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HOPE (National Institute for Health and Care Research Global Health Research Group on Homelessness and Mental Health in Africa) aims to develop and evaluate interventions that address the unmet needs of people who are homeless and have severe mental illness (SMI) living in three African countries in ways that are rights-based, contextually grounded, scalable and sustainable.
Methods
We will work in the capital city (Addis Ababa) in Ethiopia, a regional city (Tamale) in Ghana, and the capital city (Nairobi) and a rural county (Makueni) in Kenya to understand different approaches to intervention needed across varied settings.
We will be guided by the MRC/NIHR framework on complex interventions and implementation frameworks and emphasise co-production. Formative work will include synthesis of global evidence (systematic review, including grey literature, and a Delphi consensus exercise) on interventions and approaches to homelessness and SMI. We will map contexts; conduct focused ethnography to understand lived experiences of homelessness and SMI; carry out a cross-sectional survey of people who are homeless (n = 750 Ghana/Ethiopia; n = 350 Kenya) to estimate prevalence of SMI and identify prioritised needs; and conduct in-depth interviews and focus group discussions with key stakeholders to understand experiences, challenges and opportunities for intervention. This global and local evidence will feed into Theory of Change (ToC) workshops with stakeholders to establish agreement about valued primary outcomes, map pathways to impact and inform selection and implementation of interventions. Intervention packages to address prioritised needs will be co-produced, piloted and optimised for feasibility and acceptability using participatory action research. We will use rights-based approaches and focus on community-based care to ensure sustainability. Realist approaches will be employed to analyse how contextual variation affects mechanisms and outcomes to inform methods for a subsequent evaluation of larger scale implementation. Extensive capacity-strengthening activities will focus on equipping early career researchers and peer researchers. People with lived experience of SMI and policymakers are an integral part of the research team. Community engagement is supported by working closely with multisectoral Community Advisory Groups.
Conclusions
HOPE will develop evidence to support action to respond to the needs and preferences of people experiencing homelessness and SMI in diverse settings in Africa. We are creating a new partnership of researchers, policymakers, community members and people with lived experience of SMI and homelessness to enable African-led solutions. Key outputs will include contextually relevant practice and policy guidance that supports achievement of inclusive development.
Health technology assessment (HTA) is a form of policy analysis that informs decisions about funding and scaling up health technologies to improve health outcomes. An equity-focused HTA recommendation explicitly addresses the impact of health technologies on individuals disadvantaged in society because of specific health needs or social conditions. However, more evidence is needed on the relationships between patient engagement processes and the development of equity-focused HTA recommendations.
Objectives
The objective of this study is to assess relationships between patient engagement processes and the development of equity-focused HTA recommendations.
Methods
We analyzed sixty HTA reports published between 2013 and 2021 from two Canadian organizations: Canada’s Drug Agency and Ontario Health.
Results
Quantitative analysis of the HTA reports showed that direct patient engagement (odds ratio (OR): 3.85; 95 percent confidence interval (CI): 2.40–6.20) and consensus in decision-making (OR: 2.27; 95 percent CI: 1.35–3.84) were more likely to be associated with the development of equity-focused HTA recommendations than indirect patient engagement (OR: .26; 95 percent CI: .16–.41) and voting (OR: .44; 95 percent CI: .26–.73).
Conclusion
The results can inform the development of patient engagement strategies in HTA. These findings have implications for practice, research, and policy. They provide valuable insights into HTA.
We consider the holder of an individual tontine retirement account, with maximum and minimum withdrawal amounts (per year) specified. The tontine account holder initiates the account at age 65 and earns mortality credits while alive, but forfeits all wealth in the account upon death. The holder wants to maximize total withdrawals and minimize expected shortfall at the end of the retirement horizon of 30 years (i.e., it is assumed that the holder survives to age 95). The holder controls the amount withdrawn each year and the fraction of the retirement portfolio invested in stocks and bonds. The optimal controls are determined based on a parametric model fitted to almost a century of market data. The optimal control algorithm is based on dynamic programming and the solution of a partial integro differential equation (PIDE) using Fourier methods. The optimal strategy (based on the parametric model) is tested out of sample using stationary block bootstrap resampling of the historical data. In terms of an expected total withdrawal, expected shortfall (EW-ES) efficient frontier, the tontine overlay dramatically outperforms an optimal strategy (without the tontine overlay), which in turn outperforms a constant weight strategy with withdrawals based on the ubiquitous four per cent rule.
Helen Frowe argues against a common view of the standard Trolley Scenario according to which it is permissible but not required to kill the one as a side effect of saving the five. She argues that saving the five and killing the one is morally required in that scenario. I defend the intuitive verdict that it is permitted but not required to turn the trolley in the Trolley Scenario. First, I show that the crucial premise of Frowe’s argument – the premise that one has a duty to prevent harm to others when one can do so without violating anyone’s rights, and without bearing an unreasonable cost – is false. And second, I present an independent argument (one originally offered by Frances Kamm) for the permissibility of not turning the trolley in the Trolley Scenario.
This paper proposes a framework for comprehensive, collaborative, and community-based care (C4) for accessible mental health services in low-resource settings. Because mental health conditions have many causes, this framework includes social, public health, wellness and clinical services. It accommodates integration of stand-alone mental health programs with health and non-health community-based services. It addresses gaps in previous models including lack of community-based psychotherapeutic and social services, difficulty in addressing comorbidity of mental and physical conditions, and how workers interact with respect to referral and coordination of care. The framework is based on task-shifting of services to non-specialized workers. While the framework draws on the World Health Organization’s Mental Health Gap Action Program and other global mental health models, there are important differences. The C4 Framework delineates types of workers based on their skills. Separate workers focus on: basic psychoeducation and information sharing; community-level, evidence-based psychotherapeutic counseling; and primary medical care and more advanced, specialized mental health services for more severe or complex cases. This paper is intended for individuals, organizations and governments interested in implementing mental health services. The primary aim is to provide a framework for the provision of widely accessible mental health care and services.
Several scholars have recognized the limitations of theories of moral reasoning in explaining moral behavior. They have argued that moral behavior may also be influenced by moral identity, or how central morality is to one’s sense of self. This idea has been supported by findings that people who exemplify moral behavior tend to place more importance on moral traits when defining their self-concepts (Colby & Damon, 1995). This paper takes the next step of examining individual variation in a construct highly associated with immoral behavior — psychopathy. In Study 1, we test the hypothesis that individuals with a greater degree of psychopathic traits have a weaker moral identity. Within a large online sample, we found that individuals who scored higher on a measure of psychopathic traits were less likely to base their self-concepts on moral traits. In Study 2, we test whether this reduced sense of moral identity can be attributed to differences in moral judgment, which is another factor that could influence immoral behavior. Our results indicated that the reduced sense of moral identity among more psychopathic individuals was independent of variation in moral judgment. These results suggest that individuals with psychopathic traits may display immoral behavior partially because they do not construe their personal identities in moral terms.
In the UK, postnatal depression is more common in British South Asian women than White Caucasion women. Cognitive–behavioural therapy (CBT) is recommended as a first-line treatment, but there is little evidence for the adaptation of CBT for postnatal depression to ensure its applicability to different ethnic groups.
Aims
To evaluate the clinical and cost-effectiveness of a CBT-based positive health programme group intervention in British South Asian women with postnatal depression.
Method
We have designed a multicentre, two-arm, partially nested, randomised controlled trial with 4- and 12-month follow-up, comparing a 12-session group CBT-based intervention (positive health programme) plus treatment as usual with treatment as usual alone, for British South Asian women with postnatal depression. Participants will be recruited from primary care and appropriate community venues in areas of high South Asian density across the UK. It has been estimated that randomising 720 participants (360 into each group) will be sufficient to detect a clinically important difference between a 55% recovery rate in the intervention group and a 40% recovery rate in the treatment-as-usual group. An economic analysis will estimate the cost-effectiveness of the positive health programme. A qualitative process evaluation will explore barriers and enablers to study participation and examine the acceptability and impact of the programme from the perspective of British South Asian women and other key stakeholders.
We extend the Annually Recalculated Virtual Annuity (ARVA) spending rule for retirement savings decumulation (Waring and Siegel (2015) Financial Analysts Journal, 71(1), 91–107) to include a cap and a floor on withdrawals. With a minimum withdrawal constraint, the ARVA strategy runs the risk of depleting the investment portfolio. We determine the dynamic asset allocation strategy which maximizes a weighted combination of expected total withdrawals (EW) and expected shortfall (ES), defined as the average of the worst 5% of the outcomes of real terminal wealth. We compare the performance of our dynamic strategy to simpler alternatives which maintain constant asset allocation weights over time accompanied by either our same modified ARVA spending rule or withdrawals that are constant over time in real terms. Tests are carried out using both a parametric model of historical asset returns as well as bootstrap resampling of historical data. Consistent with previous literature that has used different measures of reward and risk than EW and ES, we find that allowing some variability in withdrawals leads to large improvements in efficiency. However, unlike the prior literature, we also demonstrate that further significant enhancements are possible through incorporating a dynamic asset allocation strategy rather than simply keeping asset allocation weights constant throughout retirement.
The COVID-19 pandemic has impacted community mental health, but the effect on psychiatric admissions is unknown. We investigated factors contributing to acute psychiatric admissions, and whether this changed during the first UK lockdown.
Method
A retrospective case-note review study with an exploratory mixed-methods design was used to examine factors in psychiatric admissions following the first UK 2020 lockdown compared to the same time periods in 2019 and 2018.
Result
Themes of psychopathology, risk, social stressors, community treatment issues, and physical health concerns were generated. The mean number of codes per case was 6⋅19 (s.d. = 2⋅43), with a mean number of categories per case of 3⋅73, (s.d. = 0⋅98). Changes in routines and isolation were common factors in the study year; accommodation and substance abuse were more prominent in the control year. Relationship stressors featured strongly in both groups. There were significantly more women (χ2(1, N = 98) = 20⋅80, p < 0⋅00001) and older adults (χ2(1, N = 98) = 8⋅61, p = 0⋅0033) in the study group than the control. Single people, compared to those in a relationship (χ2(1, N = 45) = 4.46, p = 0⋅035), and people with affective disorders compared to psychotic disorders ((χ2(1, N = 28) = 5.19, p = 0⋅023), were more likely to have a COVID-19 related admission factor.
Conclusion
The COVID-19 pandemic amplified pre-existing psychosocial vulnerabilities with a disproportionate psychiatric admissions impact on the mental health of women, the elderly and those with affective disorders.
There is presently a debate between Subjectivists and Objectivists about moral wrongness. Subjectivism is the view that the moral status of our actions, whether they are morally wrong or not, is grounded in our subjective circumstances – either our beliefs about, or our evidence concerning, the world around us. Objectivism, on the other hand, is the view that the moral status of our actions is grounded in our objective circumstances – all those facts other than those which comprise our subjective circumstances. A third view, Ecumenism, has it that the moral status of our actions is grounded both in our subjective and our objective circumstances. After outlining and evaluating the various arguments both against Subjectivism and against Objectivism, this Element offers a tentative defense of Objectivism about moral wrongness.
Tyler Burge first introduced his distinction between epistemic entitlement and epistemic justification in ‘Content Preservation’ in 1993. He has since deployed the distinction in over twenty papers, changing his formulation around 2011. His distinction and its basis, however, is not well understood in the literature. This chapter distinguishes two uses of ‘entitlement’ in Burge and then focuses on the contrast between justification and entitlement, two forms of warrant, where warrants consists in the exercise of a reliable belief-forming competence. Since he draws the distinction in terms of reasons, this chapter brings his account of reasons altogether in one place. The chapter introduces a decision-procedure for classifying warrants as justifications or entitlements. The distinction is not the same as the inferential vs. non-inferential distinction. Inference is distinguished from processing, thinking, reasoning, and critically reasoning. Burge’s new formulation of the distinction was driven by the recognition of non-accessible modular reasons. Three kinds of access are distinguished.
How should we undertand the role of norms – especially epistemic norms – governing assertive speech acts? Mitchell Green (2009) has argued that these norms play the role of handicaps in the technical sense from the animal signals literature. As handicaps, they then play a large role in explaining the reliability – and so the stability (the continued prevalence) – of assertive speech acts. But though norms of assertion conceived of as social norms do indeed play this stabilizing role, these norms are best understood as deterrents and not as handicaps. This paper explains the stability problem for the maintenance of animal signals, and so human communication; the mechanics of the handicap principle; the role of deterrents and punishments as an alternative mechanism; and the role of social norms governing assertion for the case of human communication.
The ‘jumping to conclusions’ (JTC) bias is associated with both psychosis and general cognition but their relationship is unclear. In this study, we set out to clarify the relationship between the JTC bias, IQ, psychosis and polygenic liability to schizophrenia and IQ.
Methods
A total of 817 first episode psychosis patients and 1294 population-based controls completed assessments of general intelligence (IQ), and JTC, and provided blood or saliva samples from which we extracted DNA and computed polygenic risk scores for IQ and schizophrenia.
Results
The estimated proportion of the total effect of case/control differences on JTC mediated by IQ was 79%. Schizophrenia polygenic risk score was non-significantly associated with a higher number of beads drawn (B = 0.47, 95% CI −0.21 to 1.16, p = 0.17); whereas IQ PRS (B = 0.51, 95% CI 0.25–0.76, p < 0.001) significantly predicted the number of beads drawn, and was thus associated with reduced JTC bias. The JTC was more strongly associated with the higher level of psychotic-like experiences (PLEs) in controls, including after controlling for IQ (B = −1.7, 95% CI −2.8 to −0.5, p = 0.006), but did not relate to delusions in patients.
Conclusions
Our findings suggest that the JTC reasoning bias in psychosis might not be a specific cognitive deficit but rather a manifestation or consequence, of general cognitive impairment. Whereas, in the general population, the JTC bias is related to PLEs, independent of IQ. The work has the potential to inform interventions targeting cognitive biases in early psychosis.
We determine the optimal asset allocation to bonds and stocks using an annually recalculated virtual annuity (ARVA) spending rule for DC pension plan decumulation. Our objective function minimizes downside withdrawal variability for a given fixed value of total expected withdrawals. The optimal asset allocation is found using optimal stochastic control methods. We formulate the strategy as a solution to a Hamilton–Jacobi–Bellman (HJB) Partial Integro Differential Equation (PIDE). We impose realistic constraints on the controls (no-shorting, no-leverage, discrete rebalancing) and solve the HJB PIDEs numerically. Compared to a fixed-weight strategy which has the same expected total withdrawals, the optimal strategy has a much smaller average allocation to stocks and tends to de-risk rapidly over time. This conclusion holds in the case of a parametric model based on historical data and also in a bootstrapped market based on the historical data.
Does epistemic justification aim at truth? The vast majority of epistemologists instinctively answer ‘Yes’; it's the textbook response. Joseph Cruz and John Pollock surprisingly say no. In ‘The Chimerical Appeal of Epistemic Externalism’ they argue that justification bears no interesting connection to truth; justification does not even aim at truth. ‘Truth is not a very interesting part of our best understanding’ of justification (C&P 2004, 137); it has no ‘connection to the truth.’ A ‘truth-aimed … epistemology is not entitled to carry the day’ (C&P 2004, 138, emphasis added).
Pollock and Cruz's argument for this surprising conclusion is of general interest for it is ‘out of step with a very common view on the part of epistemologists, both internalist and externalist alike’ (C&P 2004, 136), as nearly all ‘epistemologists have claimed that truth and falsity play a crucial role in distinguishing between justified and unjustified beliefs [for] believing truths is the ultimate aim of human rational cognition’ (C&P 2004, 125; cf. Audi 1988).
We compared systematic and random survey techniques to estimate breeding population sizes of burrow-nesting petrel species on Marion Island. White-chinned (Procellaria aequinoctialis) and blue (Halobaena caerulea) petrel population sizes were estimated in systematic surveys (which attempt to count every colony) in 2009 and 2012, respectively. In 2015, we counted burrows of white-chinned, blue and great-winged (Pterodroma macroptera) petrels within 52 randomized strip transects (25 m wide, total 144 km). Burrow densities were extrapolated by Geographic Information System-derived habitat attributes (geology, vegetation, slope, elevation, aspect) to generate island-wide burrow estimates. Great-winged petrel burrows were found singly or in small groups at low densities (2 burrows ha−1); white-chinned petrel burrows were in loose clusters at moderate densities (3 burrows ha−1); and blue petrel burrows were in tight clusters at high densities (13 burrows ha−1). The random survey estimated 58% more white-chinned petrels but 42% fewer blue petrels than the systematic surveys. The results suggest that random transects are best suited for species that are widely distributed at low densities, but become increasingly poor for estimating population sizes of species with clustered distributions. Repeated fixed transects provide a robust way to monitor changes in colony density and area, but might fail to detect the formation/disappearance of new colonies.