinopathy, nephropathy and cardiovascular disorders) and comorbid obesity generally worsens it.

CONCLUSION

Accessibility to health services aimed at reducing inequalities and constant health education and promotion and care regarding psychological and socio-economic issues should be continuously undertaken for individuals with DFS in order to improve their QoL.

Doctors have an ethical obligation to ask patients about food insecurity: what is stopping us?

Inadequate diet is the leading risk factor for morbidity and mortality worldwide. However, approaches to identifying inadequate diets in clinical practice remain inconsistent, and dietary interventions (on both individual and public health policy levels) frequently focus on facilitating 'healthy choices', with limited emphasis on structural constraints. We examine the ethical implications of introducing a routine question in the medical history about ability to access food. Not collecting data on food security means that clinicians are unable to identify people who may benefit from support on an individual level, unable to consider relevant dietary risk factors for disease and disease progression and unable to monitor population trends and inequalities in dietary access in order to design effective policy interventions. We argue that the current lack of routine screening for food insecurity is inconsistent with our approach to other health behaviours (eg, smoking and alcohol use), as well as with doctors' frequent informal role as gatekeepers to the food aid system, and recent calls for governmental action on food insecurity and health inequalities from individual clinicians and professional bodies. Potential ethical barriers to asking patients about food security are addressed, including concerns about stigma, limiting autonomy, fair resource allocation, unclear professional remits and clinicians' ability to offer effective interventions. We suggest that there is an ethical imperative for doctors to ask patients about their ability to access healthy food. Gathering this data provides a valuable first step in re-framing the social determinants of health as modifiable risks, rather than inevitable inequities.

Reflections of methodological and ethical challenges in conducting research during COVID-19 involving resettled refugee youth in Canada

Research involving migrant youth involves navigating and negotiating complex challenges in order to uphold their rights and dignity, but also all while maintaining scientific rigour. COVID-19 has changed the global landscape within many domains and has increasingly highlighted inequities that exist. With restrictions focusing on maintaining physical distancing set in place to curb the spread of the virus, conducting in-person research becomes complicated. This article reflects on the ethical and methodological challenges encountered when conducting qualitative research during the pandemic with Syrian migrant youth who are resettled in Canada. The three areas discussed from the study are recruitment, informed consent and managing the interviews. Special attention to culture as being part of the study's methodology as an active reflexive process is also highlighted. The goal of this article is to contribute to the growing understanding of complexities of conducting research during COVID-19 with populations which have layered vulnerabilities, such as migrant youth. This article hopes that the reflections may help future researchers in conducting their research during this pandemic by being cognizant of both the ethical and methodological challenges discussed.

Depressive symptoms among older adults with HIV in Namibia: the role of social support and spirituality

Background: More than 60% of older adults living with HIV reside in sub-Saharan Africa. Namibia has one of the highest HIV/AIDS prevalence rates. This study examined the association between social support, spirituality and depressive symptoms.Method and results: The sample consisted of 147 Oshiwambo-speaking older adults (mean age = 61 years, SD = 6.92 years) with HIV in Namibia. By utilising a hierarchical multivariate regression method, this study found that social support from friends and spirituality showed a significant negative relationship to depressive symptoms. In addition, self-rated health status and alcohol use were significant sociodemographic predicitive factors of depressive symptoms.Conclusion: This study suggests the need to develop interventions and support programmes that incorporate peer support and spiritual practice to promote health and well-being among older persons living with HIV in Namibia.

Triage and justice in an unjust pandemic: ethical allocation of scarce medical resources in the setting of racial and socioeconomic disparities

Shortages of life-saving medical resources caused by COVID-19 have prompted hospitals, healthcare systems, and governmentsto develop crisis standards of care, including 'triage protocols' to potentially ration medical supplies during the public health emergency. At the same time, the pandemic has highlighted and exacerbated racial, ethnic, and socioeconomic health disparities that together constitute a form of structural racism. These disparities pose a critical ethical challenge in developing fair triage systems that will maximize lives saved without perpetuating systemic inequities. Here we review alternatives to 'utilitarian' triage, including first-come first-served, egalitarian, and prioritarian systems of allocating scarce medical resources. We assess the comparative advantages and disadvantages of these allocation schemes. Ultimately, we argue that while triage protocols should not exacerbate disparities, they are not an adequate mechanism for redressing systemic health inequities. Entrenched health disparities must be addressed through broader social change.

Arguments on thin ice: on non-medical egg freezing and individualisation arguments

The aim of this article is to provide a systematic reconstruction and critique of what is taken to be a central ethical concern against the use of non-medical egg freezing (NMEF). The concern can be captured in what we can call the individualisation argument. The argument states, very roughly, that women should not use NMEF as it is an individualistic and morally problematic solution to the social problems that women face, for instance, in the labour market. Instead of allowing or expecting women to deal with them on an individual level, we should address them by challenging the patriarchal structures of the labour market-for example, by securing equal pay, or paid maternal leave, or 'paid paternal [partner] leave and sick leave and affordable child care'. It will be made clear that there are several versions of this argument. The author will try to elaborate this claim, and it will be explained that the differences depend on the way in which bioethicists believe that individuals use of NMEF is morally problematic, compared with the alternative of securing social change for women in, say, the labour market. Finally, a critical discussion of three versions of the individualisation argument will follow, and it will be shown why all versions are on rather thin ice, or in other words, that they are implausible.

Partial ectogenesis: freedom, equality and political perspective

In this commentary, I consider how Giulia Cavaliere's arguments about the limited reach of the current justifications offered for full ectogenesis in the bioethical literature apply in the context of partial ectogenesis. I suggest that considering the extent to which partial ectogenesis is freedom or equality promoting is more urgent because of the more realistic prospect of artificial womb technology being utilised to facilitate partial gestation extra uterum as opposed to facilitating complete gestation from conception to term. I highlight concerns about potentially harmful social narratives surrounding pregnancy and about the current legal framework surrounding gestation limiting access to technology in the advent of partial ectogenesis. I do not advocate that these concerns mean that we ought not develop artificial wombs, but like Cavaliere I suggest that we must be mindful of these concerns, and I posit that legal reform must accompany technological developments. Ectogenesis as a political perspective, through which we consider the value in social reproduction and the experiences of pregnant people, is useful to prevent political capture of this technology for regressive policies. Using this perspective to examine the law is also a useful tool to expose just how restrictive the law is in relation to gestation and female reproductive health.

Responsibility in healthcare across time and agents

It is unclear whether someone's responsibility for developing a disease or maintaining his or her health should affect what healthcare he or she receives. While this dispute continues, we suggest that, if responsibility is to play a role in healthcare, the concept must be rethought in order to reflect the sense in which many health-related behaviours occur repeatedly over time and are the product of more than one agent. Most philosophical accounts of responsibility are synchronic and individualistic; we indicate here what paying more attention to the diachronic and dyadic aspects of responsibility might involve and what implications this could have for assessments of responsibility for health-related behaviour.

Medical crowdfunding in China: empirics and ethics

Medical crowdfunding has become a popular choice worldwide for people with unaffordable health needs. In low-income and middle-income countries with limited social welfare arrangements and a high incidence of catastrophic health spending, the market for medical crowdfunding is booming. However, relevant research was conducted exclusively in North America and Europe; little is known about medical crowdfunding activities inother contexts. As a first step towards filling this knowledge gap, this study depicts the realities of medical crowdfunding in a middle-income country China through empirical investigation and ethical analysis. We examine 100 randomly selected medical campaigns from a major Chinese crowdfunding platform and analyse the relevance of the previously identified ethical concerns to the Chinese context. The empirical findings show that Chinese campaigns have low and uneven success rates, require legally the participation of charitable organisations and focus on financial distress and family values in appealing for donations. In addition, the ethical analysis suggests that medical crowdfunding in China shares several ethical concerns raised in developed countries such as the veracity of claims and privacy violation. More importantly, our research reveals the inadequacy of current evidence and the lack of indicators to evaluate ethical issues in practice. Additional research is needed to better understand this fundraising practice across different social and cultural contexts.

Moral case for legal age change

Should a person who feels his legal age does not correspond with his experienced age be allowed to change his legal age? In this paper, I argue that in some cases people should be allowed to change their legal age. Such cases would be when: (1) the person genuinely feels his age differs significantly from his chronological age and (2) the person's biological age is recognised to be significantly different from his chronological age and (3) age change would likely prevent, stop or reduce ageism, discrimination due to age, he would otherwise face. I also consider some objections against the view that people should be allowed to change their legal age and find them lacking.

Further defence of legal age change: a reply to the critics

In 'Moral case for legal age change', I argue that sometimes people should be allowed to change their age. I refute six immediate objections against the view that age change is permissible. I argue that the objections cannot show that legal age change should always be prohibited. In this paper, I consider some further objections against legal age change raised by Iain Brassington, Toni Saad and William Simkulet. I argue that the objections fail to show that age change should never be allowed.

Against the nihilism of 'legal age change': response to Räsänen

Räsänen has attempted to make a moral case for permitting some people to change their legal age: if someone considers that their chronological age does not correspond to their emotional age or biological age, and they face age-based discrimination as a result, they may change the legal record of their age. This response considers some of the problems with Räsänen's paper, including its reliance on equivocation. It concludes that what is billed as a moral argument turns out to be a conflicted case for deception which relies on a nihilistic outlook on reality.

Ethics of Incongruity: moral tension generators in clinical medicine

Affectively uncomfortable concern, anxiety, indecisionand disputation over 'right' action are among the expressions of moral tension associated with ethical dilemmas. Moral tension is generated and experienced by people. While ethical principles, rules and situations must be worked through in any dilemma, each occurs against a backdrop of people who enact them and stand much to gain or lose depending on how they are applied and resolved. This paper attempts to develop a taxonomy of moral tension based on its intrapersonal and interpersonal sources and expressions. The proposed 'ethics of incongruity' (EoI) outlines ways in which values, actions and needs can find themselves mismatched in morally relevant ways between patients and their clinicians, their own psychologies and their societies. Patient-clinician incongruities may manifest as discord, value misalignment and deception. Patient-patient (ie, intrapersonal) incongruities may manifest as incapacity, akrasia and self-deception. Patient-society incongruities may manifest as disenfranchisement, disaffiliation and disregard. Brief explanations of the incongruities in this scheme are provided, as are suggestions on working within them. Using concepts from moral philosophy when applicable, these suggestions may either ease direct resolution of problems arising from the incongruities, or make sense of the moral tension that arises from the human context of the ethical dilemma at hand. This presentation of content and resolution methods for the EOI is no doubt incomplete. Hopefully, refinement of this preliminary proposal will follow, particularly from clinicians, as the ones who, along with their patients, experience medical ethics in directly tension-inducing ways.

Reproductive outsourcing: an empirical ethics account of cross-border reproductive care in Canada

Cross-border reproductive care (CBRC) can be defined as the movement from one jurisdiction to another for medically assisted reproduction (MAR). CBRC raises many ethical concerns that have been addressed extensively. However, the conclusions are still based on scarce evidence even considering the global scale of CBRC. Empirical ethics appears as a way to foster this ethical reflection on CBRC while attuning it with the experiences of its main actors. To better understand the 'in and out' situation of CBRC in Canada, we conducted an ethnographic study taking a 'critically applied ethics' approach. This article presents a part of the findings of this research, obtained by data triangulation from qualitative analysis of pertinent literature, participant observation in two Canadian fertility clinics and 40 semidirected interviews. Based on participants' perceptions, four themes emerged: (1) inconsistencies of the Canadian legal framework; (2) autonomy and the necessity to resort to CBRC; (3) safety and the management of CBRC individual risks; and (4) justice and solidarity. The interaction between these four themes highlights the problematic of 'reproductive outsourcing' that characterised the Canadian situation, a system where the controversial aspects of MAR are knowingly pushed outside the borders.

How important is social support in determining patients' suitability for transplantation? Results from a National Survey of Transplant Clinicians

BACKGROUND

National guidelines require programmes use subjective assessments of social support when determining transplant suitability, despite limited evidence linking it to outcomes. We examined how transplant providers weigh the importance of social support for kidney transplantation compared with other factors, and variation by clinical role and personal beliefs.

METHODS

The National survey of the American Society of Transplant Surgeons and the Society of Transplant Social Work in 2016. Using a discrete choice approach, respondents compared two hypothetical patient profiles and selected one for transplantation. Conditional logistic regression estimated the relative importance of each factor; results were stratified by clinical role (psychosocial vs medical/surgical providers) and beliefs (outcomes vs equity).

RESULTS

Five hundred and eighy-four transplant providers completed the survey. Social support was the second most influential factor among transplant providers. Providers were most likely to choose a candidate who had social support (OR=1.68, 95% CI 1.50 to 1.86), always adhered to a medical regimen (OR=1.64, 95% CI 1.46 to 1.88), and had a 15 years life expectancy with transplant (OR=1.61, 95% CI 1.42 to 1.85). Psychosocial providers were more influenced by adherence and quality of life compared with medical/surgical providers, who were more influenced by candidates' life expectancy with transplant (p<0.05). For providers concerned with avoiding organ waste, social support was the most influential factor, while it was the least influential for clinicians concerned with fairness (p<0.05).

CONCLUSIONS

Social support is highly influential in listing decisions and may exacerbate transplant disparities. Providers' beliefs and reliance on social support in determining suitability vary considerably, raising concerns about transparency and justice.

Chronic disease as risk multiplier for disadvantage

This paper starts by establishing a prima facie case that disadvantaged groups or individuals are more likely to get a chronic disease and are in a disadvantaged position to adhere to chronic treatment despite access through Universal Health Coverage. However, the main aim of this paper is to explore the normative implications of this claim by examining two different but intertwined argumentative lines that might contribute to a better understanding of the ethical challenges faced by chronic disease health policy. The paper develops the argument that certain disadvantages which may predispose to illness might overlap with disadvantages that may hinder self-management, potentially becoming disadvantageous in handling chronic disease. If so, chronic diseases may be seen as disadvantages in themselves, describing a reproduction of disadvantage among the chronically ill and a vicious circle of disadvantage that could both predict and shed light on the catastrophic health outcomes among disadvantaged groups-or individuals-dealing with chronic disease.

Risky consumption of alcohol and drugs among employees at ski resorts

AIM

To evaluate risky consumption of alcohol and drugs among Swedish men and women who are employed at ski resorts.

METHODS

A cross-sectional sample of 611 employees in 48 small and medium-sized enterprises responded to a questionnaire covering alcohol and drug use, social aspects around work and working conditions. Consumption of alcohol and drugs in the study sample was compared to population data. Data were analysed using Mann-Whitney U-tests and logistic regression analyses.

RESULTS

Compared to the general population, the study group of ski resort employees had higher scores on the Alcohol Use Disorders Identification Test (AUDIT) in all age groups except 35+ for men. Regarding the Drug Use Disorders Identification Test (DUDIT) scores, only men in the 18-24 age group had higher scores compared to the general population. The prevalence of risky alcohol and drug use was higher among seasonally employed individuals; 82.9%, compared to 58.0% among other employees for alcohol; 8.3% compared to 2.8% for drugs. The regression analysis indicated that social aspects such as living together with colleagues and having co-workers/friends who are frequently inebriated were the most significant explanatory variables for explaining risk consumption of alcohol (OR 16.82 and OR 4.33). Risky use of drugs was associated with being younger (OR 0.15) and male (OR 0.86), as well as with having co-workers/friends who are frequently inebriated (OR 4.25).

CONCLUSIONS

The study showed a high prevalence of risky alcohol consumption among ski resort employees compared to the general population, with higher risky drug consumption found only among younger men. Social aspects such as living with colleagues and having co-workers or friends who are often inebriated, were identified as important explanatory factors. Preventive measures should be introduced, targeting norms and work culture surrounding alcohol and drug use among ski resort employees.

Metabolic syndrome, hypertension, and nervous system injury: Epidemiological correlates

Metabolic syndrome (MetS) is a common and complex disorder combining hypertension, obesity, dyslipidemia, and insulin resistance. MetS represents a risk factor for changes in cognitive functions in older age, and several studies have suggested that MetS may be linked to dementia. This article reviews the main evidences about the relationship between MetS and neurodegenerative disease. Starting from an epidemiological point of view, the article analyzes medico-social aspects related to MetS, considering the reduction of work capacity and the condition of disability that it involves. Some authors affirm that on the basis of current Italian legislation, it is possible to consider the syndrome as a disability. This is because all the diseases that make up MetS are high-risk clinical pathological conditions. For these reasons, a joint action is required to contain the incidence of MetS, the high social costs, and the loss of productivity related to the syndrome. In conclusion, healthcare initiatives could be adopted in order to increase the understanding of the pathogenic contributions of each element on MetS and how they can be modified. These actions will be useful to reduce healthcare costs and can lead to more effective prevention of metabolic disease, thus promoting good health.

ABBREVIATIONS

MetS: Metabolic syndrome; WHO: World Health Organization; CVD: cerebrovascular diseases; AD: Alzheimer's Disease; VaD: Vascular Dementia; IDF: International Diabetes Federation; T2DM: type 2 diabetes mellitus; CAD: coronary artery disease; MCI: mild cognitive impairment; NCDs: Non Communicable Diseases; BMI: Body Mass Index; ICIDH: International classification of impairments, disabilities and handicaps.

The ethics of HIV research with people who inject drugs in Africa: a desk review

Injecting drug use is a growing problem in Africa and a growing risk factor for contracting HIV in the region. It is imperative that HIV research includes injecting drug users so that they too are able to benefit from safe and effective behavioural interventions and biomedical HIV prevention and treatment products. This article relates a critical review of the findings of a desk review of previously published literature. The article examines injecting drug use in relation to HIV-related risk and research in Kenya, Mauritius, Nigeria, South Africa and Tanzania. The ethical challenges of including people who inject drugs in HIV research in Africa are also presented. The review found injecting drug use to be on the increase in all the countries reviewed. HIV-risk behaviour among people who inject drugs, such as needle-sharing and higher-risk sexual behaviour, was also found to be widespread. Furthermore, criminalisation of drug use and strict anti-drug laws are common in the countries reviewed, while harm-reduction programmes for people who inject drugs were found to be limited. The review identified a number of ethical challenges to the involvement of people who inject drugs in HIV research in Africa. This includes the illegal status and stigma surrounding injecting drug use, which may complicate participant recruitment, enrolment and retention. In addition, a lack of funding for supportive programmes to help injecting drug users may hinder the provision of appropriate standards of prevention and care and treatment for those who seroconvert.

Children as caregivers of older relatives living with HIV and AIDS in Nyang'oma division of western Kenya

There is growing debate about the situations of children who care for a relative with HIV-related illness, especially in developing countries with high HIV prevalence. In particular, there is inadequate information on the long-term consequences of children taking on this caregiving role. The article reanalyses data collected between January and November 2006 in a rural setting in western Kenya where 19 children caring for a total of 15 people living with HIV or AIDS (PLHIV) participated. Data were collected through in-depth interviews, participant observation, focus group discussions and narratives. The findings show that children regularly become involved in caregiving due to lack of a responsible adult to perform the role, which may be as a result of HIV stigma and rejection of the care recipient by extended family members and neighbours or because of cultural barriers. Fulfilling the responsibilities of caregiving had profound repercussions for the children's lives, including psychological distress, physical burden, dropping out of school, participation in wage labour, and forced early marriage. Financial needs pushed some girls into transactional sexual relations, predisposing them to the risks of unwanted pregnancy or sexually transmitted infections. Since the children providing care for PLHIV are themselves vulnerable, we recommend that they should be targeted with support.

A qualitative exploration of the impact of HIV and ART on social disruption and household continuity in Uganda

With increased uptake of antiretroviral therapy (ART) throughout sub-Saharan Africa, it is critical to have a better understanding of the impact of ART on all health dimensions since the treatment can have the expected benefits as well as unintended negative consequences. We conducted semi-structured interviews with 24 adult HIV clients (19 women and 5 men) in Uganda who had been on ART for at least six months. A grounded approach and content analysis were used to explore the effects of having HIV and undergoing ART on household continuity, social engagement, experience of support and stigma, and children's school attendance. Most of the participants reported loss of a spouse/partner and household discontinuity (e.g. having to move in with extended family) because of HIV, and this was largely unchanged after being on ART. While experiences of HIV stigma and social disengagement were common after an HIV diagnosis, most participants reported improved social interaction after having commenced ART, which for some was tied to economic productivity. Many of the participants' children who had stopped going to school were able to return after the parent was on ART. HIV care and ART, with related improvements in clients' physical and work-related functioning, together with family support, helped to reverse some of the deleterious effects of having HIV. Nonetheless, support that augments healthcare is needed to help individuals provide for themselves and their families, both socially and economically.

Ethical and economic considerations of rare diseases in ethnic minorities: the case of mucopolysaccharidosis VI in Colombia

Mucopolysaccharidosis VI is an autosomal recessive lysosomal storage disorder associated with severe disability and premature death. The presence of a mucopolysaccharidosis-like disease in indigenous ethnic groups in Colombia can be inferred from archaeological findings. There are several indigenous patients with mucopolysaccharidosis VI currently receiving enzyme replacement therapy. We discuss the ethical and economic considerations, regarding both direct and indirect costs, of a high-cost orphan disease in a marginalised minority population in a developing country.

Prevention of alcohol misuse among children, youths and young adults

BACKGROUND

Despite many activities to prevent risky alcohol consumption among adolescents and young adults there is an increase of alcohol intoxications in the group of ten to twenty year old juveniles.

OBJECTIVES

This report gives an overview about the recent literature as well as the German federal prevention system regarding activities concerning behavioral and policy prevention of risky alcohol consumption among children, adolescents and young adults. Furthermore, effective components of prevention activities are identified and the efficiency and efficacy of ongoing prevention programs is evaluated.

METHODS

A systematic literature review is done in 34 databases using Bool'sche combinations of the key words alcohol, prevention, treatment, children, adolescents and young adults.

RESULTS

401 studies were found and 59 studies were selected for the health technology assessment (HTA). Most of the studies are done in USA, nine in Germany. A family strengthening program, personalized computer based intervention at schools, colleges and universities, brief motivational interventions and policy elements like increase of prices and taxes proved effective.

DISCUSSION

Among the 59 studies there are three meta-analyses, 15 reviews, 17 randomized controlled trials (RCT) and 18 cohort studies. Despite the overall high quality of the study design, many of them have methodological weaknesses (missing randomization, missing or too short follow-ups, not clearly defined measurement parameters). The transferability of US-results to the German context is problematic. Only a few prevention activities reach a sustainable reduction of frequency and/or amount of alcohol consumption.

CONCLUSION

The HTA-report shows the need to develop specific and target group focused prevention activities for the German situation. Essential for that is the definition of target goals (reduction of consumption, change of behaviour) as well as the definition and empirical validation of risky alcohol consumption. The efficacy of prevention activities should be proven before they are launched. At present activities for the reduction or prevention of risky alcohol consumption are not sufficiently evaluated in Germany concerning their sustainable efficacy.