Global health ethics: critical reflections on the contours of an emerging field, 1977-2015.

BACKGROUND: The field of bioethics has evolved over the past half-century, incorporating new domains of inquiry that signal developments in health research, clinical practice, public health in its broadest sense and more recently sensitivity to the interdependence of global health and the environment. These extensions of the reach of bioethics are a welcome response to the growth of global health as a field of vital interest and activity. METHODS: This paper provides a critical interpretive review of how the term "global health ethics" has been used and defined in the literature to date to identify ethical issues that arise and need to be addressed when deliberating on and working to improve the discourse on ethical issues in health globally. RESULTS: Selected publications were analyzed by year of publication and geographical distribution, journal and field, level of engagement, and ethical framework. Of the literature selected, 151 articles (88%) were written by authors in high-income countries (HIC), as defined by the World Bank country classifications, 8 articles (5%) were written by authors in low- or middle-income countries (LMIC), and 13 articles (7%) were collaborations between authors in HIC and LMIC. All of the articles selected except one from 1977 were published after 1998. Literature on global health ethics spiked considerably from the early 2000s, with the highest number in 2011. One hundred twenty-seven articles identified were published in academic journals, 1 document was an official training document, and 44 were chapters in published books. The dominant journals were the American Journal of Bioethics (n = 10), Developing World Bioethics (n = 9), and Bioethics (n = 7). We coded the articles by level of engagement within the ethical domain at different levels: (1) interpersonal, (2) institutional, (3) international, and (4) structural. The ethical frameworks at use corresponded to four functional categories: those examining practical or narrowly applied ethical questions; those concerned with normative ethics; those examining an issue through a single philosophical tradition; and those comparing and contrasting insights from multiple ethical frameworks. CONCLUSIONS: This critical interpretive review is intended to delineate the current contours and revitalize the conversation around the future charge of global health ethics scholarship.

Referral to and engagement in substance use disorder treatment within opioid intervention courts in New York: a qualitative study of implementation barriers and facilitators.

BACKGROUND: People with opioid use disorder (OUD) are frequently in contact with the court system and have markedly higher rates of fatal opioid overdose. Opioid intervention courts (OIC) were developed to address increasing rates of opioid overdose among court defendants by engaging court staff in identification of treatment need and referral for opioid-related services and building collaborations between the court and OUD treatment systems. The study goal was to understand implementation barriers and facilitators in referring and engaging OIC clients in OUD treatment. METHODS: Semi-structured interviews were conducted with OIC stakeholders (n = 46) in 10 New York counties in the United States, including court coordinators, court case managers, and substance use disorder treatment clinic counselors, administrators, and peers. Interviews were recorded and transcribed and thematic analysis was conducted, guided by the Exploration, Preparation, Implementation, Sustainment (EPIS) framework, employing both inductive and deductive coding. RESULTS: Results were conceptualized using EPIS inner (i.e., courts) and outer (i.e., OUD treatment providers) implementation contexts and bridging factors that impacted referral and engagement to OUD treatment from the OIC. Inner factors that facilitated OIC implementation included OIC philosophy (e.g., non-punitive, access-oriented), court organizational structure (e.g., strong court staff connectedness), and OIC court staff and client characteristics (e.g., positive medications for OUD [MOUD] attitudes). The latter two also served as barriers (e.g., lack of formalized procedures; stigma toward MOUD). Two outer context entities impacted OIC implementation as both barriers and facilitators: substance use disorder treatment programs (e.g., attitudes toward the OIC and MOUD; operational characteristics) and community environments (e.g., attitudes toward the opioid epidemic). The COVID-19 pandemic and bail reform were macro-outer context factors that negatively impacted OIC implementation. Facilitating bridging factors included staffing practices that bridged court and treatment systems (e.g., peers); barriers included communication and cultural differences between systems (e.g., differing expectations about OIC client success). CONCLUSIONS: This study identified key barriers and facilitators that OICs may consider as this model expands in the United States. Referral to and engagement in OUD treatment within the OIC context requires ongoing efforts to bridge the treatment and court systems, and reduce stigma around MOUD.

Bridging juvenile justice and behavioral health systems: development of a clinical pathways approach to connect youth at risk for suicidal behavior to care.

BACKGROUND: Justice-involved youth have high rates of suicidal behavior and co-morbid psychiatric disorders, yet low rates of service use. Implementation efforts aimed at supporting cross-agency linkage protocols may be useful components of interventions promoting behavioral healthcare service access for youths on probation. The purpose of this study was to develop clear referral Pathways for three suicide risk classifications of youth, across 10 counties in a single state through a community-academic partnership in New York state, a strategic planning process between county Probation departments and community Behavioral Health. RESULTS: We sought to clarify service destinations for youth in three classes of risk for suicidal behavior: Class I (Crisis, Imminent Risk); Class II (Crisis, Non-Imminent Risk); and Class III (Non-Crisis but in Need of Service). Prior to Pathway Meetings, there was a low degree of agreement between Probation and Behavioral Health leadership for the appropriate service destination for youths in crisis, whether at imminent risk (Class I: 57.8% overlap) or at lower than imminent risk (Class II: 45.6% overlap). Options for referral destinations for Classes I and II decreased significantly (indicating greater overlap) as a result of Pathway Meetings [(Class I: from 2.5 to 1.1 (t(9) = 3.28, p < 0.01); Class II: from 2.8 to 1.3 (t(9) = 4.025, p < 0.003)]. Pathway Meetings allowed Behavioral Health and Juvenile Justice systems to make joint decisions regarding referral pathways, resulting in innovative solutions, such as the use of mobile crisis. CONCLUSIONS: The community-academic partnership served to bring internal (Juvenile Justice) and external (Behavioral Health) contexts together to successfully generate agreed upon Pathways to care for youths demonstrating risk for suicidal behavior. Bridging Behavioral Health and Juvenile Justice systems together to agree to referral Pathways for each risk class can increase appropriate service use. TRIAL REGISTRATION: ClinicalTrials.gov , NCT03586895 . Registered 21 June 2018, https://register.clinicaltrials.gov/prs/app/template/EditRecord.vm?epmode=Edit&listmode=Edit&uid=U0003B7I&ts=4&sid=S00080NN&cx=-n4kinh.