Ethics and reflective practice : continuing the conversation

This paper is a response to the question asked by Tony Ghaye in Reflective Practice Volume 8, Number 2, 2007, ‘Is reflective practice ethical?’. My response is to re‐consider the pervasive idea in reflective practice that experience is always private and personal. This common understanding of experience leads to a reluctance when writing for the purpose of assessment and to a type of writing that tends towards the confessional. Contrary to that notion of experience, I suggest that a return to Charles Sanders Peirce enables the acknowledgement that experience is not personally owned but rather a conversation between the self and that which is not‐yet known. This conversation is precipitated by the element of surprise, thus making the study of surprise a central feature of reflective practice. This argument is illustrated through examining a dramatic moment in Friedrich Nietzsche’s philosophical novel Thus spake Zarathustra (1887) in which Zarathustra’s teaching techniques are challenged and rendered different. Eschewing the belief that experience is ‘personal’ offers a version of reflective practice as the attempt to continually engage in conversations precipitated by the Other

Developmental origins of obesity and the metabolic syndrome : the role of maternal obesity

Obesity and its sequelae may prove to be the greatest threat to human lifestyle and health in the developed world this century. The so called obesity epidemic has seen the incidence of obesity and overweight almost double in Western societies and the trend is mirrored in nations that are transitioning to first world economies. There is no doubt that much of the rise in obesity can be attributed to lifestyle factors such as the excess consumption of energy-dense foods and the decline in physical activity. However, the ‘fetal origins’hypothesis, first proposed by Barker and colleagues and elaborated by several groups over the past 15 years to be termed the ‘Developmental Origins of Adult Health and Disease’ (DOHaD), provides an alternative explanation for the rising rates of obesity. The DOHaD hypothesis states that exposure to an unfavourable environment during development (either in utero or in the early postnatal period) programmes changes in fetal or neonatal development such that the individual is then at greater risk of developing adulthood disease. This chapter discusses the effects of maternal obesity on fetal development and birth outcomes as well as the manner in which DOHaD may contribute to the obesity epidemic.

Race, genetic determinism and the media: an exploratory study of media coverage of genetics and Indigenous Australians

Social scientists and Indigenous people have voiced concerns that media messages about genetics and race may increase the public's belief in genetic determinism and even increase levels of racism. The degree of genetic determinism in media messages has been examined as a determining factor. This study is the first to consider the implications of this area of scholarship for the indigenous minority in Australia. A search of the last two decades of major Australian newspapers was undertaken for articles that discussed Indigenous Australians and genetics. The review found 212 articles, of which 58 concerned traits or conditions that were presented in a genetically deterministic or antideterministic fashion. These 58 articles were analysed by topic, slant, and time period. Overall, 23 articles were anti-deterministic, 18 were deterministic, 14 presented both sides and three were ambiguous. There was a spike in anti-deterministic articles in the years after the Human Genome Diversity Project, and a parallel increase in deterministic articles since the completion of the Human Genome Project in 2000. Potential implications of the nature of media coverage of genetics for Indigenous Australians is discussed. Further research is required to test directly the impact of these messages on Australians.

The influence of protective and risk factors in individual, peer and school domains on Thai adolescents' alcohol and illicit drug use: a survey

This study investigates risk and protective factors for substance abuse in a sample of 1778 students attending technical colleges in Bangkok and Nakhon Ratchasima provinces of Thailand using a self-report questionnaire modified from the Communities That Care youth survey. Low school commitment was strongly associated with illicit drug use, with adjusted odds ratios ranging from 2.84 (glue sniffing) to 10.06 (ecstasy). Having friends using drugs, and friends with delinquent behaviors increased the risk of using alcohol and illegal drugs, with adjusted odds ratios of 6.84 and 6.72 respectively for marijuana use. For protective factors, approximately 40-60% of students with high levels of moral belief, participation in religious activities, and social skills were less likely to use alcohol. It is concluded that peer influence is a significant contributor to Thai adolescents' participation in substance abuse and that engaging in religiosity may assist adolescents to internalize negative aspects of harmful drugs into positive perceptions and encourage them to avoid alcohol and illegal drugs.

Exploring motivation and confidence in taking prescribed medicines in coexisting diseases: a qualitative study

Aims and objectives: To explore the motivation and confidence of people with coexisting diabetes, chronic kidney disease (CKD) and hypertension to take their medicines as prescribed. Background: These comorbidities are major contributors to disease burden globally. Self-management of individuals with these coexisting diseases is much more complicated than that of those with single diseases and is critical for improved health outcomes. Design: Motivational interviewing telephone calls were made with participants with coexisting diabetes, CKD and hypertension. Methods: Patients aged ≥18 years with diabetes, CKD and systolic hypertension were recruited from outpatient clinics of an Australian metropolitan hospital between 2008-2009. An average of four motivational interviewing telephone calls was made with participants (n = 39) in the intervention arm of a randomised controlled trial. Data were thematically analysed using the modified Health Belief Model as a framework. Results: Participants' motivation and confidence in taking prescribed medicines was thwarted by complex medicine regimens and medical conditions. Participants wanted control over their health and developed various strategies to confront threats to health. The perceived barriers of taking recommended health action outweighed the benefits of taking medicines as prescribed and were primarily related to copious amounts of medicines. Conclusion: Taking multiple prescribed medicines in coexisting diabetes, CKD and hypertension is a perpetual vocation with major psychosocial effects. Participants were overwhelmed by the number of medicines that they were required to take. The quest for personal control of health, fear of the future and the role of stress and gender in chronic disease management have been highlighted. Participants require supportive emotional interventions to self-manage their multiple medicines on a daily basis. Relevance to clinical practice: Reducing the complexity of medicine regimens in coexisting diseases is paramount. Individualised psychosocial approaches that address the emotional needs of patients with regular follow-up and feedback are necessary for optimal chronic disease self-management. © 2013 John Wiley & Sons Ltd.

‘Moral luck’ and the question of autonomy, choice, and control in end-of-life decision making

It is commonly assumed that, in the realm of ethical decision making at the end-of-life, ‘luck’ and ‘risk’ do not intrude. Nonetheless ‘moral luck’ (where happenstance makes a moral difference) does intrude and can have an unanticipated impact on the ultimate moral outcomes of end-of-life care. In the interests of upholding the ethical standards of end-of-life care, healthcare providers have increasingly relied on ethical principlism as a rational decision-guiding frame in the sincere belief that such an approach will enable patient selfdetermination and control over treatment decisions when needing end-of-life care. Due to contextual variables and associated uncertainties in end-of-life care, however, the intended moral outcomes of appeals to commonly accepted ethical principles (in particular the principle of autonomy) are not always realized. What is not always appreciated is that whether ‘good’ or ‘bad’ moral outcomes are achieved can be as much a matter of chance as of choice. This essay explores the relevance and possible implications of moral luck in end-of-life decision making and care. A key conclusion of the paper is that the notion of moral luck needs to be taken seriously in end-of-life care contexts since it can have an unanticipated impact on the outcomes of the decisions that are made and thereby on the moral interests of patients facing the end of their lives.

Religion, heritage and the sustainable city : Hinduism and urbanisation in Jaipur

The speed and scale of urbanisation in India is unprecedented almost anywhere in the world and has tremendous global implications. The religious influence on the urban experience has resonances for all aspects of urban sustainability in India and yet it remains a blind spot while articulating sustainable urban policy.This book explores the historical and on-going influence of religion on urban planning, design, space utilisation, urban identities and communities. It argues that the conceptual and empirical approaches to planning sustainable cities in India need to be developed out of analytical concepts that define local sense of place and identity. Examining how Hindu religious heritage, beliefs and religiously influenced planning practices have impacted on sustainable urbanisation development in Jaipur and Indian cities in general, the book identifies the challenges and opportunities that ritualistic and belief resources pose for sustainability. It focuses on three key aspects: spatial segregation and ghettoisation; gender-inclusive urban development; and the nexus between religion, nature and urban development. This cutting-edge book is one of the first case studies linking Hindu religion, heritage, urban development, women and the environment in a way that responds to the realities of Indian cities. It opens up discussion on the nexus of religion and development, drawing out insightful policy implications for the sustainable urban planning of many cities in India and elsewhere in South Asia and the developing world.

Digital shimmer: popular music and the intimate nexus between fan and star

Conception of ‘star performance’ through popular music is stratified which generates diverse and often contradictory forms of thought. For example, stars and celebrities plausibly act as a ‘culture medium’ in which, through imagination, one’s identity is assembled, realised or constructed. What to become and how to be are questions we individually and collectively contend with throughout our lives to varying degrees (Maslow, 1954; 1968). Predominant use of digital technologies has seen the delivery of sound much altered. Music, be it Giuseppe Verdi’s La Traviata or Iron Maiden’s The Number of the Beast, once sourced via analogue legacy devices such as ‘old-school’ tape cassette or vinyl record is now a series of zero and one digits. Advocates argue that the key benefit of digitalisation is the ability to compress data because sound generates large files of information. The discourse of digitalisation begs the question of how a series of ones and zeros, albeit in a plethora of configurations, registers with listening bodies and affects ‘the sublime’. It is without doubt that some musical experiences afford indescribable, unlocatable sensation—even enchantment (as defined by Bennett, 2001: 5 and called forth by Redmond: 2014: 126). Such musical experiences might be in the presence of the performer or in their absence such as in the case of recorded music. In this context, any sense of ’real’ space and place is less definitive allowing for ‘special encounters’ to be imagined and felt. For these reasons, music and all that the use of the word might convey, the proposed notion of phaino-ken here, acts as the lens through which to examine the meaning and value of celebrity and star embodiment.

'Of course I didn't work … only when I had to': narratives of women's working lives and what really counted

There was a long-held belief, that, prior to the 1970s, women were no longer involved in paid labour once they were married or began to have children. Official statistics also supported this particular national narrative. This paper argues that this narrative did not accurately reflect the historical situation because the methods used to determine who worked and when did not fully capture all of women's paid labour at the time. This is reflected in a small study of older women and their recollections of paid employment. Some women initially claimed that they did no paid work after marriage, but with low key, in-depth and persistent questioning, it became clear that many women did work in an unofficial capacity (in the black economy) or alongside their husbands in their paid employment. This is a preliminary study that underlines the importance of life-course narratives in the social sciences to delve deeply into women's memories and thus their experiences.

Friend or foe? Finding common ground between development and Pentecostalism

Religious belief is a common human characteristic, with 80 per cent of the world's population professing some religious affiliation. Indeed, global surveys report an increase in "religiosity" across the globe in recent decades. Within Christianity, Pentecostalism has experienced considerable growth, in contrast with the more traditional Christian churches. This growth is occurring across the globe, but is extremely evident within developing countries. Within development studies (both the theory and practice), religion has been negatively portrayed, misunderstood or set aside as not being of importance to development outcomes. Such an approach towards religion is misguided and limits development effectiveness. While religion is certainly not the "answer" to eradicating poverty or overcoming global injustices, authentic engagement by development actors with religion does provide important opportunities to enhance development outcomes. This paper will consider the basic tenets of development theory and practice, and contrast those against Pentecostal theological teaching in order to determine where there exists common ground and where there exists misalignment of values and thus tension. Such assessment is important in order to enhance the religious literacy of the development sector and to better understand how to authentically engage with communities expressing this belief.

Susceptibility of reproduction in female pigs to impairment by stress and the role of the hypothalamo-pituitary-adrenal axis

Although it is generally considered that stress can impair reproduction, we suggest that the impact of acute or repeated acute stress or acute or repeated acute elevations of cortisol are of little consequence in female pigs, even if these occur during the series of endocrine events that induce oestrus and ovulation. It is important to understand the impact of acute stress on reproduction because, in the intensive production of livestock, animals are often subjected to short-term challenges. There seems little doubt that reproduction in a proportion of female pigs is susceptible to impairment by severe and prolonged stress or the sustained elevation of cortisol but only when this continues for a substantial period. In female pigs, where reproduction is susceptible to impairment by severe prolonged stress, it is possible that the mediators of this suppression are cortisol, corticotrophin-releasing factor and vasopressin but, in pigs, there is evidence to suggest that adrenocorticotrophic hormone is not involved. Other substances secreted during stress may be involved but these are not considered in this review. It is possible that the mediators of stress act at any level of the hypothalamo-pituitary-ovarian axis. Although a variety of experimental manipulations have provided potential mediators and mechanisms for the stress-induced suppression of reproduction, these experimental manipulations rarely represented physiological circumstances so it is not clear if such mechanisms would be important in a physiological context. The precise mediators and mechanisms by which hormones released during stress may inhibit reproductive processes during severe prolonged stress are yet to be determined.

Implementation of the diabetes and hypertension guideline lifestyle recommendations in urban Mongolia: A qualitative study of primary care providers

Abstract
Background: Hypertension and diabetes, key risk factors for cardiovascular disease, are significant health problems globally. As cardiovascular disease is one of the leading causes of mortality in Mongolia since 2000, clinical guidelines on arterial hypertension and diabetes were developed and implemented in 2011. This paper explores the barriers and enablers influencing the implementation of these guidelines in the primary care setting.
Methods: A phenomenological qualitative study with semi-structured interviews was conducted to explore the implementation of the diabetes and hypertension guidelines at the primary care level, as well as to gain insight into how practitioners view the usability and practicality of the guidelines. Ten family health centres were randomly chosen from a list of all the family health centres (n = 136) located in Ulaanbaatar City. In each centre, a focus group discussion with nurses (n = 20) and individual interviews with practice doctors (n =10) and practice managers (n= 10) were conducted. Data was analysed using a thematic approach utilising the Theoretical Domains Framework.
Results: The majority of the study participants reported being aware of the guidelines and that they had incorporated them into their daily practice. They also reported having attended guideline training sessions which were focused on practice skill development. The majority of participants expressed satisfaction with the wide range of resources that had been supplied to them by the Mongolian Government to assist with the implementation of the guidelines. The resources, supplied from 2011 onwards, included screening devices, equipment for blood tests, medications and educational materials. Other enablers were the participants’ commitment and passion for guideline implementation and their belief in the simplicity and practicality of the guidelines. Primary care providers reported a number of challenges in implementing the guidelines, including frustration caused by increased workload and long waiting times, time constraints, difficulties with conflicting tasks and low patient health literacy.
Conclusions: This study provides evidence that comprehensive and rigorous dissemination and implementation strategies increase the likelihood of successful implementation of new guidelines in low resource primary care settings. It also offers some key lessons that might be carefully considered when other evidence-based clinical guidelines are to be put into effect in low resource settings and elsewhere.

Implementation of clinical guidelines on diabetes and hypertension in urban Mongolia: a qualitative study of primary care providers' perspectives and experiences

BACKGROUND: Hypertension and diabetes, key risk factors for cardiovascular disease, are significant health problems globally. As cardiovascular disease is one of the leading causes of mortality in Mongolia since 2000, clinical guidelines on arterial hypertension and diabetes were developed and implemented in 2011. This paper explores the barriers and enablers influencing the implementation of these guidelines in the primary care setting.

METHODS: A phenomenological qualitative study with semi-structured interviews was conducted to explore the implementation of the diabetes and hypertension guidelines at the primary care level, as well as to gain insight into how practitioners view the usability and practicality of the guidelines. Ten family health centres were randomly chosen from a list of all the family health centres (n = 136) located in Ulaanbaatar City. In each centre, a focus group discussion with nurses (n = 20) and individual interviews with practice doctors (n = 10) and practice managers (n = 10) were conducted. Data was analysed using a thematic approach utilising the Theoretical Domains Framework.

RESULTS: The majority of the study participants reported being aware of the guidelines and that they had incorporated them into their daily practice. They also reported having attended guideline training sessions which were focused on practice skill development. The majority of participants expressed satisfaction with the wide range of resources that had been supplied to them by the Mongolian Government to assist with the implementation of the guidelines. The resources, supplied from 2011 onwards, included screening devices, equipment for blood tests, medications and educational materials. Other enablers were the participants' commitment and passion for guideline implementation and their belief in the simplicity and practicality of the guidelines. Primary care providers reported a number of challenges in implementing the guidelines, including frustration caused by increased workload and long waiting times, time constraints, difficulties with conflicting tasks and low patient health literacy.

CONCLUSIONS: This study provides evidence that comprehensive and rigorous dissemination and implementation strategies increase the likelihood of successful implementation of new guidelines in low resource primary care settings. It also offers some key lessons that might be carefully considered when other evidence-based clinical guidelines are to be put into effect in low resource settings and elsewhere.