Deliberative water governance : theory and practice in the Mekong region

This thesis explores the research question: How can water governance be fairer and more effective in Mekong Region and beyond? In doing so, it examines the theory and practice of deliberative water governance, informed and illustrated in a region that comprises Cambodia, Laos, Myanmar, Thailand, Vietnam and China's Yunnan Province. Water governance can be understood along a spectrum, from a means to achieve pre{u00AD}determined objectives to a social process of dialogue, negotiation and decision-making. This thesis is most interested in the latter conception, in the context of 'the Mekong', where choices are being made about using and sharing transboundary waters. These choices might produce more energy; both increase and decrease food production; sustain or threaten livelihoods; and, maintain or degrade vital ecosystems and their services, upon which societies depend. An introductory chapter (Part A, Chapter 1) contextualises and explains the logic of the research. I next explore contested waterscapes (Part B, Chapters 2-5) focusing on the complex tapestry of Mekong regionalisms and governance, hydropower expansion, and a marginalised Mekong River Commission. The analysis confirmed that significant scope exists for improving water governance, and that deliberation - debate and discussion aimed at producing reasonable, well-informed opinions - has been in short supply. Deliberation deficits observed and reported in Part B provoked exploration of deliberative processes (Part C, Chapters 6-11) as a potential pathway to improving water governance. I examine firstly international practice, including still-topical issues from the World Commission on Dams, and the potential of multi-stakeholder platforms. I then examine Mekong practice and the efficacy of multi-stakeholder platforms as a governance tool; and the politics of deliberation, scales and levels. The final chapter of this section introduces a framework for analysing transboundary water governance complexes and distils suggestions for making water governance more deliberative and as a consequence, fairer and more effective. Part C analyses a range of governance challenges, and provides evidence that deliberative processes, where inserted into political arenas, are making water governance fairer and more effective, by reducing power imbalances among stakeholders and assisting negotiations to be more transparent and informed. In the final section and chapter (Part D, Chapter 12), I summarise and reflect on my practice and exploration of the topics. Drawing together the lessons from my research, I present my aspirational vision of Deliberative Water Governance - a new frontier in the field of deliberative governance: Constructive engagement that enables fairer and more effective water governance through inclusive, deliberative processes that emphasise different perspectives, learning, analysis and institution-building. The vision is inspired by promising examples, from the Mekong Region and elsewhere, examined in the thesis chapters, which demonstrate the need for and added-value provided by deliberation when it is information-rich, flexibly facilitated and actively promotes analysis of different views. In conclusion, I contend that, via its action research and publishing orientation, this thesis has contributed uniquely to both the theory and practice of Deliberative Water Governance in the dynamic Mekong Region and more widely

Relations Among Type 2 Diabetes, Arterial Stiffness and Cognitive Functioning

Although the associations among diabetes mellitus, cognitive functioning and arterial stiffness have been explored previously, the degree to which arterial stiffness is responsible for the association between diabetes and cognitive function has not been examined. The primary aim of the current investigations is to examine the extent to which arterial stiffness mediates the association between diabetes and cognitive function, as well as the extent to which this indirect effect is modified by age and APOE genotype. The sample included 590 participants (age 23-94, 62% women, 12% African- American) from the seventh wave of the Maine-Syracuse Longitudinal Study. Individuals with history of stroke, probable dementia, and PWV error of estimate \u3e0.20 were excluded. Diabetes was defined as elevated glucose or treatment. Pulse wave velocity was used to as an indirect measure of arterial stiffness. Multiple statistical methods were used to examine the association between diabetes and cognitive function, as well as between PWV and cognitive function. Then, path analysis was used to examine the direct and indirect (through PWV) associations between diabetes and cognitive function. With adjustment for demographic and CVD risk variables, associations between diabetes and multiple measures of cognitive ability were observed for the APOE-ε4 carriers only. PWV was related to multiple cognitive measures, and this association was modified by age such that the lowest performance was observed in older individuals with elevated PWV. When diabetes, PWV and cognitive function were included together in the analysis of paths between variables, an indirect association between diabetes and cognitive function through PWV was observed, such that diabetes related to higher PWV, and lower cognitive function in older APOE-ε4 carriers. These findings may have important clinical implications with regard to attenuating the pronounced association between diabetes and cognitive function observed for persons who carry the APOE-ε4 allele. Accelerated arterial stiffness may possibly be treated by the same methods that are used to treat hypertension. Clinical trials are necessary to determine if modification of levels of PWV by drugs and other treatments will lead to an improvement in cognitive performance. Treatment specific to APOE genotype are also a possibility

Kidney Disease and Cognitive Function

We provide a brief review of research on chronic kidney disease and cognitive performance, including dementia. We touch briefly on the literature relating end-stage-renal disease to cognitive function, but focus on studies of modest and moderate forms of chronic kidney disease (CKD) that precede dialysis and transplantation. We summarize previous reviews dealing with case control studies of patients but more fully examine community-based studies with large samples and necessary controls for demographic risk factors, cardiovascular variables, and other confounds such as depression. In addition we suggest potential biological and social-psychological mediators between CKD and cognition. Studies follow in two categories of design: (1) cross-sectional studies; (2) longitudinal studies. In each, CKD is related to a wide range of deficits in cognitive functioning including, verbal and visual-memory and organization, and components of executive functioning and fluid intellect. In general, prior to the need to treat with hemodialysis (HD) or kidney transplant (KT), magnitude of effect with relation to CKD and function are small or modest in persons free from acute stroke and dementia. However, HD and KT can result in major impairment. We discuss needed controls, the greater demand on controls after HD and KT begin, and suggest that mechanisms intervening relations between hypertension, or diabetes, and cognitive performance may be similar to those intervening between hypertension and cognitive performance and the hypertension and diabetes literature on cognition provides a good model for the study of early stage kidney disease and cognitive ability. We posit that the mechanisms linking CKD and cognition may be similar to those linking hypertension or diabetes to cognition. We identify the need for more studies with multiple cognitive test batteries, measures of every-day cognitive abilities relevant to patient understanding of the disease and treatments, and more studies with prevalent and incident dementia outcomes

Hypertension and Cognitive Functioning: A Perspective in Historical Context

Our objective is to characterize the development of the literature on hypertension and cognitive functioning from a historical perspective. This goal was stimulated by the review on “Historical Trends and Milestones in Hypertension Research” in the October 2012 issue of Hypertension. Our specific aims are threefold: (1) to trace and describe the history of this area of research; (2) to identify milestones in knowledge and methods; and (3) to discuss briefly how this literature translates into patient care. The topic is of major relevance to research and practice because hypertension is a well-known risk factor for decline in cognitive performance within the normal range of cognitive functioning, mild cognitive impairment (MCI) and dementia. It is important to emphasize 3 features of the review: (1) it is not designed as a critical review of the literature, but rather to describe the historical influences on our current knowledge base (poor, mediocre and outstanding papers from the past have all shaped our present); (2) word-count limitations require that we omit statistical detail except to emphasize effect sizes in pivotal papers; and (3) each milestone topic is addressed by noting the earliest work then followed by examples of papers representing pivotal events. A number of comprehensive re- views of this literature are available, including a seminal paper summarizing the formative years of this research. Please see http://hyper.ahajournals.org for citations to additional reviews of the literature and papers published in Hypertension. We recognize the importance of the emerging literature on hypotension and cognitive function, but refer the readers to previous reviews which include this topic

The changing characteristics of patients with chronic hepatitis C prescribed direct acting antiviral medicines in general practice since listing of the medicines on the Australian Pharmaceutical Benefits Scheme

Background and Aim: The primary objective of this study was to determine whether the characteristics of patients prescribed direct acting antiviral (DAA) medicines have changed since initial listing of the medicines on the Australian Pharmaceutical Benefits Scheme (PBS). Methods: A cross-sectional study was conducted using data from MedicineInsight, an Australian database of general practice electronic health records, from March 2016 to August 2018. We compared sociodemographic, comorbidity, and clinical characteristics of patients aged at least 18 years who were prescribed at least one DAA in the first 4 months of PBS listing in 2016 with those prescribed at least one DAA in 2018. Results: There were 2251 eligible adult patients prescribed a DAA during the study period, 62% were men and 59% were aged 50 years and older. Patients prescribed DAA medicines initially were older (aged ≥50 years: 67.9% vs 49.3%; P 1 (20.4% vs 8.9%; P < 0.001) than those prescribed DAA medicines in 2018. A greater proportion of patients in regional/remote (46.5% vs 35.6%; P < 0.001) and socioeconomically disadvantaged areas (44.4% vs 34.5%; P = 0.003) accessed treatment in 2018 compared with 2016. Conclusions: Despite evidence of decreasing uptake of DAA medicines across Australia, this study indicates broadened uptake among younger age groups and those residing in regional/remote and socioeconomically disadvantaged areas since 2016. While uptake of DAA medicines in some population subgroups appears to have improved, continuous efforts to improve uptake across the Australian population are essential

High Rates of Uncontrolled Blood Pressure: Pulse Wave Velocity and Future Opportunities

The recent commentary on high rates of uncontrolled blood pressure (BP) and opportunities for health care providers in this Journal prompted an examination of treated but uncontrolled BP in relation to pulse wave velocity (PWV) in the Maine Syracuse Longitudinal Study (MSLS). Cohen and Townsend noted that a Center for Disease Control analysis2 of National Health and Nutrition Examination Survey (NHANES) data (2003–2010) indicated that the presence of uncontrolled hypertension (≥140 mm Hg systolic and ≥90 mm Hg diastolic) in US adults was 53.5%. They further noted that approximately 45% of these individuals with uncontrolled hypertension were aware of their hypertension and were receiving treatment

Systolic orthostatic hypotension is related to lowered cognitive function: Findings from the Maine-Syracuse Longitudinal Study

The aim of the present study was to examine the relationship between orthostatic changes in blood pressure (BP) and cognition, with consideration given to cardiovascular risk factors and lifestyle variables. The cross-sectional analysis included 961 community-dwelling participants of the Maine-Syracuse Longitudinal Study, for whom BP clinic measures (five sitting, five recumbent, and five standing) were obtained. Eighteen percent of participants had orthostatic hypotension (fall in systolic BP ≥20 mm Hg or diastolic BP ≥10 mm Hg upon standing) and 6% had orthostatic hypertension (rise in systolic BP ≥20 mm Hg). Orthostatic hypotension and hypertension defined using traditional criteria were unrelated to cognition with covariate adjustment. However, an examination of systolic and diastolic BP change independently revealed that participants with systolic orthostatic hypotension had poorer global cognition, verbal memory, and scanning and tracking scores than those with normal systolic BP change. The authors conclude that systolic orthostatic hypotension is significantly associated with reduced cognitive function

From Blood Pressure to Physical Disability: The Role of Cognition

We examined the hypothesis that lowered cognitive performance plays a role in the relation between elevated blood pressure and physical disability in performing basic physical tasks. A community-based sample (N = 1025) free from stroke and dementia (mean age: 61.1 years; SD: 13.0 years; 59.8% women) was used. Using path analysis, systolic and diastolic blood pressures (predictor variable) measured over multiple longitudinal examinations were averaged and related to multiple measures of cognition (intermediate variable) and physical ability (PA; outcome variable) measured at wave 6 of the Maine-Syracuse Study. PA was indexed by time required to execute standing, walking, and turning tests. A best-fit path model including blood pressure and multiple demographic and cardiovascular disease covariates was used. Paths from systolic blood pressure toglobal performance, verbal memory, andabstract reasoning (Similarities test) were significant (