A theoretical framework for ethical decision-making during public health emergencies / Un marco teórico para la toma de decisiones éticas durante emergencias de salud pública / Um referencial teórico para tomada de decisão ética durante emergências de saúde pública

Abstract: The new theoretical ethical framework is a general frame or tool for ethical agents, developed to guide ethical reasoning during public health emergency preparedness and response. The TEF is based on the assumption that no existing ethical discourse in medical ethics alone is sufficient to address ethical issues of a PHE. The solutions suggested by existing approaches are limited in practicability and effectiveness, because they cannot address root problems and interplay among ethical problems. The reason for this insufficiency rests on the argument that ethical problems of PHEs have causal and reciprocal relationships, and any ethical decision-making framework should provide a wide enough perspective to consider relevant ethical norms and theories to suggest practical, implementable, coherent solutions compatible with the communal values and cultural norms. The TEF we suggest for PHEs embraces a holistic and integrated ethical perspective that enables us to comprehend that ethical problems that arise in various settings caused by PHE phenomena are in relationship with each other instead of addressing them as a standalone problem. The TEF provides decision-makers to achieve a coherent web of considered judgements compatible with ethical values and principles in various settings. This type of conceptualization offers a wide perspective to see causal and relational relationships among problems and produce outcomes that would not be possible by eclectic approaches.

Resumen: El nuevo Marco Ético Teórico (MET) es una estructura general o herramienta para eticistas, desarrollada para guiar el razonamiento ético durante la preparación y respuesta a emergencias de salud pública (ESP). Supone que no existe un discurso ético en la ética médica que por sí solo sea suficiente para abordar temas éticos de ESP. Las soluciones sugeridas de aproximaciones existentes son limitadas en la práctica y en la efectividad, debido a que no pueden abordar problemas de raíz sin considerar las interacciones entre los problemas éticos. Esta insuficiencia es porque los problemas éticos de ESP tiene relaciones causales y recíprocas, y cualquier estructura de toma de decisiones éticas debería proporcionar una perspectiva suficientemente amplia como para considerar normas éticas y teorías relevantes, y sugerir soluciones prácticas que sean coherentes y compatibles con valores comunes y normas culturales. El MET que sugerimos para ESP abarca una perspectiva ética integral e integrada, que posibilita la comprensión de que los problemas éticos que surgen en varías situaciones causadas por fenómenos ESP se hallan en relación entre ellos, en vez de abordarlos como un problema aislado. El MET proporciona a los que toman decisiones el lograr una red coherente de juicios compatibles con los valores y principios éticos en varias situaciones. Este tipo de conceptualización ofrece una amplia perspectiva para ver relaciones causales y relacionales entre problemas y producir resultados que no serían posibles mediante aproximaciones eclécticas.

Resumo: O novo referencial ético teórico (NT: TEF, sigla em inglês) é um referencial geral ou instrumento para agentes éticos, desenvolvido para guiar o raciocínio ético durante o preparo e resposta a emergências de saúde pública (NT: PHE, sigla em inglês). O TEF é baseado na suposição de que nenhum discurso ético existente em ética médica sozinho é suficiente para abordar aspectos éticos de uma PHE. As soluções sugeridas pelas abordagens existentes são limitadas em praticabilidade e efetividade, porque elas não podem abordar problemas fundamentais e inter-relacionar problemas éticos. A razão para essa insuficiência repousa no argumento de que problemas éticos de PHEs têm relações causais e recíprocas, e qualquer referencial para tomada de decisão ética deve propiciar uma perspectiva ampla o suficiente para considerar normas e teorias éticas relevantes para sugerir soluções práticas, implementáveis e coerentes, compatíveis com valores comunitários e normas culturais. A TEF que sugerimos para PHEs abarca uma perspectiva ética holística e integrada que nos permite compreender que os problemas éticos que surgem em diversos ambientes causados pelo fenômeno da PHE estão em relação entre si, ao invés de abordá-los como um problema isolado. O TFE propicia a tomadores de decisões alcançar uma rede de julgamentos considerados compatíveis com valores e princípios éticos em ambientes diversos. Esse tipo de conceitualização oferece uma perspectiva ampla para observar relações causais e relacionais entre problemas e produzir desfechos que não seriam possíveis por abordagens ecléticas.

A proposed one-stop-shop approach for the delivery of integrated oral, mental, sexual and reproductive healthcare to adolescents in Nigeria.

The interconnectedness of oral, mental, sexual, and reproductive health (OMSRH) in adolescents prompts exploration of novel approaches to facilitate comprehensive access of this population to the relevant health services. This paper proposes an integrated one-stop-shop approach to increasing adolescents' access to OMSRH care by leveraging on dental clinics as a template for integration, using a non-stigmatized platform to deliver stigmatized healthcare. Novel healthcare delivery models are needed to enhance adolescents' access to the comprehensive prevention and treatment services that they critically need. Effective, integrated health care for this population is lacking, especially across various health areas. This is a proposal for leveraging dental clinics for integrated OMSRH care, using facility-based services, to adolescents. Emphasis will be placed on reducing stigma as a barrier to service accessibility, acceptability, equitability and appropriateness. Empirical studies will be required to test the feasibility, validity and effectiveness of this proposed model.

Associations between Forced Sexual Initiation, HIV Status, Sexual Risk Behavior, Life Stressors, and Coping Strategies among Adolescents in Nigeria.

OBJECTIVES: Some individuals experience their first sexual intercourse through physically forced sex, which affects the way they experience and cope with stress. We examined differences in sexual risk behavior, experience of stressors, and use of stress-coping strategies among adolescents in Nigeria based on their history of forced sexual initiation and HIV status. METHODS: We analyzed data from 436 sexually active 10-19-year-old adolescents recruited through a population-based survey from 12 Nigerian states. Using Lazarus and Folkman's conceptual framework of stress and coping, we assessed if adolescents who reported forced sexual initiation were more likely to report HIV sexual risk practices, to report as stressors events related to social expectations, medical care and body images, and loss and grief, and to use more avoidance than adaptive coping strategies to manage stress. We also assessed if HIV status affected experience of stressors and use of coping strategies. RESULTS: Eighty-one adolescents (18.6%) reported a history of forced sexual initiation; these participants were significantly more likely to report anal sex practices (OR: 5.04; 95% CI: 2.14-11.87), and transactional sex (OR: 2.80; 95% CI: 1.56-4.95). Adolescents with no history of forced sexual initiation were more likely to identify as stressors, life events related to social expectations (OR: 1.03; 95% CI: 0.96-1.11) and loss and grief (OR: 1.34; 95% CI: 0.73-2.65), but not those related to medical care and body images (OR: 0.63; 95% CI: 0.34-1.18). They were also more likely to use adaptive responses (OR: 1.48; 95% CI: 0.62-3.50) than avoidance responses (OR: 0.90; 95% CI: 0.49-1.64) to cope with stress, though these differences were not significant. More adolescents with a history of forced sexual initiation who were HIV positive identified as stressors, life events related to medical care and body images (p = 0.03) and loss and grief (p = 0.009). Adolescents reporting forced sexual initiation and HIV-negative status were significantly less likely to use religion as a coping strategy (OR: 0.28; 95% CI: 0.09-0.83). CONCLUSION: History of forced sexual initiation and HIV status affected perception of events as stressors and use of specific coping strategies. Our study findings could inform best practice interventions and policies to prevent and address forced sexual initiation among adolescents in Nigeria and other countries.

Tackling the sexual and reproductive health and rights of adolescents living with HIV/AIDS: a priority need in Nigeria.

Very little is known about the sexual and reproductive health (SRH) needs of adolescents living with HIV (ALHIV) in general and the needs of those in Nigeria specifically. A review was conducted to identify the SRH of ALHIV, assess if these are different from the SRH of adolescents who are free from HIV infection, and from those of adults living with HIV. Few research have been conducted on how ALHIV deal with sexual and reproductive health challenges faced in their everyday lives - as adolescents and as persons living with HIV living in sub-Saharan Africa - to help make any meaningful inferences on these differing needs. The review suggests that the SRH needs and practices of ALHIV may differ from that of other adolescents and that of adults living with HIV. ALHIV would require support to cope with sex and sexual needs, through full integration of individualized SRH services into the HIV services received. Service providers need to appreciate the individualistic nature of health problems of ALHIV and address their health care from this holistic perspective. A 'one-size-fits-all' approach for designing SRH programmes for ALHIV would not be appropriate. We conclude that research evidence should inform the design and implementation of ALHIV friendly SRH programmes services in both urban and rural settings in Nigeria.