The Ethics of Ethics Reviews in Global Health Research: Case Studies Applying a New Paradigm

With increasing calls for global health research there is growing concern regarding the ethical challenges encountered by researchers from high-income countries (HICs) working in low or middle-income countries (LMICs). There is a dearth of literature on how to address these challenges in practice. In this article, we conduct a critical analysis of three case studies of research conducted in LMICs.We apply emerging ethical guidelines and principles specific to global health research and offer practical strategies that researchers ought to consider. We present case studies in which Canadian health professional students conducted a health promotion project in a community in Honduras; a research capacity-building program in South Africa, in which Canadian students also worked alongside LMIC partners; and a community-university partnered research capacity-building program in which Ecuadorean graduate students, some working alongside Canadian students, conducted community-based health research projects in Ecuadorean communities.We examine each case, identifying ethical issues that emerged and how new ethical paradigms being promoted could be concretely applied.We conclude that research ethics boards should focus not only on protecting individual integrity and human dignity in health studies but also on beneficence and non-maleficence at the community level, explicitly considering social justice issues and local capacity-building imperatives.We conclude that researchers from HICs interested in global health research must work with LMIC partners to implement collaborative processes for assuring ethical research that respects local knowledge, cultural factors, the social determination of health, community participation and partnership, and making social accountability a paramount concern.

The Ethics of Ethics Reviews in Global Health Research: Case Studies Applying a New Paradigm

With increasing calls for global health research there is growing concern regarding the ethical challenges encountered by researchers from high-income countries (HICs) working in low or middle-income countries (LMICs). There is a dearth of literature on how to address these challenges in practice. In this article, we conduct a critical analysis of three case studies of research conducted in LMICs.We apply emerging ethical guidelines and principles specific to global health research and offer practical strategies that researchers ought to consider. We present case studies in which Canadian health professional students conducted a health promotion project in a community in Honduras; a research capacity-building program in South Africa, in which Canadian students also worked alongside LMIC partners; and a community-university partnered research capacity-building program in which Ecuadorean graduate students, some working alongside Canadian students, conducted community-based health research projects in Ecuadorean communities.We examine each case, identifying ethical issues that emerged and how new ethical paradigms being promoted could be concretely applied.We conclude that research ethics boards should focus not only on protecting individual integrity and human dignity in health studies but also on beneficence and non-maleficence at the community level, explicitly considering social justice issues and local capacity-building imperatives.We conclude that researchers from HICs interested in global health research must work with LMIC partners to implement collaborative processes for assuring ethical research that respects local knowledge, cultural factors, the social determination of health, community participation and partnership, and making social accountability a paramount concern.

Are the debates on water privatization missing the point? Experiences from Africa, Asia and Latin America

This paper has two principal aims: first, to unravel some of the arguments mobilized in the controversial privatization debate, and second, to review the scale and nature of private sector provision of water and sanitation in Africa, Asia and Latin America. Despite being vigorously promoted in the policy arena and having been implemented in several countries in the South in the 1990s, privatization has achieved neither the scale nor benefits anticipated. In particular, the paper is pessimistic about the role that privatization can play in achieving the Millennium Development Goals of halving the number of people without access to water and sanitation by 2015. This is not because of some inherent contradiction between private profits and the public good, but because neither publicly nor privately operated utilities are well suited to serving the majority of low-income households with inadequate water and sanitation, and because many of the barriers to service provision in poor settlements can persist whether water and sanitation utilities are publicly or privately operated. This is not to say that well-governed localities should not choose to involve private companies in water and sanitation provision, but it does imply that there is no justification for international agencies and agreements to actively promote greater private sector participation on the grounds that it can significantly reduce deficiencies in water and sanitation services in the South.

The politics of in-work benefits: The case of the ‘active income of solidarity’ in France

In-work benefits have been introduced in a number of Bismarckian welfare regimes in a context of austerity despite being targeted at politically weak constituents and representing a deviation from prevailing welfare institutions. This article addresses this puzzle by looking at the introduction in 2008 of an in-work benefit scheme in France, the Active Income of Solidarity. The analysis reveals that this reform was the result of a cross-cutting alliance between the conservative party and employers, as well as parts of the socialist party and the union movement. The alliance was possible thanks to actors’ multiple interpretations of the reform. The reform was difficult to oppose given its support by experts and public opinion and because it entailed an increase in revenues for low-income workers.

Marine protected areas in artisanal fisheries: a spatial bio-economic model based on observations in Costa Rica and Tanzania

In many lower-income countries, the establishment of marine protected areas (MPAs) involves significant opportunity costs for artisanal fishers, reflected in changes in how they allocate their labor in response to the MPA. The resource economics literature rarely addresses such labor allocation decisions of artisanal fishers and how, in turn, these contribute to the impact of MPAs on fish stocks, yield, and income. This paper develops a spatial bio-economic model of a fishery adjacent to a village of people who allocate their labor between fishing and on-shore wage opportunities to establish a spatial Nash equilibrium at a steady state fish stock in response to various locations for no-take zone MPAs and managed access MPAs. Villagers’ fishing location decisions are based on distance costs, fishing returns, and wages. Here, the MPA location determines its impact on fish stocks, fish yield, and villager income due to distance costs, congestion, and fish dispersal. Incorporating wage labor opportunities into the framework allows examination of the MPA’s impact on rural incomes, with results determining that win-wins between yield and stocks occur in very different MPA locations than do win-wins between income and stocks. Similarly, villagers in a high-wage setting face a lower burden from MPAs than do those in low-wage settings. Motivated by issues of central importance in Tanzania and Costa Rica, we impose various policies on this fishery – location specific no-take zones, increasing on-shore wages, and restricting MPA access to a subset of villagers – to analyze the impact of an MPA on fish stocks and rural incomes in such settings.

Intersections of Jane Jacobs’ conditions for diversity and low-carbon urban systems: a look at four global cities

Countless cities are rapidly developing across the globe, pressing the need for clear urban planning and design recommendations geared towards sustainability. This article examines the intersections of Jane Jacobs’ four conditions for diversity with low-carbon and low-energy use urban systems in four cities around the world: Lyon (France), Chicago (United-States), Kolkata (India), and Singapore (Singapore). After reviewing Jacobs’ four conditions for diversity, we introduce the four cities and describe their historical development context. We then present a framework to study the cities along three dimensions: population and density, infrastructure development/use, and climate and landscape. These cities differ in many respects and their analysis is instructive for many other cities around the globe. Jacobs’ conditions are present in all of them, manifested in different ways and to varying degrees. Overall we find that the adoption of Jacobs' conditions seems to align well with concepts of low-carbon urban systems, with their focus on walkability, transit-oriented design, and more efficient land use (i.e., smaller unit sizes). Transportation sector emissions seems to demonstrate a stronger influence from the presence of Jacobs' conditions, while the link was less pronounced in the building sector. Kolkata, a low-income, developing world city, seems to possess many of Jacobs' conditions, while exhibiting low per capita emissions - maintaining both of these during its economic expansion will take careful consideration. Greenhouse gas mitigation, however, is inherently an in situ problem and the first task must therefore be to gain local knowledge of an area before developing strategies to lower its carbon footprint.

El Niño 2015/2016: impact analysis of past El Niños

This is a DfID (Department for International Development) commissioned report on the impact of historical El Niño events on low- and middle-income countries across Africa and elsewhere. The report identifies El Niño events in the past 35 years and highlights regions and countries vulnerable to their impacts. The impacts on rainfall and temperature are broken down by season and country as the El Niño develops, peaks and decays and are represented in at-a-glance Impact Tables. The Impact Tables also include an extensive review of literature (e.g., peer-reviewed, grey literature and media reports) to identify potential socio-economic impacts in vulnerable sectors such as water, infrastructure, energy and health. The risk of such impacts are graded as high, medium or potential depending on the meteorological signal and the robustness of evidence available.

Recent Trends in Maternal, Newborn, and Child Health in Brazil: Progress Toward Millennium Development Goals 4 and 5

We analyzed Brazil`s efforts in reducing child mortality, improving maternal and child health, and reducing socioeconomic and regional inequalities from 1990 through 2007. We compiled and reanalyzed data from several sources, including vital statistics and population-based surveys. We also explored the roles of broad socioeconomic and demographic changes and the introduction of health sector and other reform measures in explaining the improvements observed. Our findings provide compelling evidence that pro-active measures to reduce health disparities accompanied by socioeconomic progress can result in measurable improvements in the health of children and mothers in a relatively short interval. Our analysis of Brazil`s successes and remaining challenges to reach and surpass Millennium Development Goals 4 and 5 can provide important lessons for other low- and middle-income countries. (Am J Public Health. 2010;100:1877-1889. doi:10.2105/AJPH.2010.196816)

Investigating Environmental Determinants of Diet, Physical Activity, and Overweight among Adults in Sao Paulo, Brazil

There is worldwide recognition that the burden of noncommunicable diseases (NCDs) and obesity-related health problems is rapidly increasing in low- and middle-income countries. Environmental determinants of obesity are likely to differ between countries, particularly in those undergoing rapid socioeconomic and nutrition transitions such as Brazil. This study aims to describe some built environment and local food environment variables and to explore their association with the overweight rate and diet and physical activity area-level aggregated indicators of adults living in the city of Sao Paulo, the largest city in Brazil. This formative study includes an ecological analysis of environmental factors associated with overweight across 31 submunicipalities of the city of Sao Paulo using statistical and spatial analyses. Average prevalence of overweight was 41.69% (95% confidence interval 38.74, 44.64), ranging from 27.14% to 60.75% across the submunicipalities. There was a wide geographical variation of both individual diet and physical activity, and indicators of food and built environments, favoring wealthier areas. After controlling for area socioeconomic status, there was a positive correlation between regular fruits and vegetables (FV) intake and density of FV specialized food markets (r = 0.497; p < 0.001), but no relationship between fast-food restaurant density and overweight prevalence was found. A negative association between overweight prevalence and density of parks and public sport facilities was seen (r = -0.527; p < 0.05). Understanding the relationship between local neighborhood environments and increasing rates of poor diet, physical activity, and obesity is essential in countries undergoing rapid economic and urban development, such as Brazil, in order to provide insights for policies to reduce increasing rates of NCDs and food access and health inequalities.

Exploring the influence of context in a community-based facilitation intervention focusing on neonatal health and survival in Vietnam : a qualitative study

Background In the Neonatal health – Knowledge into Practice (NeoKIP) trial in Vietnam, local stakeholder groups, supported by trained laywomen acting as facilitators, promoted knowledge translation (KT) resulting in decreased neonatal mortality. In general, as well as in the community-based NeoKIP trial, there is a need to further understand how context influences KT interventions in low- and middle-income countries (LMICs). Thus, the objective of this study was to explore the influence of context on the facilitation process in the NeoKIP intervention. Methods A secondary content analysis was performed on 16 Focus Group Discussions with facilitators and participants of the stakeholder groups, applying an inductive approach to the content on context through naïve understanding and structured analysis. Results The three main-categories of context found to influence the facilitation process in the NeoKIP intervention were: (1) Support and collaboration of local authorities and other communal stakeholders; (2) Incentives to, and motivation of, participants; and (3) Low health care coverage and utilization. In particular, the role of local authorities in a KT intervention was recognized as important. Also, while project participants expected financial incentives, non-financial benefits such as individual learning were considered to balance the lack of reimbursement in the NeoKIP intervention. Further, project participants recognized the need to acknowledge the needs of disadvantaged groups. Conclusions This study provides insight for further understanding of the influence of contextual aspects to improve effects of a KT intervention in Vietnam. We suggest that future KT interventions should apply strategies to improve local authorities’ engagement, to identify and communicate non-financial incentives, and to make disadvantaged groups a priority. Further studies to evaluate the contextual aspects in KT interventions in LMICs are also needed.

Knowledge translation in Uganda : a qualitative study of Ugandan midwives' and managers' perceived relevance of the sub-elements of the context cornerstone in the PARIHS framework

BACKGROUND: A large proportion of the annual 3.3 million neonatal deaths could be averted if there was a high uptake of basic evidence-based practices. In order to overcome this 'know-do' gap, there is an urgent need for in-depth understanding of knowledge translation (KT). A major factor to consider in the successful translation of knowledge into practice is the influence of organizational context. A theoretical framework highlighting this process is Promoting Action on Research Implementation in Health Services (PARIHS). However, research linked to this framework has almost exclusively been conducted in high-income countries. Therefore, the objective of this study was to examine the perceived relevance of the subelements of the organizational context cornerstone of the PARIHS framework, and also whether other factors in the organizational context were perceived to influence KT in a specific low-income setting. METHODS: This qualitative study was conducted in a district of Uganda, where focus group discussions and semi-structured interviews were conducted with midwives (n = 18) and managers (n = 5) within the catchment area of the general hospital. The interview guide was developed based on the context sub-elements in the PARIHS framework (receptive context, culture, leadership, and evaluation). Interviews were transcribed verbatim, followed by directed content analysis of the data. RESULTS: The sub-elements of organizational context in the PARIHS framework--i.e., receptive context, culture, leadership, and evaluation--also appear to be relevant in a low-income setting like Uganda, but there are additional factors to consider. Access to resources, commitment and informal payment, and community involvement were all perceived to play important roles for successful KT. CONCLUSIONS: In further development of the context assessment tool, assessing factors for successful implementation of evidence in low-income settings--resources, community involvement, and commitment and informal payment--should be considered for inclusion. For low-income settings, resources are of significant importance, and might be considered as a separate subelement of the PARIHS framework as a whole.

Infecção por HELICOBACTER PYLORI em crianças com dor abdominal crônica e sua associação com a gastrite endoscópica nodular

A infecção por Helicobacter pylori (Hp) é uma das infecções bacterianas mais comuns em todo o mundo. As maiores prevalências da infecção foram encontradas nos países em desenvolvimento, onde, em geral são altas já na infância. O método diagnóstico considerado mais acurado para a infecção por Hp, em crianças, é o exame endoscópico com biópsias gástricas. Alguns autores referem que o único aspecto macroscópico que pode predizer a infecção é o da presença de nodosidades na mucosa gástrica. Este aspecto é denominado de gastrite endoscópica nodular. A especificidade da gastrite endoscópica nodular para a infecção por Hp, entretanto, recentemente foi questionada por outros autores. Realizamos um estudo transversal em uma amostra de crianças (um a 12 anos) com dor abdominal crônica, que preenchiam os critérios para a realização de endoscopia digestiva alta, no Hospital da Criança Conceição e no Hospital de Clínicas de Porto Alegre, de setembro de 1997 a setembro de 1999. O objetivo principal foi verificar a associação entre a infecção por Hp e a gastrite endoscópica nodular nessas crianças. A amostra foi constituída de 185 crianças de ambos os sexos, com baixa renda familiar, cujos pais apresentavam baixo nível de escolaridade. Foi realizado estudo histológico das lâminas de biópsia gástrica (no mínimo cinco fragmentos, corados com H-E ou Giemsa), conforme o Sistema Sydney modificado. A infecção por Hp foi caracterizada pela presença de Hp na lâminas de biópsias gástricas dos pacientes e a gastrite folicular, pela presença de folículos linfóides bem formados, em mucosa gástrica inflamada. A prevalência da infecção por Hp nas crianças com dor abdominal crônica foi de 27% (IC 95%: 20,8-34,0). Foi demonstrada uma associação muito forte entre a infecção por Hp e a gastrite endoscópica nodular nessas crianças (P<0,001; RP = 29,7). Houve um aumento da prevalência tanto da infecção por Hp como da gastrite endoscópica nodular com a idade dos pacientes. A gastrite endoscópica nodular , embora tenha demostrado uma baixa sensibilidade (44,0%), apresentou um valor preditivo positivo de 91,7% para a infecção por Hp. Tanto o teste de urease, como a gastrite endoscópica nodular mostraram-se muito específicas, 94,5% e 98,5%, respectivamente, para o diagnóstico da infecção. Quando se combinou o teste de urease com o aspecto de gastrite endoscópica nodular, encontrou-se, uma sensibilidade muito baixa (34,7%), mas uma especificidade de 100% para a infecção por Hp. A sensibilidade do teste de urease, isolado, para a infecção foi de 60,4% e o seu valor preditivo positivo de 80,5%. O aspecto endoscópico (gastrite endoscópica nodular) teve associação com o microscópico (gastrite folicular) (P<0,001). Houve uma forte e significativa associação entre a infecção por Hp e a gastrite crônica ativa ( P<0,001; RP = 10,8). O mesmo foi demonstrado entre a gastrite nodular e a gastrite crônica ativa (P<0,001; RP = 8,6). Também foi verificado um nítido aumento das razões de prevalência da gastrite crônica ativa e da gastrite endoscópica nodular, com a acentuação dos graus de densidade de Hp. Finalmente, foi demonstrada a importante correlação entre o grau de intensidade da gastrite, verificado no exame histológico, e a gastrite endoscópica nodular (r = 0,97; P<0,001). A prevalência da infecção por Hp encontrada em Porto Alegre, nas crianças, foi menor do que a de outras cidades brasileiras e similar àquela registrada em algumas cidades do primeiro mundo. A presença de nodosidade na mucosa gástrica foi a alteração, à endoscopia, mais freqüentemente verificada nas crianças com infecção por Hp. Considerando a baixa prevalência da infecção encontrada na nossa amostra, a presença de gastrite endoscópica nodular significa uma elevada probabilidade de infecção por Hp, dado o alto valor preditivo verificado. O achado negativo para a gastrite endoscópica nodular, entretanto, não exclui a possibilidade da presença de infecção por Hp. Uma maior colonização bacteriana da mucosa gástrica estaria associada ao aparecimento da gastrite endoscópica nodular, já que a sua prevalência aumentou com os graus de densidade de Hp, assim como ocorreu com a gastrite crônica ativa. E quando ocorre, nas crianças, há maior probabilidade de se tratar de uma gastrite mais ativa e mais intensa.

On the long run effects of barriers to trade

We study the macroeconomic effects of international trade policy by integrating a Hecksher-Ohlin trade model into an optimal-growth framework. The model predicts that a more open economy will have higher factor productivity. Furthermore, there is a "selective development trap," an additional steady state with low income, to which countries may or may not converge, depending on policy. Income at the development trap falls as trade barriers increase. Hence, cross-country differences in barriers to trade may help explain the dispersion of per-capita income observed across countries. The effects are quantified and we show that protectionism can explain a relevant fraction of TFP and long-run income differentials across countries.

On the growth effects of barriers to trade

We study the macroeconomic effects of international trade policy by integrating a Hecksher-Ohlin trade model into an optimal-growth framework. The model predicts that an open economy will have higher factor productivity and faster growth. Also, under protectionist policies there may be “development traps,” or additional steady states with low income. In the last case, higher tariffs imply lower incomes, so that the large cross-country differences in barriers to trade may explain part of the huge dispersion of per capita income observed across countries. The model simulation shows that the link between trade and macroeconomic performance may be quantitatively important.

Trabalhadores na reciclagem do lixo : dinâmicas econômicas, sócio-ambientais e políticas na perspectiva de empoderamento

Esta pesquisa enfoca as dinâmicas econômicas, sócio-ambientais e políticas de organização, construção da identidade coletiva e empoderamento de trabalhadores em associações de reciclagem, levando-se em conta suas relações com diversos agentes externos. A escolha desse objeto do estudo prende-se a dois aspectos principais: - à caracterização dessa atividade como uma ocupação em estruturação e processo de reconhecimento, representando uma possibilidade de sustentabilidade e autonomia para setores da população de baixa renda em países em desenvolvimento; - a uma situação peculiar de relação entre Estado e sociedade, na qual as associações de catadores/recicladores interagem simultaneamente com órgãos dos governos municipais respectivos, do governo estadual e com entidades não-governamentais, como setores da Igreja Católica e ONGs nacionais e internacionais. Através da análise comparativa das características de três associações de reciclagem na Região Metropolitana de Porto Alegre, verificam-se resultados diferenciados no que diz respeito a processos internos de organização do trabalho e de participação nas decisões, bem como em relação às percepções, motivações e expectativas dos catadores/recicladores quanto a sua ocupação.