BackgroundAlcohol and illicit drug use has been recognized as a growing problem among adolescents in Botswana. Little is known about factors affecting alcohol and drug use among Botswana’s secondary school students. To aid the design and implementation of effective public health interventions, we sought to determine the prevalence of alcohol and drug use in secondary school students in urban and peri-urban areas of Botswana, and to evaluate risk and protective factors for substance use.MethodsWe performed a 72-item cross-sectional survey of students in 17 public secondary schools in Gaborone, Lobatse, Molepolole and Mochudi, Botswana. The World Health Organization’s (WHO) Alcohol Use Disorder Identification Test (AUDIT) was used to define hazardous drinking behavior. Using Jessor’s Problem Behavior Theory (PBT) as our conceptual framework, we culturally-adapted items from previously validated tools to measure risk and protective factors for alcohol and drug use. Between-group differences of risk and protective factors were compared using univariate binomial and multinomial-ordinal logit analysis. Relative risks of alcohol and drug use by demographic, high risks and low protections were calculated. Multivariate ordinal-multinomial cumulative logit analysis, multivariate nominal-multinomial logit analysis, and binominal logit analysis were used to build models illustrating the relationship between risk and protective factors and student alcohol and illicit drug use. Clustered data was adjusted for in all analyses using Generalized Estimating Equations (GEE) methods.ResultsOf the 1936 students surveyed, 816 (42.1%) reported alcohol use, and 434 (22.4%) met criteria for hazardous alcohol use. Illicit drug use was reported by 324 students (16.7%), with motokwane (marijuana) being the most commonly used drug. Risk factors more strongly associated with alcohol and drug use were reported alcohol availability, individual and social vulnerability factors, and poor peer modeling. Individual and social controls protections appear to mitigate risk of student alcohol and drug use.ConclusionsAlcohol and illicit drug use is prevalent among secondary school students in Botswana. Our data suggest that interventions that reduce the availability of alcohol and drugs and that build greater support networks for adolescents may be most helpful in decreasing alcohol and drug use among secondary school students in Botswana.Electronic supplementary materialThe online version of this article (10.1186/s12889-018-6263-2) contains supplementary material, which is available to authorized users.
Since the inception of their profession, genetic counselors have helped patients and families adapt to varied circumstances and make decisions influenced by powerful emotions. In doing so, they have had to reconcile ethical principles with the diverse values of their patients. While this challenge is not unique in medicine, it has preoccupied genetic counselors disproportionately because such a large share of genetic counseling work involves nuanced discussions about reproductive choices and the impact of difference and disability on people's lives. Historically, the profession of genetic counseling has relied on 'nondirectiveness' to guide practice. Nondirectiveness has been defined in various ways: as a counseling method designed to be value-neutral (Caplan, 1993); as the prevention of coercion or persuasion in genetic counseling(Hamby & Biesecker, 2000); as a commitment not to impose one's own values on patients (Fine, 1993); and as a counseling strategy that supports autonomous decision-making (Bartels, LeRoy, McCarthy, & Caplan, 1997). The original ethical justification for practicing nondirectively was to respect individual patient autonomy, construed largely as non-interference in patient decision-making (Stern, 2009). This ethos grew out of a genuine respect for persons, particularly concerning reproductive choice and disability rights. The profession's emphasis on nondirectiveness has also been understood as an effort to distance genetic counseling from the morally fraught history of eugenics (Resta, 1997).
Rollouts of COVID-19 vaccines in the USA were opportunities to redress disparities that surfaced during the pandemic. Initial eligibility criteria, however, neglected geographic, racial/ethnic, and socioeconomic considerations. Marginalized populations may have faced barriers to then-scarce vaccines, reinforcing disparities. Inequalities may have subsided as eligibility expanded. Using spatial modeling, we investigate how strongly local vaccination levels were associated with socioeconomic and racial/ethnic composition as authorities first extended vaccine eligibility to all adults. We harmonize administrative, demographic, and geospatial data across postal codes in eight large US cities over 3 weeks in Spring 2021. We find that, although vaccines were free regardless of health insurance coverage, local vaccination levels in March and April were negatively associated with poverty, enrollment in means-tested public health insurance (e.g., Medicaid), and the uninsured population. By April, vaccination levels in Black and Hispanic communities were only beginning to reach those of Asian and White communities in March. Increases in vaccination were smaller in socioeconomically disadvantaged Black and Hispanic communities than in more affluent, Asian, and White communities. Our findings suggest vaccine rollouts contributed to cumulative disadvantage. Populations that were left most vulnerable to COVID-19 benefited least from early expansions in vaccine availability in large US cities.
Respect for patient autonomy has served as the dominant ethical principle of genetic counselling, but as we move into a genomic era, it is time to actively reexamine the role that this principle plays in genetic counselling practice. In this paper, we argue that the field of genetic counselling should move away from its emphasis on patient autonomy and toward the incorporation of a more balanced set of principles that allows counsellors to offer clear guidance about how best to obtain or use genetic information. We begin with a brief history of how respect for patient autonomy gained such emphasis in the field and how it has taken on various manifestations over time, including the problematic concept of nondirectiveness. After acknowledging the field's preliminary move away from nondirectiveness, we turn to a series of arguments about why the continued dominance of patient autonomy has become untenable given the arrival of the genomic era. To conclude, we describe how a more complete set of bioethical principles can be adapted and used by genetic counsellors to strengthen their practice without undermining patient autonomy.
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