Questioning our presumptions about the presumption of capacity
In this ethical consideration of capacity, Astrachan et al (2023) introduce a philosophical aspect which is relevant to many health professionals who deal with patients. The presumption of capacity is central to the contemporary doctrine of decision-making capacity (DMC) that helps protect an individual's autonomy.
However, the presumption of capacity is not necessarily straightforward, and the authors consider possible problems. For instance, we can either assume person P has DMC or it is established that P lacks DMC. Let us consider P, who shows signs of impairment and must decide between treatment options X or Y. P is evaluated to determine whether they have the DMC to decide. During the evaluation, P states that they want X. If we presume that P has DMC, then in principle the evaluation should stop and treatment X begun.
But, in practice, this is never done, and as the authors make clear: ‘There is an important distinction between no longer presuming something is true, which leaves open the possibility that it is true or false, and the conclusion that it is true or false.’ Between these two, the authors suggest, is an important unanswered question about what happens during a capacity evaluation, when it is not yet established whether P does or does not have capacity. This unanswered question is explored by the authors.
The effect of HPV vaccination on the rate of cytology in women attending cervical screening
Around 70% of cervical cancers are caused by persistent infection with human papilloma virus (HPV) subtypes 16 and 18, and vaccination targeting both subtypes has been available in Ireland since 2010/11. This is cited by Rourke et al (2023) who note that women vaccinated through the initial catch-up HPV vaccination programme (2011/12 to 2013/14) first became eligible for cervical screening in 2019 at age 25 years.
With international evidence strongly suggesting a reduced rate of high-grade (HG) cytology in HPV-vaccinated populations, women vaccinated through Ireland's initial catch-up HPV vaccination programme (2011/12, 2012/13 and 2013/14) were first eligible for cervical screening in 2019. In this study, Rourke et al (2023) examined the changes in detection of HG cytology outcomes in 25-year-olds screened from 2010 to 2022 compared to population data on HPV vaccination.
The study found that the rate of HG cytology in 25-year-olds in 2015–2018 was 3.7% of all cytology tests taken in this age group, whereas for the corresponding period from 2019 to 2022 (when vaccinated women were attending screening), the average percentage of HG cytology in 25-year-olds was 1.5%. This study, the authors state, ‘provides early evidence of the potential impact of HPV vaccination on cervical disease in the Republic of Ireland (which supports the HPV vaccination, cervical screening, and cancer treatment approach of the WHO Strategy for Cervical Cancer Elimination).’
Childhood contact with social services and risk of suicide or sudden death
Childhood out-of-home care is associated with premature death in adulthood, especially death by suicide, accidents, and violence, but little is known about the mortality risk in the larger population of adults that had contact with social services in childhood but never entered out-of-home care.
In this population-wide, longitudinal, record-linkage study of around 437 000 Northern Ireland adults born between 1985 and 1997, McKenna et al (2023) determined the association between all levels of childhood contact with social services in Northern Ireland and death by suicide, sudden death, and all-cause mortality in young adulthood. Everyone in the study cohort was followed from age 18 years to July 2021.
The study found that 51 097 individuals who had childhood social care contact comprised only 11.7% of the cohort yet comprised 35.3% of sudden deaths and 39.7% of suicide deaths. Further the ‘[r]isk of suicide or sudden death increased stepwise with level of childhood contact and was highest in adults with a history of out-of-home care.’
The authors suggest that they have identified a need for an intersecting health and social policy that reduces the negative consequences of early life adversity and improves access to appropriate health services, including those that support mental well-being, noting that ‘[i]Individuals who did not meet the threshold for children's social care services may benefit from targeted interventions.’
Evaluation frameworks for mental health servicesThe integration of primary care and mental health care is commonly known as Collaborative Mental Health Care (CMHC). In this mixed-methods study Sapag et al (2023) developed and pilot-tested a feasible and meaningful evaluation framework ‘to support the ongoing improvement and performance measurement of services and systems in Latin America regarding CMHC.The study included (1) a critical literature review; (2) an environmental appraisal at three selected health networks in Mexico, Nicaragua, and Chile; (3) a Delphi group with appropriate expertise; (4) a final consultation at the three sites; and (5) a pilot-test of the framework. The framework was successfully piloted, and its implementation was conducted through consultations with programme stakeholders, like the heads of local health networks in the research sites, all of whom ‘indicated their desires for the development of such a framework but expressed their wishes to have it effectively tuned to local realities.’The authors suggest that the framework model is applicable to other healthcare-related evaluations in Latin America beyond CMHC. Other areas they identify as potentially benefitting from similar frameworks are initiatives that help to improve and evaluate ‘geriatric care, youth-oriented services, domestic violence services, sexual and reproductive health services, and chronic disease prevention and services, all within primary care.’