The challenge of community engagement and informed consent in rural Zambia: an example from a pilot study.

BACKGROUND: There is a need for empirically based research on social and ethical challenges related to informed consent processes, particularly in studies focusing on adolescent sexual and reproductive health. In a pilot study of a school-based pregnancy prevention intervention in rural Zambia, the majority of the guardians who were asked to consent to their daughters' participation, refused. In this paper we explore the reasons behind the low participation in the pilot with particular attention to challenges related to the community engagement and informed consent process. METHODS: The pilot was implemented in two schools and examined the acceptability of a package of interventions including economic support to families to keep their girls in school, pocket money for girls, youth club meetings on reproductive health, and community meetings to sensitize the community. Focus group discussions (4) were conducted with girls who participated in the pilot, boys in their class and with parents. Individual semi-structured interviews (11) were conducted with teachers, peer educators and community health workers involved in the coordination of the intervention as well as with religious and traditional leaders. Data were analyzed through thematic analysis. RESULTS: The findings indicate that inadequate use of recognized community communication channels during the community engagement process and dissemination of information about the pilot resulted in limited understanding of the pilot concept by the community. This surfaced through uncertainty and fear that the intervention may result in loss of control over daughters, worries about why money was provided unconditionally to girls, and suspicion of links to satanism. The sense of insecurity appeared to be exacerbated by low literacy levels, poverty, fear of loss of bride wealth, perceived disregard for local perceptions of social status, and scanty trust in the actors implementing the pilot. CONCLUSIONS: Inadequate use of locally appropriate channels in the dissemination of information created room for interpretation and facilitated development of mistrust, undermining the conditions for community engagement and actual informed consent. A key lesson learnt is the importance of taking seriously the complexity of local values and structures that may impact people's capability to consent or not consent to a study in an informed manner.

La preparación para dirigir el diagnóstico de estudiantes con necesidades educativas especiales asociadas al comportamiento / Training to manage the diagnosis of students with special educational needs associated to behavior

El diagnóstico escolar es una de las herramientas con las que cuenta el personal docente, pero se necesita de una preparación previa para su dirección.Objetivo: Diagnosticar la preparación de los directores de las escuelas primarias para dirigir el proceso de diagnóstico de los estudiantes que evidencian necesidades educativas especiales asociadas al comportamiento.Metodología: Se realizó una investigación con diseño no experimental y enfoque cuantitativo en la Universidad de Sancti Spíritus José Martí Pérez, que incluyó ocho directores de escuelas primarias urbanas. Se aplicaron métodos y técnicas de la investigación pedagógica(AU)

La preparación para dirigir el diagnóstico de estudiantes con necesidades educativas especiales asociadas al comportamiento / Training to manage the diagnosis of students with special educational needs associated to behavior

El diagnóstico escolar es una de las herramientas con las que cuenta el personal docente, pero se necesita de una preparación previa para su dirección.Objetivo: Diagnosticar la preparación de los directores de las escuelas primarias para dirigir el proceso de diagnóstico de los estudiantes que evidencian necesidades educativas especiales asociadas al comportamiento.Metodología: Se realizó una investigación con diseño no experimental y enfoque cuantitativo en la Universidad de Sancti Spíritus José Martí Pérez, que incluyó ocho directores de escuelas primarias urbanas. Se aplicaron métodos y técnicas de la investigación pedagógica

Ethical issues in obesity prevention for school children: a systematic qualitative review.

OBJECTIVES: Planning and conducting preventive measures against obesity for school children is beset with ethical issues which should be known to make well-informed decisions. The goal of this study was to provide a comprehensive spectrum of these ethical issues by means of a systematic review. In this context, the study also assesses the value of different search strategies for ethical literature in public health. METHODS: Literature was searched in Medline, EBSCO and others. Three different search strategies with varied scopes were applied and their output was compared. Qualitative content analysis was used for extracting and categorizing ethical issues. RESULTS: 109 publications (published from 1995 to 2015) were finally included. The qualitative analysis resulted in 60 potentially relevant ethical issues. The three search strategies showed substantial differences regarding their search results. CONCLUSIONS: The presented spectrum provides an initial evidence base for dealing with ethical issues adequately. The findings of the study further suggest that a broader scope is more fruitful for systematic reviews on ethical issues in the field of public health.

Headteachers' prior beliefs on child health and their engagement in school based health interventions: a qualitative study.

BACKGROUND: Schools play an important role in promoting the health of children. However, little consideration is often given to the influence that headteachers' and school staff's prior beliefs have on the implementation of public health interventions. This study examined primary school headteachers' and school health co-ordinators' views regarding child health in order to provide greater insights on the school's perspective for those designing future school-based health interventions. METHODS: A qualitative study was conducted using 19 semi-structured interviews with headteachers, deputy headteachers and school health co-ordinators in the primary school setting. All transcripts were analysed using thematic analysis. RESULTS: Whilst many participants in this study believed good health was vital for learning, wide variance was evident regarding the perceived health of school pupils and the magnitude of responsibility schools should take in addressing child health behaviours. Although staff in this study acknowledged the importance of their role, many believed the responsibility placed upon schools for health promotion was becoming too much; suggesting health interventions need to better integrate school, parental and societal components. With mental health highlighted as an increasing priority in many schools, incorporating wellbeing outcomes into future school based health interventions is advocated to ensure a more holistic understanding of child health is gained. CONCLUSION: Understanding the health beliefs of school staff when designing interventions is crucial as there appears to be a greater likelihood of interventions being successfully adopted if staff perceive a health issue as important among their pupils. An increased dependability on schools for addressing health was expressed by headteachers in this study, highlighting a need for better understanding of parental, child and key stakeholder perspectives on responsibility for child health. Without this understanding, there is potential for certain child health issues to be ignored.

Ethical Challenges in School-Based Immunization Programs for Adolescents: A Qualitative Study.

OBJECTIVES: We investigated ethical issues in school-based immunization programs for adolescents and how they are addressed. METHODS: We used qualitative methods and an ethnographic approach to observe 9 secondary schools on immunization days in South Australia in 2011; concurrently, we conducted 9 focus groups with female secondary school students, 6 semistructured interviews with parents, and 10 interviews with nurses and teachers. We explored ethical challenges from the perspective of these groups. RESULTS: We identified ethical challenges for the delivery of adolescent immunization in a school-based setting in 3 main areas: informed consent, restrictions on privacy, and harm to students in the form of fear and anxiety. CONCLUSIONS: We found areas in which the design and delivery of school-based immunization programs can be improved. Information about immunization should be provided in ways that are appropriate to young people and their parents, and privacy protections should be enhanced when possible. Involving young people in the design and delivery of programs would assist with making these improvements.

Evaluating programs that address ideological issues: ethical and practical considerations for practitioners and evaluators.

There are important practical and ethical considerations for organizations in conducting their own, or commissioning external, evaluations and for both practitioners and evaluators, when assessing programs built on strongly held ideological or philosophical approaches. Assessing whether programs "work" has strong political, financial, and/or moral implications, particularly when expending public dollars, and may challenge objectivity about a particular program or approach. Using a case study of the evaluation of a school-based abstinence-until-marriage program, this article discusses the challenges, lessons learned, and ethical responsibilities regarding decisions about evaluation, specifically associated with ideologically driven programs. Organizations should consider various stakeholders and views associated with their program to help identify potential pitfalls in evaluation. Once identified, the program or agency needs to carefully consider its answers to two key questions: Do they want the answer and are they willing to modify the program? Having decided to evaluate, the choice of evaluator is critical to assuring that ethical principles are maintained and potential skepticism or criticism of findings can be addressed appropriately. The relationship between program and evaluator, including agreements about ownership and eventual publication and/or promotion of data, should be addressed at the outset. Programs and organizations should consider, at the outset, their ethical responsibility when findings are not expected or desired. Ultimately, agencies, organizations, and programs have an ethical responsibility to use their data to provide health promotion programs, whether ideologically founded or not, that appropriately and effectively address the problems they seek to solve.

Challenges for consent and community engagement in the conduct of cluster randomized trial among school children in low income settings: experiences from Kenya.

BACKGROUND: There are a number of practical and ethical issues raised in school-based health research, particularly those related to obtaining consent from parents and assent from children. One approach to developing, strengthening, and supporting appropriate consent and assent processes is through community engagement. To date, much of the literature on community engagement in biomedical research has concentrated on community- or hospital-based research, with little documentation, if any, of community engagement in school-based health research. In this paper we discuss our experiences of consent, assent and community engagement in implementing a large school-based cluster randomized trial in rural Kenya. METHODS: Data collected as part of a qualitative study investigating the acceptability of the main trial, focus group discussions with field staff, observations of practice and authors' experiences are used to: 1) highlight the challenges faced in obtaining assent/consent; and 2) strategies taken to try to both protect participant rights (including to refuse and to withdraw) and ensure the success of the trial. RESULTS: Early meetings with national, district and local level stakeholders were important in establishing their co-operation and support for the project. Despite this support, both practical and ethical challenges were encountered during consenting and assenting procedures. Our strategy for addressing these challenges focused on improving communication and understanding of the trial, and maintaining dialogue with all the relevant stakeholders throughout the study period. CONCLUSIONS: A range of stakeholders within and beyond schools play a key role in school based health trials. Community entry and information dissemination strategies need careful planning from the outset, and with on-going consultation and feedback mechanisms established in order to identify and address concerns as they arise. We believe our experiences, and the ethical and practical issues and dilemmas encountered, will be of interest for others planning to conduct school-based research in Africa. TRIAL REGISTRATION: National Institute of Health NCT00878007.

Protecting the rights of school children with diabetes.

School children with diabetes are facing increasing difficulties in receiving care during the school day. Despite theexistence of federal statutes ensuring their rights to a free, appropriate public education, many school districts throughout the country do little, if anything, to ensure that their condition is treated throughout the school day. The chronic shortage of school nurses has resulted in hardships on families, relatives, and friends to ensure that care, including insulin, is timely and appropriately provided. While many states have taken measures to provide care by unlicensed trained volunteers, efforts to accomplish this in California have resulted in prolonged litigation. A variety of nursing organizations oppose all efforts to train unlicensed volunteers, arguing that such is not permitted by California law. The issue is unresolved and currently pending in the California Supreme Court.

Does school ethos explain the relationship between value-added education and teenage substance use? A cohort study.

Previous studies found lower substance use in schools achieving better examination and truancy results than expected, given their pupil populations (high value-added schools). This study examines whether these findings are replicated in West Scotland and whether school ethos indicators focussing on pupils' perceptions of schooling (environment, involvement, engagement and teacher-pupil relations) mediate the associations. Teenagers from forty-one schools (S2, aged 13, n = 2268; S4, aged 15, n = 2096) previously surveyed in primary school (aged 11, n = 2482) were surveyed in the late 1990s. School value-added scores were derived from standardised residuals of two regression equations separately predicting from pupils' socio-demographic characteristics (1) proportions of pupils passing five Scottish Standard Grade Examinations, and (2) half-day truancy loss. Outcomes were current smoking, monthly drinking, ever illicit drug use. Random effects logistic regression models adjusted for potential pupil-level confounders were used to assess (1) associations between substance use and school-level value-added scores and (2) whether these associations were mediated by pupils' perceptions of schooling or other school-level factors (school roll, religious denomination and mean aggregated school-level ethos scores). Against expectations, value-added education was positively associated with smoking (Odds Ratios [95% confidence intervals] for one standard deviation increase in value-added scores were 1.28 [1.02-1.61] in S2 and 1.13 [1.00-1.27] in S4) and positively but weakly and non-significantly associated with drinking and drug use. Engagement and positive teacher-pupil relations were strongly and negatively associated with all substance use outcomes at both ages. Other school-level factors appeared weakly and largely non-significantly related to substance use. Value-added scores were unrelated to school ethos measures and no ethos measure mediated associations between value-added education and substance use. We conclude that substance use in Scotland is more likely in high value-added schools, among disengaged students and those with poorer student-teacher relationships. Understanding the underpinning mechanisms is a potentially important public health concern.

An analysis of ethical issues in using wastewater analysis to monitor illicit drug use.

AIMS: To discuss ethical issues that may arise in using WWA to monitor illicit drug use in the general population and in entertainment precincts, prisons, schools and work-places. METHOD: Review current applications of WWA and identify ethical and social issues that may be raised with current and projected future uses of this method. RESULTS: Wastewater analysis (WWA) of drug residues is a promising method of monitoring illicit drug use that may overcome some limitations of other monitoring methods. When used for monitoring purposes in large populations, WWA does not raise major ethical concerns because individuals are not identified and the prospects of harming residents of catchment areas are remote. When WWA is used in smaller catchment areas (entertainment venues, prisons, schools or work-places) their results could, possibly, indirectly affect the occupants adversely. Researchers will need to take care in reporting their results to reduce media misreporting. Fears about possible use of WWA for mass individual surveillance by drug law enforcement officials are unlikely to be realized, but will need to be addressed because they may affect public support adversely for this type of research. CONCLUSIONS: Using wastewater analysis to monitor illicit drug use in large populations does not raise major ethical concerns, but researchers need to minimize possible adverse consequences in studying smaller populations, such as workers, prisoners and students.

Ethics in stuttering treatment in the schools: issues and intersections.

When the challenges of providing speech-language pathology services in school settings intersect with the complexities of meeting the unique needs of students who stutter, clinicians may encounter a variety of ethical issues. This article explores some of the ethical challenges of treating stuttering in school settings by discussing three clinical scenarios. Seedhouse's Ethics Grid is provided as a scaffold to support the critical analysis of school-based stuttering treatment issues. Factors examined include creating and respecting autonomy, serving student needs, doing good and minimizing risks, and telling the truth and keeping promises. In addition, clinical outcomes are considered in terms of their impact on students and family members, clinicians, students with communication disorders other than stuttering, and school personnel. Finally, some of the practical concerns when treating stuttering in school settings are discussed, including the law, codes of practice, wishes of others, as well as the effectiveness and efficiency of actions.

School-based smoking prevention programmes: ethical aspects.

School-based health education has the potential to inform and educate young people, in order to promote healthy behaviours among them, which will help to prevent diseases and social problems. The present study gives an overview of several ethical issues which must be considered in different phases of school-based smoking prevention programs. This will help health educators, public health professionals and researchers in their activity of health education in schools. The ethical issues must be taken into consideration during all the activities and refer to the involvement of officials, schools, parents, young people who participate into the program, authors and persons/institutions responsible with the implementation, evaluation or funding of the programs. The application into practice of these ethical principles, influence the quality of the health education, its acceptability BY the target group and the correctness of results. Also, it prevents possible problems and misunderstandings between persons and institutions involved in the health education and smoking prevention process, which could seriously affect and even destroy implementation of such health education activities.

Un protocolo de buenas prácticas en la intervención con alumnos con trastorno de la conducta en centros educativos / A protocol of good practice in intervention with children with conduct disorder in schools

Este artículo plantea, desde el punto de vista de los Equipos de Orientación que intervienen en Educación Infantil y Primaria y en base a la experiencia de los autores, una manera de abordar los problemas de conducta que presentan algunos alumnos. El punto de partida tiene en cuenta las aportaciones de lapsicología evolutiva y laperspectiva conductal de sistemas. El centro escolar forma parte del conjunto de sistemas relacionados donde se presentan estos problemas y en muchas ocasiones se generan situaciones de estrés añadido y de reto para los profesionales implicados. Se plantean aquí una serie de actuaciones y procedimientos que los autores han denominado "buenas practicas" dirigidas a contar e implicar a las estructuras formales habituales de los centros con el fin de encauzar de manera adecuada la solución de estos problemas, colaborar con otros sistemas -familias, unidades de salud, servicios sociales- y tratar de minimizar los efectos colaterales que habitualmente se producen a la hora de intervenir. Se con cluye con la necesaria colaboración entre todos lso csitemas implicados para tratar de dar alternativas a las dificultades que se originan en estas situaciones y la formación de los profesionales de la educación en el conocimiento y aplicación de programas de intervención con base empírica(AU)

This article argues, from the standpoint of Guidance Teams involved in school and Primary Education and based on the authors' experience, a way to address behavior problems presented by some students. The starting point takes into account the contributions of lapsicología laperspectiva evolutionary behavioral systems. The school is part of the set of related systems where these problems occur and often generate added stress and challenge for the professionals involved. Raised here a series of actions and procedures that the authors have named "best practices" designed to count and to involve the usual formal structures of the centers in order to properly channel the solution of these problems, collaborate with other systems - families, health care, social services, and try to minimize side effects that often occur when to intervene. It concludes with the necessary cooperation between all csitemas lso involved in trying to provide alternatives to the difficulties that arise in these situations and the training of education professionals in the knowledge and implementation of empirically-based intervention (AU)

Estratégias de enfrentamento dos dilemas bioéticos gerados pela violência na escola / Coping strategies to bioethical dilemmas generated by school violence

A violência na escola é um problema social que perpassa o âmbito da educação e da saúde pública, envolve aspectos bioéticos e requer mecanismos de enfrentamento, a partir da educação em saúde. Este estudo objetiva discutir estratégias fundamentadoras da educação em saúde, sobre aspectos bioéticos no domínio da violência escolar. Consiste em uma revisão bibliográfica crítico-reflexiva por meio do acesso a banco de dados da Biblioteca Virtual de Saúde (BVS), utilizando os descritores "violência and bioética" e "violência na escola", considerando os estudos publicados no período de 2004 a 2009. Realizamos também levantamento das obras de Paulo Freire e Pedro Demo, teóricos da Educação Libertadora. A leitura do material conduziu-nos a definição e discussão de três eixos temáticos: 1) bioética como instrumento reflexivo para a retomada dos valores morais na sociedade; 2) escola como formadora ética e de exercício de cidadania; 3) educação em saúde como instrumento para o enfrentamento da violência na escola. Acreditamos que a violência escolar envolve questões bioéticas que devem ser alvo de intervenções educativas na perspectiva libertadora, no intuito de gerar reflexões sobre o caráter negativo da violência escolar, tanto para o ensino-aprendizagem, como para o adoecimento dos atores envolvidos nessa problemática. Os profissionais da saúde poderão estabelecer a intersetorialidade com a educação e contribuir na prevenção da violência na escola, por meio de ações educativas em saúde, mobilizando cidadãos para uma sociedade comprometida em promover a vida; e que os profissionais da educação sejam receptivos e coparticipantes do processo intersetorial de educação e saúde.

School violence is a social problem that pervades the educational and public health context, involving bioethical issues and requires coping mechanisms from health education. This study aims to discuss strategies that underlie health education, on bioethical issues in the school violence field. It consists of a critical-reflexive literature review by accessing the Virtual Health Library (VHL) database, using the keywords: "violence and bioethics", and "violence at school", considering the studies published from 2004 to 2009. We also surveyed Paulo Freire's and Pedro Demo's works, theorists of Libertarian Education, which led us define and discuss three thematic areas: 1) bioethics as a reflective instrument for the moral values resumption in the society, 2) school as an ethics and citizenship practice creator, 3) health education as a contributor to coping with violence at school. We believe that school violence involves bioethical issues that should be the target of educational interventions in the liberating perspective, in order to generate reflections on the negative character of school violence, both for teaching and learning, as to the sickening of the actors involved in this issue. Health professionals may establish the intersectoriality with the education and contribute in preventing violence at school, through health education actions, mobilizing citizens for a society committed to promoting life. And the education professionals must be receptive and co-participants in the education and health intersectorial process.

Ethical principles as a guide in implementing policies for the management of food allergies in schools.

Food allergy in children is a growing public health problem that carries a significant risk of anaphylaxis such that schools and child care facilities have enacted emergency preparedness policies for anaphylaxis and methods to prevent the inadvertent consumption of allergens. However, studies indicate that many facilities are poorly prepared to handle the advent of anaphylaxis and policies for the prevention of allergen exposure are missing essential components. Furthermore, certain policies are inappropriate because they are blatantly discriminatory. This article aims to provide further guidance for school health officials involved in creating food allergy policies. By structuring policies around ethical principles of confidentiality and anonymity, fairness, avoiding stigmatization, and empowerment, policy makers gain another method to support better policy making. The main ethical principles discussed are adapted from key values in the bioethics and public health ethics literatures and will be framed within the specific context of food allergy policies for schools.

Ethical issues in providing services in schools to children with swallowing and feeding disorders.

PURPOSE: This article is a commentary and discussion of ethical issues in dysphagia services as related to school-based practice in speech-language pathology. METHOD: A review of the literature on ethical issues in the provision of speech-language pathology services to individuals with dysphagia was conducted, with particular emphasis on students receiving school-based services. RESULTS: Issues in dysphagia management that were identified in the literature review are discussed from the perspective of biomedical ethics, professional ethics, and professional practice issues pertinent to the school setting. CONCLUSION: Considerations, suggestions, and resources for ethically responsive action on the part of the school-based speech-language pathologist are provided.

Conflict of interest in the evaluation and dissemination of "model" school-based drug and violence prevention programs.

Conflict of interest refers to a set of conditions in which professional judgment concerning the validity of research might be influenced by a secondary competing interest. The competing interest that has received most attention in the literature addressing the prevalence and effects of such conflicts on the practice of empirical research has been that of financial relationships between investigators and research sponsors. The potential for conflicts of interest to arise in the evaluation of drug prevention programs was raised by Moskowitz in this journal in 1993, but to date there has been no attempt made to estimate the scope of this problem. The present study addressed this issue using a sample of "model" school-based drug and violence prevention interventions by first, identifying the types or relationships that exist between program developers and program distributors, and, second, by assessing how many of the evaluations of these programs published in peer-reviewed journals had been conducted by the developers of the programs compared to independent evaluation teams. The data presented indicate that there are relatively few published evaluations that do not involve program developers and that there are few instances in which there is complete separation between the program developer and program distributor. Using the open systems model of the Institute of Medicine Committee on Research Integrity as a framework, it is argued that the culture and norms of the program developer and those of the program evaluator are fundamentally distinct and therefore failure to separate these roles produces high potential for conflict of interest to arise.

Some doubts about one of the largest smoking prevention programmes in Europe, the smokefree class competition.

With over 600,000 participants in 16 countries, the smokefree class competition is one of the largest smoking prevention programmes in Europe. Participating classes that maintain a smoking prevalence usually below 10% are eligible for a contest and the winner is rewarded with money. There is however no convincing evidence that this competition has any effect on smoking prevalence beyond the short term, and this approach raises serious ethical issues. In particular, the central principle of this competition is to apply negative peer pressure upon teenage smokers. However, promoters of this competition have neglected to report the possible adverse consequences of using negative peer pressure upon smokers. This is a concern, because teenage smokers are more vulnerable than non-smokers, and they are at higher risk of suffering from psychological problems and school failure.