Ethical issues in denial of church wedding based on couple's hemoglobin genotype in Enugu, south eastern Nigeria.

BACKGROUND: Sickle cell anemia (SCA) is a major genetic disease with the greatest burden in sub-Saharan Africa. To try to help reduce this burden, some churches in Nigeria conduct premarital sickle cell hemoglobin screening and refuse to conduct weddings when both individuals are identified as carriers of sickle cell trait. MAIN BODY: This paper explores the ethical challenges involved in such denials. We assess whether churches have the right to decline to marry adults who understand the risks and still prefer to get married, and whether couples should be denied church weddings based on the risk that their child may suffer from sickle cell anemia. We examine the moral and ethical dimensions of such denials and explore the underlying socio-cultural context involving the purpose of marriage and the meaning of the wedding ceremony in societies where premarital screening is one of the few tools available to reduce the risk of having children with SCA. The potential role of the church is also examined against the background of church beliefs, the duty of the church to its members and its role in reducing the suffering of its members and /or their children. CONCLUSION: We argue that the church should impose these burdens on couples only if doing so promotes a sufficiently compelling goal and there is no less burdensome way to achieve it. We then argue that the goal of reducing the number of individuals in Nigeria who have SCA is compelling. However, testing earlier in life offers a less burdensome and potentially even more effective means of achieving this goal. This suggests that, advocating for earlier screening and helping to support these programs, would likely better promote the church's own goals of helping its parishioners, increasing the number of church weddings, and reducing the burden of SCA in Nigeria.

Autonomy and couples' joint decision-making in healthcare.

BACKGROUND: Respect for autonomy is a key principle in bioethics. However, respecting autonomy in practice is complex because most people define themselves and make decisions influenced by a complex network of social relationships. The extent to which individual autonomy operates for each partner within the context of decision-making within marital or similar relationships is largely unexplored. This paper explores issues related to decision-making by couples (couples' joint decision-making) for health care and the circumstances under which such a practice should be respected as compatible with autonomous decision-making. DISCUSSION: We discuss the concept of autonomy as it applies to persons and to actions, human interdependency and gender roles in decision-making, the dynamics and outcomes of couples' joint decision-making, and the ethics of couples' joint decision-making. We believe that the extent to which couples' joint decision-making might be deemed ethically acceptable will vary depending on the context. Given that in many traditional marriages the woman is the less dominant partner, we consider a spectrum of scenarios of couples' joint decision-making about a woman's own health care that move from those that are acceptably autonomous to those that are not consistent with respecting the woman's autonomous decision-making. To the extent that there is evidence that both members of a couple understand a decision, intend it, and that neither completely controls the other, couples' joint decision-making should be viewed as consistent with the principle of respect for the woman's autonomy. At the other end of the spectrum are decisions made by the man without the woman's input, representing domination of one partner by the other. CONCLUSIONS: We recommend viewing the dynamics of couples' joint decision-making as existing on a continuum of degrees of autonomy. This continuum-based perspective implies that couples' joint decision-making should not be taken at face value but should be assessed against the specific cultural, ethnic, and religious backgrounds and personal circumstances of the individuals in question.

Women's autonomy in health care decision-making in developing countries: a synthesis of the literature.

Autonomy is considered essential for decision-making in a range of health care situations, from health care seeking and utilization to choosing among treatment options. Evidence suggests that women in developing or low-income countries often have limited autonomy and control over their health decisions. A review of the published empirical literature to identify definitions and methods used to measure women's autonomy in developing countries describe the relationship between women's autonomy and their health care decision-making, and identify sociodemographic factors that influence women's autonomy and decision-making regarding health care was carried out. An integrated literature review using two databases (PubMed and Scopus) was performed. Inclusion criteria were 1) publication in English; 2) original articles; 3) investigations on women's decision-making autonomy for health and health care utilization; and 4) developing country context. Seventeen articles met inclusion criteria, including eleven from South Asia, five from Africa, and one from Central Asia. Most studies used a definition of autonomy that included independence for women to make their own choices and decisions. Study methods differed in that many used study-specific measures, while others used a set of standardized questions from their countries' national health surveys. Most studies examined women's autonomy in the context of reproductive health, while neglecting other types of health care utilized by women. Several studies found that factors, including age, education, and income, affect women's health care decision-making autonomy. Gaps in existing literature regarding women's autonomy and health care utilization include gaps in the areas of health care that have been measured, the influence of sex roles and social support, and the use of qualitative studies to provide context and nuance.

Decision-making and motivation to participate in biomedical research in southwest Nigeria.

Motivations and decision-making styles that influence participation in biomedical research vary across study types, cultures, and countries. While there is a small amount of literature on informed consent in non-western cultures, few studies have examined how participants make the decision to join research. This study was designed to identify the factors motivating people to participate in biomedical research in a traditional Nigerian community, assess the degree to which participants involve others in the decision-making process, and examine issues of autonomy in decision-making for research. A descriptive cross-sectional study was conducted with 100 adults (50 men, 50 women) in an urban Nigerian community who had participated in a biomedical research study. Subjects were interviewed using a survey instrument. Two-thirds of the respondents reported participating in the biomedical study to learn more about their illness, while 30% hoped to get some medical care. Over three-quarters (78%) of participants discussed the enrollment decision with someone else and 39% reported obtaining permission from a spouse or family member to participate in the study. Women were more than twice as likely as men to report obtaining permission from someone else before participating. More specifically, half of the female participants reported seeking permission from a spouse before enrolling. The findings suggest that informed consent in this community is understood and practised as a relational activity that involves others in the decision making process. Further studies are needed in non-Western countries concerning autonomy, decision-making, and motivation to participate in research studies.

Factors associated with treatment compliance in hypertension in southwest Nigeria.

Hypertension is an important condition among adults, affecting nearly one billion people worldwide. Treatment with appropriate medication is a key factor in the control of hypertension and reduction in associated risk of complications. However, compliance with treatment is often sub-optimal, especially in developing countries. The present study investigated the factors associated with self-reported compliance among hypertensive subjects in a poor urban community in southwest Nigeria. This community-based cross-sectional study employed a survey of a convenience sample of 440 community residents with hypertension and eight focus-group discussions (FGDs) with a subset of the participants. Of the 440 hypertensive respondents, 65.2% were women, about half had no formal education, and half were traders. Over 60% of the respondents sought care for their condition from the hospital while only 5% visited a chemist or a patent medicine vendor (PMV). Only 51% of the subjects reported high compliance. Factors associated with high self-reported compliance included: regular clinic attendance, not using non-Western prescription medication, and having social support from family members or friends who were concerned about the respondent's hypertension or who were helpful in reminding the respondent about taking medication. Beliefs about cause of hypertension were not associated with compliance. The findings of the FGDs showed that the respondents believed hypertension is curable with the use of both orthodox and traditional medicines and that a patient who 'feels well' could stop using antihypertensive medication. It is concluded that treatment compliance with antihypertensive medication remains sub-optimal in this Nigerian community. The factors associated with high self-reported compliance were identified. More research is needed to evaluate how such findings can be used for the control of hypertension at the community level.

Complementary and alternative medicine in the management of hypertension in an urban Nigerian community.

BACKGROUND: Hypertension is a common non communicable condition worldwide. In developing countries (including Nigeria), the use of complementary and alternative medicine (CAM) is common. This study investigated the frequency and factors associated with use of CAM among hypertensive subjects in an urban Nigerian community. Perspectives about the management of hypertension were obtained from CAM practitioners in the community. METHODS: Four hundred and forty hypertensive subjects in Idikan community, Ibadan, were interviewed using a semi-structured survey instrument. Association between categorical variables was tested using the chi-square test. Logistic regression analysis was done to identify independent predictor variables of CAM use, with CAM use as the outcome variable and the demographic and belief items as predictor variables. In-depth interviews were conducted with all known CAM practitioners in the community on issues relating to their beliefs, knowledge, practice and experiences in managing patients with hypertension in the community. RESULTS: In the study sample, 29% used CAM in the management of their hypertension. Among those using CAM, the most common forms used were herbs (63%) and garlic (21%). Logistic regression analysis revealed that four variables were independent predictors of CAM use: being male (OR 2.58, p < 0.0001), belief in supernatural causes of hypertension (OR 2.11, p = 0.012), lack of belief that hypertension is preventable (OR 0.57, p = 0.014) and having a family history of hypertension (OR1.78, p = 0.042). Other factors such as age, educational level and occupation were not independent predictors of CAM use. Interviews with CAM practitioners revealed that they believed hypertension was caused by evil forces, stress or "too much blood in the body". They also thought they could cure hypertension but that reduced costs (compared to hospitals) was one of the reasons most of their clients consult them. CONCLUSIONS: The use of CAM is common among hypertensive subjects in this urban Nigerian community. Men were more than twice as likely to use CAM and belief in supernatural causes of hypertension was the most notable belief predicting CAM use. Interviews with CAM practitioners yielded useful perspectives about the role they play in hypertension management in the community. This study adds to the small but growing literature about the use of CAM in hypertension in sub Saharan Africa. Further studies in hypertension and other non communicable disease are needed.

Interactions between patent medicine vendors and customers in urban and rural Nigeria.

Patent medicine vendors (PMVs) supply a large portion of the drugs used by the public in African countries to treat their illnesses. Little has been reported about what actually transpires between PMVs and their customers, but nevertheless, concerns have been raised about the potential for abuse of their position. This study conducted 720 observations of PMV-customer interaction in 444 medicine shops in both the metropolis of Ibadan and the rural town of Igbo-Ora in Oyo State, Nigeria. Each interaction lasted 2 minutes on average. A quarter of the customers shared their illness problems with the shop attendant, 9% presented a prescription and the majority simply requested items for purchase. Most customers (73%) were buying drugs for themselves, while the remainder had been sent to purchase for another person. The former were more likely to be adults, while the latter were more often children and adolescents. The most common PMV behaviours are: selling the requested medicine (69%), giving their own suggestions to the customer (30%), asking questions about the illness (19%) and providing instructions on how to take the medicine (21%). Only three referrals were observed. The large number of specific drug requests was evidence of a public that was actively involved in self-care, and thus the major role of the PMV appeared to be one of salesperson meeting that need. A second role became evident when the customer actually complained about his/her illness, a practice associated with the more active PMVs who asked questions, gave suggestions and provided information. These PMV roles can be enhanced through consumer education, PMV training and policy changes to standardize and legitimize PMV contributions to primary health care.