Developing the ethics of implementation research in health

Implementation research (IR) is growing in recognition as an important generator of practical knowledge that can be translated into health policy. With its aim to answer questions about how to improve access to interventions that have been shown to work but have not reached many of the people who could benefit from them, IR involves a range of particular ethical considerations that have not yet been comprehensively covered in international guidelines on health research ethics. The fundamental ethical principles governing clinical research apply equally in IR, but the application of these principles may differ depending on the IR question, context, and the nature of the proposed intervention. IR questions cover a broad range of topics that focus on improving health system functioning and improving equitable and just access to effective health care interventions. As such, IR designs are flexible and often innovative, and ethical principles cannot simply be extrapolated from their applications in clinical research. Meaningful engagement with all stakeholders including communities and research participants is a fundamental ethical requirement that cuts across all study phases of IR and links most ethical concerns. Careful modification of the informed consent process may be required in IR to permit study of a needed intervention. The risks associated with IR may be difficult to anticipate and may be very context-specific. The benefits of IR may not accrue to the same groups who participate in the research, therefore justifying the risks versus benefits of IR may be ethically challenging. The expectation that knowledge generated through IR should be rapidly translated into health policy and practice necessitates up-front commitments from decision-makers to sustainability and scalability of effective interventions. Greater awareness of the particular ethical implications of the features of IR is urgently needed to facilitate optimal ethical conduct of IR and uniform ethical review

Factors governing the performance of Auxiliary Nurse Midwives in India: a study in Pune district

Background: The Auxiliary nurse midwife (ANM) cadre was created to focus on maternal and child health. ANMs are respected members of their communities and established providers of maternal and child health care within the community and at the facility level. Over time, additional roles and responsibilities have been added. Despite the importance of ANMs in the primary healthcare system in India, studies that consider factors governing the performance of ANMs in their workplaces are limited. We aimed to study factors governing performance of ANMs in Pune district, India. Methods: Semi-structured interviews were conducted with 13 purposely selected key informants at facility, district, state, and national levels. Focus group discussions were conducted with 41 ANMs and 25 members of the community. Non-participatory observations with eight ANMs provided information to expand on and scrutinise findings that emerged from the other lines of inquiry. A realist lens was applied to identify ANMs’ performance as a result of “mechanisms” (training, supervision, accountability mechanisms) within the given “context” (regulatory system, infrastructure and resources, ANMs’ expanded scope of work, gender roles and norms). Results: Weak enforcement of regulatory system led to poor standardisation of training quality among training institutions. Challenges in internal accountability mechanisms governing ANMs within the health system hierarchy made it difficult to ensure individual accountability. Training and supervision received were inadequate to address current responsibilities. The supervisory approach focused on comparing information in periodic reports against expected outputs. Clinical support in workplaces was insufficient, with very little problem identification and solving. Conclusion: Focusing on the tasks of ANMs with technical inputs alone is insufficient to achieve the full potential of ANMs in a changing context. Systematic efforts tackling factors governing ANMs in their workplaces can produce a useful cadre, that can play an important role in achieving universal health coverage in India

Ethical guidelines for Public Health in developing countries – A review

Ethical principles and guidelines are essential for the practice of public health. With many developing countries rapidly expanding the scope of public health interventions, there is a need to incorporate public health ethics in their health systems. Public health is characterized by the values of common good, respect, solidarity, utility, trust and long term self interest of communities. The field of public health easily lends itself to the utilitarian, communitarian and Kantian deontological theoretical concepts. There are eight popular guidelines in the field of public health ethics. These frameworks are discussed in brief in this paper. Certain unique socio-cultural dimensions of health in developing countries lead to an immediate need for a comprehensive set of ethical guidelines for public health interventions

Knowledge, attitudes and utilization of food labels among undergraduate medical students in a medical college in Chennai – A cross sectional survey

Introduction: Food labeling is an important method of providing food-related information on the package of food products, to facilitate people's choice of safe and appropriate foods. Medical students are potential agents of change in food label utilization behavior in the community. The objectives of this study were to evaluate the knowledge, attitudes, and utilization of food labels among undergraduate medical students in a medical college in Chennai. Material & Methods: We conducted a cross-sectional survey of 200 students studying in the 1st to 3rd year in a medical college through an online Google Forms survey, self-administered by the students after online informed consent was obtained. We gathered information on their knowledge, attitudes, and utilization of food labels. Results: Of 400 students approached, 200 responded to the online survey. They had good knowledge about food labels. Female students had 3.4 (1.59 to 7.25) times better knowledge compared to men. The students had a positive attitude toward food labels, and a majority thought that the food labels are useful. Utilization of food labels to understand the nutritive content (55%), additives (57%), and manufacturer details (47%) was poor. Utilization of food labels was 2.7 times more (1.142–6.587) among those who did regular exercise, and it was 0.2 (0.09 to 0.9) times less among those who were on a strict diet. Conclusion: Medical students had a sound knowledge and good attitude toward food labels, but their food label utilization patterns were still poor. There is a need to incorporate food labeling in the undergraduate medical curriculum and inculcate better food label utilization behavior

Trust in Healthcare: Need for Perspectives from Developing Healthcare Settings

10.1353/asb.2015.0005Asian Bioethics Review7198-10

Emotional intelligence among medical students: a mixed methods study from Chennai, India

Abstract Background Emotional Intelligence is the ability of a person to understand and respond to one’s own and others’ emotions and use this understanding to guide one’s thoughts and actions. To assess the level of emotional intelligence of medical students in a medical college in Chennai and to explore their understanding of the role of emotions in medical practice. Methods A quantitative, cross sectional, questionnaire based, survey was conducted among 207 medical students in a college in Chennai, India using the Quick Emotional Intelligence Self Assessment Test and some hypothetical emotional clinical vignettes. This was followed by a qualitative moderated fish-bowl discussion to elicit the opinion of medical students on role of emotions in the practice of medicine. Results The mean score of Emotional Intelligence was 107.58 (SD 16.44) out of a maximum possible score of 160. Students who went to government schools for high school education had greater emotional intelligence than students from private schools (p = 0.044) and women were more emotionally intelligent in their response to emotional vignettes than men (p = 0.056). The fish bowl discussion highlighted several positive and negative impacts of emotions in clinical care. The students concluded at the end of the discussion that emotions are inevitable in the practice of medicine and a good physician should know how to handle them. Conclusions Medical students, both men and women, had good level of emotional intelligence in the college that was studied. Students from collectivist social settings like government high schools have better emotional intelligence, which may indicate that a collectivist, community oriented medical education can serve the same purpose. Though students have diverse opinions on the role of emotions in clinical care, cognitive reflection exercises can help them understand its importance

Dimensions and determinants of trust in health care in resource poor settings--a qualitative exploration.

BACKGROUND: Trust in health care has been intensely researched in resource rich settings. Some studies in resource poor settings suggest that the dimensions and determinants of trust are likely to be different. OBJECTIVES: This study was done as a qualitative exploration of the dimensions and determinants of trust in health care in Tamil Nadu, a state in south India to assess the differences from dimensions and determinants in resource rich settings. METHODOLOGY: The participants included people belonging to marginalized communities with poor access to health care services and living in conditions of resource deprivation. A total of thirty five in depth interviews were conducted. The interviews were summarized and transcribed and data were analyzed following thematic analysis and grounded theory approach. RESULTS: The key dimensions of trust in health care identified during the interviews were perceived competence, assurance of treatment irrespective of ability to pay or at any time of the day, patients' willingness to accept drawbacks in health care, loyalty to the physician and respect for the physician. Comfort with the physician and health facility, personal involvement of the doctor with the patient, behavior and approach of doctor, economic factors, and health awareness were identified as factors determining the levels of trust in health care. CONCLUSIONS: The dimensions and determinants of trust in health care in resource poor settings are different from that in resource rich settings. There is a need to develop scales to measure trust in health care in resource poor settings using these specific dimensions and determinants

Do supportive family behaviors promote diabetes self-management in resource limited urban settings? A cross sectional study

Abstract Background Self-management is an essential component of prevention and treatment of type 2 diabetes. Social and family support has been shown to influence self-management behaviors as well as glycemic control and complications. This study was conducted to assess whether diabetes family support improves diabetes self-management and glycemic control in a typical urban population in India. Methods A cross-sectional study using a questionnaire that had items from the Summary of Diabetes Self Care Activities Scale (SDSCA), the Diabetes Family Behavior Checklist (DFBC) and some sociodemographic and diabetes related clinical data was conducted. The participants were consecutively sampled from the diabetes outpatient department in a tertiary care hospital in Chennai, south India. Results A total of 200 consecutive patients from the diabetes outpatient department were interviewed. Diabetes self-management practices were good with respect to avoiding fatty foods and carbohydrates and undergoing regular blood testing for glucose. But the self-management with respect to exercise and foot related care was rare. It was observed that a vast majority of the patients did not report receiving any support from their families. However, in the small proportion who did receive good family support, there is an association between diabetes self-management and diabetes family support (β = 0.527; p = 0.015). Further, the path model showed that there is a positive statistically significant association between family support score and the diabetes self-management score (β = 0.254, p < 0.001). However, the negative association between the diabetes self-management score and the mean plasma glucose did not reach statistical significance (β = − 46.378, p = 0.082). Conclusions In the urban south Indian setting, family support was significantly associated with better self-management activities, but better self-management did not reflect as better glycaemic control