The Infancy Defense in the Modern Contract Age: A Useful Vestige

This Note argues that the state of a modern consumer society, when evaluated against the culture of marketing and consumerism surrounding America’s youth, calls for persisting protection of children in contract formation through retention of the infancy defense. Part II of this Note introduces the infancy defense, the philosophy behind it, the various exceptions to the defense, and how these exceptions have adapted to the modern marketplace to assure equitable results for adults. This Part also discusses other arenas of the law in which children are afforded special protection. Part III addresses the current state of the infancy doctrine as demonstrated in the 2008 Virginia case A.V. v. iParadigms, in which the United States District Court for the Eastern District of Virginia dismissed high school students’ attempts to disaffirm an online contract under the infancy defense, holding that the plaintiffs could not disaffirm because they had retained the benefits of the contract. Part IV replies to the predominant arguments against the infancy doctrine and explains why equitable concerns about the infancy defense’s impact on adults are unwarranted. Part V examines the ongoing relevancy of the infancy defense in light of technological advancements, suggesting ways in which minors continue to be vulnerable to more sophisticated adults and businesses. This includes a discussion of the commercialization of childhood and the ways in which marketing companies target children in order to further the prevalence of materialism, consumer debt, and the earn-and-spend lifestyle. This Part also discusses the types of agreements that are prevalent online, such as adhesion contracts and clickwrap agreements, and argues that young people are particularly incompetent to consent to these forms of contracts. Finally, Part VI concludes with the contention that the infancy defense is still important and should be retained with its current exceptions

Tourism in the Most Reclusive Country on Earth

Tourism In The Most Reclusive Country On Earth explores the tourism growth on the Korea Peninsula through qualitative data to analyze how tourism can be a vehicle in reuniting North and South Korea. Through an extensive literature review, the history of the Korean Peninsula was explored in order to grasp the understanding on why North and South Koreans are so similar yet differ in terms of what type of governance is present in the country. Current social issues in North and South Korea were also explored, along with the advancement of technology. These points were considered in order to show how Korea can become one again as tourism increases in both the North and South, and as the interactions between citizens from each country increases. This study explores the opportunity for tourism in North Korea and how inbound tourism in the country can increase the interaction between South and North Korea through a two track system. It also considers present day technological, social, and political changes that are occurring in both countries, as these factors will escalate when the two countries will unite. This paper is advantageous to the tourism industry as it assesses the potential for North Korean tourism which supports the thesis on how and when South and North Korea will reunite

Psychometric evaluation of the Questionnaire about the Process of Recovery (QPR)

Background: Supporting recovery is the aim of national mental health policy in many countries, including England. There is a need for standardised measures of recovery, to assess policy implementation and inform clinical practice. Only one measure of recovery has been developed in England: the Questionnaire about the Process of Recovery (QPR) which measures recovery from the perspective of adult mental health service users with a psychosis diagnosis. Aims: To independently evaluate the psychometric properties of the 15-item and 22-item versions of QPR. Method: Two samples were used: Dataset 1 (n=88) involved assessment of QPR at baseline, two weeks and three months. Dataset 2 (n=399; ISRCTN02507940) involved assessment of QPR at baseline and one year. Results: For the 15-item version, internal consistency was 0.89, convergent validity was 0.73, test-retest reliability was 0.74 and sensitivity to change was 0.40. Confirmatory factor analysis showed the 15-item version offered a good fit. For the 22 item version comprising two sub-scales, the Interpersonal sub-scale was found to under-perform and the Intrapersonal sub-scale overlaps substantially with the 15 item version. Conclusions: Both the 15-item and the Intrapersonal sub-scale of the 22-item versions of the QPR demonstrated satisfactory psychometric properties. The 15-item version is slightly more robust and also less burdensome, so it can be recommended for use in research and clinical practice. Declaration of interest: None

Development and evaluation of an Individualised Outcome Measure (IOM) for randomised controlled trials in mental health

Predefined, researcher-selected outcomes are routinely used as the clinical end-point in randomised controlled trials (RCTs); however, individualised approaches may be an effective way to assess outcome in mental health research. The present study describes the development and evaluation of the Individualised Outcome Measure (IOM), which is a patient-specific outcome measure to be used for RCTs of complex interventions. IOM was developed using a narrative review, expert consultation and piloting with mental health service users (n=20). The final version of IOM comprises two components: Goal Attainment (GA) and Personalised Primary Outcome (PPO). For GA, patients identify one relevant goal at baseline and rate its attainment at follow-up. For PPO, patients choose an outcome domain related to their goal from a predefined list at baseline, and complete a standardised questionnaire assessing the chosen outcome domain at baseline and follow-up. A feasibility study indicated that IOM had adequate completion (89%) and acceptability (96%) rates in a clinical sample (n=84). IOM was then evaluated in an RCT (ISRCTN02507940). GA and PPO components were associated with each other and with the trial primary outcome. The use of the PPO component of IOM as the primary outcome could be considered in future RCTs

The relationship between clinical and recovery dimensions of outcome in mental health

Background: Little is known about the empirical relationship between clinical and personal recovery. Aims: To examine whether there are separate constructs of clinical recovery and personal recovery dimensions of outcome, how they change over time and how they can be assessed. Method: Standardised outcome measures were administered at baseline and one-year follow-up to participants in the REFOCUS Trial (ISRCTN02507940). An exploratory factor analysis was conducted and a confirmatory factor analysis assessed change across time. Results: We identified three factors: patient-rated personal recovery, patient-rated clinical recovery and staff-rated clinical recovery. Only the personal recovery factor improved after one year. HHI, CANSAS-P and HoNOS were the best measures for research and practice. Conclusions: The identification of three rather than two factors was unexpected. Our findings support the value of concurrently assessing staff and patient perceptions of outcome. Only the personal recovery factor changed over time, this desynchrony between clinical and recovery outcomes providing empirical evidence that clinical recovery and personal recovery are not the same. We did not find evidence of a trade-off between clinical recovery and personal recovery outcomes. Optimal assessment based on our data would involve assessment of hope, social disability and patient-rated unmet need

Evaluating the feasibility of complex interventions in mental health services: standardised measure and reporting guidelines

Aims: To develop a) an empirically-based standardised measure of the feasibility of complex interventions for use within mental health services and b) reporting guidelines to facilitate feasibility assessment. Method: A focussed narrative review of studies assessing implementation blocks and enablers was conducted with thematic analysis and vote counting used to determine candidate items for the measure. Twenty purposively sampled studies (15 trial reports, 5 protocols) were included in the psychometric evaluation, spanning different interventions types. Cohen’s Kappa was calculated for inter-rater reliability and test-retest reliability. Results: 95 influences on implementation were identified from 299 reviewed references. The final measure - Structured Assessment of Feasibility (SAFE) - comprises 16 items rated on a Likert scale. SAFE demonstrated excellent inter-rater (kappa 0.84, 95% CI 0.79 - 0.89) and test re-test reliability (kappa 0.89, 95% CI 0.85 - 0.93). Cost information and training time were the two influences least likely to be reported in intervention papers. SAFE Reporting Guidelines include 16 items organised into 3 categories (Intervention, Resource consequences, Evaluation). Conclusion: SAFE is a novel approach to evaluating interventions, and supplements efficacy and health economic evidence. SAFE Reporting Guidelines will allow feasibility of an intervention to be systematically assessed

A national survey of recovery practice in community mental health teams

Background There is a policy and professional consensus about the importance of ‘recovery’ in mental health services, but the link between recovery-orientation of mental health teams and personal recovery of service users has been under-researched. Aims To investigate differences in team leader, clinician and service user perspectives of recovery orientation of community adult mental health teams in England. Objectives: (1) To compare variations between NHS Trust, team type and participant ratings of recovery-orientation of mental health teams; (2) To explore the relationship between service user ratings of recovery orientation and personal recovery; (3) To test the hypothesis that clinician-rated recovery orientation differs between clinicians with and without personal experience of mental illness or supporting a family member or friend with mental illness. Method In six English Mental Health NHS Trusts (purposively sampled to maximise geographic and demographic spread), randomly-chosen community adult mental health teams were surveyed. A random sample of ten service users, one team leader and a convenience sample of five clinicians were surveyed from each team. All respondents rated the recovery orientation of their team using parallel versions of the Recovery Self Assessment (RSA). In addition, service users also rated their own personal recovery using Questionnaire about Processes of Recovery (QPR). Results Team leaders (n=22) rated recovery orientation higher than clinicians (n=109) or service users (n=120) (Wald(7)=7.0, p=0.03), and both NHS Trust and team type influenced RSA ratings. Service user-rated recovery orientation was a predictor of personal recovery (b=0.52, p <.001; 95%CI: .31 to .74). Team leaders and clinicians with experience of mental illness (39%) or supporting a family member or friend with mental illness (76%) did not differ in their RSA ratings from other team leaders or clinicians. Conclusions Compared with team leaders, frontline clinicians and service users have less positive views on recovery orientation. Increasing recovery orientation may support personal recovery

Service user experiences of REFOCUS: a process evaluation of a pro-recovery complex intervention

Purpose: Policy is increasingly focused on implementing a recovery-orientation within mental health services, yet the subjective experience of individuals receiving a pro-recovery intervention is under-studied. The aim of this study was to explore the service user experience of receiving a complex, pro-recovery intervention (REFOCUS), which aimed to encourage the use of recovery-supporting tools and support recovery-promoting relationships. Methods: Interviews (n=24) and two focus groups (n=13) were conducted as part of a process evaluation and included purposive sample of service users who received the complex, pro-recovery intervention within the REFOCUS randomised controlled trial (ISRCTN02507940). Thematic analysis was used to analyse the data. Results: Participants reported that the intervention supported the development of an open and collaborative relationship with staff, with new conversations around values, strengths and goals. This was experienced as hope-inspiring and empowering. However, others described how the recovery tools were used without context, meaning participants were unclear of their purpose and did not see their benefit. During the interviews, some individuals struggled to report any new tasks or conversations occurring during the intervention. Conclusion: Recovery-supporting tools can support the development of a recovery-promoting relationship, which can contribute to positive outcomes for individuals. The tools should be used, in a collaborative and flexible manner. Information exchanged around values, strengths and goals should be used in care-planning. As some service users struggled to report their experience of the intervention, alternative evaluation approaches need to be considered if the service user experience is to be fully captured

An interpretive phenomenological analysis of the experiences of mothers who continue to breastfeed despite facing difficulties.

BackgroundBreastfeeding offers many health benefits to mother and infant.ProblemBreastfeeding difficulties are common and are linked with postnatal distress.AimTo explore the lived experiences of breastfeeding continuation despite facing difficulties.MethodsQualitative semi-structured interviews were conducted with eight women who had experienced breastfeeding difficulties yet continued breastfeeding. Interviews were analysed using Interpretative Phenomenological Analysis (IPA).FindingsThe first superordinate theme, 'Radical acceptance of the imperfect' included sub-themes of: 'Taking it day-by-day', 'Breastfeeding takes a community', and, 'Finding what works for you'. The second superordinate theme, 'Determination and persistence' included sub-themes of: 'Adopting a headstrong attitude' and 'Transient challenges versus lifelong achievement'.DiscussionParticipants found radical acceptance of breastfeeding as an imperfect, variable process which enabled them to sustain breastfeeding despite challenges. Participants proactively drew on social and personal resources to navigate guidance and to find solutions which worked for their individual circumstances. Finally, open-mindedness, optimism, self-compassion, and being headstrong and determined were all personal qualities which facilitated breastfeeding during exceptionally difficult moments on their breastfeeding journey.ConclusionRecommendations are made for healthcare professionals: to provide emotional counselling during routine care (with an aim to instil breastfeeding self-efficacy) and to encourage breastfeeding advocacy among fathers and the maternal social support network (with an aim to further scaffold successful breastfeeding). Recommendations are also made for mothers: to develop and refine maternal confidence, patience, flexibility, self-compassion, and trust

The contribution of advisory committees and public involvement to large studies: case study

Background: Many large studies have complex advisory committee structures, yet there is no empirical evidence regarding their optimal composition, scope and contribution. The aim of this study was to inform the committee and advice infrastructure for future research studies. Methods: In the context of a five-year study funded by the UK National Institute for Health Research, three advisory committees were formed. In addition, advice was obtained from individual experts. All recommendations received in the start-up phase (first seven months) of the study were recorded, along with the decision about implementation of the recommendation. A particular focus was on the impact of public involvement. Results: A total of 172 recommendations were made, including 70 from 20 individual experts. The recommendations were grouped into five emergent themes: Scientific, Pragmatic, Resources, Committee and Collaboration. Most recommendations related to strengthening existing components or adding new components to the study protocol. Very few recommendations either proposed removing study components or contradicted other recommendations. Three 'implementation criteria' were identified: scientific value, pragmatic feasibility, and paradigmatic consistency. 103 (60%) of recommendations were implemented and 25 (15%) were not implemented. The benefits identified by the research team were improved quality and confidence, and the costs were increased cognitive demands, protocol revision time, and slower progress. Conclusions: The findings are discussed in the context of the wider literature on public involvement in research. Six recommendations are identified. First, have a clear rationale for each advisory committee expressed as terms of reference, and consider the best balance between committees and individual consultation with experts. Second, an early concern of committees is inter-committee communication, so consider cross-representation and copying minutes between committees. Third, match the scope of advisory committees to the study, with a less complex advisory structure for studies with more finalised designs. Fourth, public involvement has a mixed impact, and relies on relationships of trust, which take time to develop. Fifth, carefully consider the match between the scientific paradigm applied in the study and the contribution of different types of knowledge and expertise, and how this will impact on possibilities for taking on advice. Finally, responding to recommendations uses up research team resources, and the costs can be reduced by using the three implementation criteria