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Sravya Reddy, MDPediatric Resident at The University of Texas how to spot fake kamagra at Austin Dell Medical SchoolMember, Texas Medical AssociationHow does the erectile dysfunction treatment kamagra factor into potentially abusive situations? buy kamagra 100mg oral jelly uk. To stop the spread of erectile dysfunction treatment, we have isolated ourselves into small family units to avoid catching and transmitting the kamagra. While saving so many buy kamagra 100mg oral jelly uk from succumbing to a severe illness, socially isolating has unfortunately posed its own problems.

Among those is the increased threat of harm from intimate partner violence, which includes physical violence, sexual violence, stalking, or psychological harm by a current or former partner or spouse. Potential child abuse is an increased threat as well. The impact of this kamagra happened buy kamagra 100mg oral jelly uk so rapidly that society did not have time to think about all the consequences of social isolation before implementing it.

Now those consequences are becoming clear.Social isolation due to the kamagra is forcing victims to stay home indefinitely with their abusers. Children and adolescents also have been forced to stay at home since many school districts have made education virtual to keep everyone safe from the kamagra. Caregivers are also home because they are working buy kamagra 100mg oral jelly uk remotely or because they are unemployed.

With the increase in the number of erectile dysfunction treatment cases, financial strain due to the economic downturn, and concerns of contracting the kamagra and potentially spreading it to family members, these are highly stressful times. Stress leads to an increase in the rate of intimate partner violence. Even those who suffer from it can begin to become buy kamagra 100mg oral jelly uk abusive to other household members, thus amplifying the abuse in the household.

Some abuse may go unrecognized by the victims themselves. For example, one important and less well-known type of abuse is coercive control. It’s the type of buy kamagra 100mg oral jelly uk abuse that doesn’t leave a physical mark, but it’s emotional, verbal, and controlling.

Victims often know that something is wrong – but can’t quite identify what it is. Coercive control can still buy kamagra 100mg oral jelly uk lead to violent physical abuse, and murder. The way in which people report abuse has also been altered by the kamagra.People lacking usual in-person contacts (with teachers, co-workers, or doctors) and the fact that some types of coercive abuse are less recognized lead to fewer people reporting that type of abuse.

Child abuse often is discovered during pediatricians’ well-child visits, but the kamagra has limited those visits. Many teachers, who might also notice buy kamagra 100mg oral jelly uk signs of abuse, also are not able to see their students on a daily basis. Some abuse victims visit emergency departments (EDs) in normal times, but ED visits are also down due to erectile dysfunction treatment.Local police in China report that intimate partner violence has tripled in the Hubei province.

The United Nations reports it also increased 30% in France as of March 2020 and increased 25% in Argentina. In the U.S buy kamagra 100mg oral jelly uk. The conversation about increased intimate partner violence during these times has just now started, and we are beginning to gather data.

Preliminary analysis shows police reports of intimate partner violence have increased by 18% to 27% across several U.S. Cities. Individuals affected by addiction have additional stressors and cannot meet with support groups.

Children and adolescents who might otherwise use school as a form of escape from addicted caregivers are no longer able to do so. Financial distress can also play a factor. According to research, the rate of violence among couples with more financial struggles is nearly three and a half times higher than couples with fewer financial concerns.Abuse also can come from siblings.

Any child or adolescent with preexisting behavioral issues is more likely to act out due to seclusion, decreased physical activity, or fewer positive distractions. This could increase risk for others in the household, especially in foster home situations. These other residents might be subject to increased sexual and physical abuse with fewer easy ways to report it.

What can we do about this while abiding by the rules of the kamagra?. How can physicians help?. Patients who are victims of intimate partner violence are encouraged to reach out to their doctor.

A doctor visit may be either in person or virtual due to the safety precautions many doctors’ offices are enforcing due to erectile dysfunction treatment. During telehealth visits, physicians should always ask standard questions to screen for potential abuse. They can offer information to all patients, regardless of whether they suspect abuse.People could receive more support if we were to expand access to virtual addiction counseling, increase abuse counseling, and launch more campaigns against intimate partner violence.

The best solution might involve a multidisciplinary team, including psychiatrists, social workers, child abuse teams and Child Protective Services, and local school boards. Physicians can help in other ways, too. Doctors can focus on assessing mental health during well-child and acute clinic visits and telehealth visits.

A temporary screening tool for behavioral health during the kamagra might be beneficial. Governments could consider allocating resources to telepsychiatry. Many paths can be taken to reduce the burden of mental health issues, and this is an ongoing discussion.

How should physicians approach patients who have or may have experienced intimate partner violence?. Victims of domestic assault can always turn to their physician for guidance on next steps. In response, doctors can:Learn about local resources and have those resources available to your patients;Review safety practices, such as deleting internet browsing history or text messages.

Saving abuse hotline information under other listings, such as a grocery store or pharmacy listing. And creating a new, confidential email account for receiving information about resources or communicating with physicians.If the patient discloses abuse, the clinician and patient can establish signals to identify the presence of an abusive partner during telemedicine appointments.To my fellow physicians, I suggest recognizing and talking about the issue with families.Medical professionals take certain steps if they suspect their patient’s injuries are a result of family violence, or if the patient discloses family violence. Physicians will likely screen a patient, document their conversation with the patient, and offer support and inform the patient of the health risks of staying in an abusive environment, such as severe injuries or even death.

A doctor’s priority is his or her patient’s safety, regardless of why the victim might feel forced to remain in an abusive environment. While physicians only report child and elderly abuse, they should encourage any abused patient to report her or his own case, while also understanding the complexity of the issue. Under no circumstance should any form of abuse be tolerated or suffered.

Any intimate partner violence should be avoided, and reported if possible and safe. My hope is that with more awareness of this rising public health concern, potential victims can better deal with the threat of abuse during this stressful kamagra – and hopefully avoid it..

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Additionally, there are currently more than 15 650 journal titles available via the Directory of Open Access Journals (DOAJ).2 This wealth of available resources has allowed for immediate access of information by clinicians, scientists and researchers. However, it poses challenges for authors when attempting to submit and publish their work.The transition to open accessThe wide adoption of the internet has sparked a transition kamagra thailand price towards distributing scholarly content digitally.3 This kamagra reviews users has been a major change from the traditional model of sending physical, printed volumes to subscribers. The idea behind the transition to open-access publishing was to remove the barriers to rapid dissemination of scholarly work that existed because of publishers holding copyright on articles, and only allowing access to journal subscribers in a pay-to-read model.4 Open-access publishing, which refers to unrestricted online access to articles published in scholarly journals, allows for free and immediate access to scholarly content upon publishing to anyone who has access to the internet. In this model, kamagra reviews users the cost to provide journal services has changed dramatically.

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IntroductionIn the field of medicine, the process of disseminating knowledge and information is paramount buy kamagra 100mg oral jelly uk to the advancement of our check this site out discipline. When new observations are made, researchers share their findings with their colleagues via publication in medical journals, which allows for other clinicians to discover and implement these findings in clinical practice. This process began in the 17th century, with the publication of the first English medical journal in 1684, titled Medicina Curiosa.1 Over the years, the number of journals and the way buy kamagra 100mg oral jelly uk in which we access this information has changed, but the premise remains the same. In the 21st century, we live in a digital age where we procure the majority of our information from the internet.

Additionally, there are currently more than 15 650 journal titles available via the Directory of Open Access Journals (DOAJ).2 This wealth of available resources has allowed for immediate access of information by clinicians, scientists and researchers. However, it poses challenges for authors when attempting to submit and buy kamagra 100mg oral jelly uk publish their work.The transition to open accessThe wide adoption of the internet has sparked a transition towards distributing scholarly content digitally.3 This has been a major change from the he has a good point traditional model of sending physical, printed volumes to subscribers. The idea behind the transition to open-access publishing was to remove the barriers to rapid dissemination of scholarly work that existed because of publishers holding copyright on articles, and only allowing access to journal subscribers in a pay-to-read model.4 Open-access publishing, which refers to unrestricted online access to articles published in scholarly journals, allows for free and immediate access to scholarly content upon publishing to anyone who has access to the internet. In this model, the cost to provide journal services buy kamagra 100mg oral jelly uk has changed dramatically.

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• certain drugs for high blood pressure
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New mums requiring specialist care for a severe mental illness can now have their babies Discover More stay with them at NSW's first public, purpose-built Mother and Baby Unit.Premier Dominic Perrottet and Minister for Mental Health Bronnie Taylor opened the new facility at kamagra soft chewable Royal Prince Alfred (RPA) Hospital in Camperdown today after meeting with the unit's specialist team.Mr Perrottet said it is the first state-wide facility designed to keep families together when a mother requires hospitalisation for a severe perinatal mental illness. "We know how important it is for new parents to form an emotional bond in those early formative months after child-birth and this unit will enable new mums to do that while also receiving the specialist care and support they need," Mr Perrottet said.Named 'Naamuru', a local Aboriginal dialect word meaning 'leading the way', the unit will care for up to 120 NSW residents a year who have infants up to 12 months of age.Mrs Taylor said the eight-bed unit is staffed by specialist perinatal health professionals who can attend to the mental health needs of the mother, as well as facilitate appropriate care of the baby and promote positive mother-baby interactions."New mums can now receive the best possible perinatal treatment close to their newest family members, while being supported to form a strong attachment with their baby. Partners will be welcome kamagra soft chewable to stay for certain periods, so they can be an active supporter in the recovery process," Mrs Taylor said. Mr Hazzard said the unit complements a range of mental health services provided by the nearby Professor Marie Bashir Centre and RPA's Women and Babies services.

"Being a new parent is challenging at the best of times. This wonderful new facility aims to provide the right kind kamagra soft chewable of support to mums with a mental illness so they can rejoin their loved ones at home as quickly as possible," Mr Hazzard said.Each bedroom is large enough to accommodate the mother, up to two infants under 12-months of age and a partner or family member. There are also therapeutic spaces, including a 24-hour respite nursery. A mothercraft room.

Dining and kamagra soft chewable kitchen areas. Outdoor courtyards. Play areas. And a retreat room."RPA is proud to be the home of the state's first public unit providing acute, inpatient care and treatment for parents from across NSW who are experiencing psychiatric illness in the perinatal period alongside their baby," Sydney Local Health District Chief Executive kamagra soft chewable Dr Teresa Anderson said.

The Mother and Baby Unit is part of the NSW Government's $700 million Statewide Mental Health Infrastructure Program – the single biggest investment in mental health infrastructure in NSW to date. A second state-wide facility at Westmead Hospital is expected to open later in the year..

New mums requiring specialist care for a severe mental illness can now have their babies stay with them at NSW's first public, purpose-built Mother and Baby Unit.Premier Dominic Perrottet and Minister for Mental Health Bronnie Taylor opened the new facility at Royal Prince Alfred (RPA) Hospital in Camperdown this link today after meeting with the unit's specialist team.Mr Perrottet said it is the first state-wide facility designed to keep families together when a mother requires hospitalisation buy kamagra 100mg oral jelly uk for a severe perinatal mental illness. "We know how important it is for new parents to form an emotional bond in those early formative months after child-birth and this unit will enable new mums to do that while also receiving the specialist care and support they need," Mr Perrottet said.Named 'Naamuru', a local Aboriginal dialect word meaning 'leading the way', the unit will care for up to 120 NSW residents a year who have infants up to 12 months of age.Mrs Taylor said the eight-bed unit is staffed by specialist perinatal health professionals who can attend to the mental health needs of the mother, as well as facilitate appropriate care of the baby and promote positive mother-baby interactions."New mums can now receive the best possible perinatal treatment close to their newest family members, while being supported to form a strong attachment with their baby. Partners will be welcome to buy kamagra 100mg oral jelly uk stay for certain periods, so they can be an active supporter in the recovery process," Mrs Taylor said. Mr Hazzard said the unit complements a range of mental health services provided by the nearby Professor Marie Bashir Centre and RPA's Women and Babies services. "Being a new parent is challenging at the best of times.

This wonderful new facility aims to provide the right kind of support to mums with a mental illness so they can rejoin their loved ones at home as quickly as possible," buy kamagra 100mg oral jelly uk Mr Hazzard said.Each bedroom is large enough to accommodate the mother, up to two infants under 12-months of age and a partner or family member. There are also therapeutic spaces, including a 24-hour respite nursery. A mothercraft room. Dining and buy kamagra 100mg oral jelly uk kitchen areas. Outdoor courtyards.

Play areas. And a retreat room."RPA is proud to be the home of the state's first public unit providing acute, buy kamagra 100mg oral jelly uk inpatient care and treatment for parents from across NSW who are experiencing psychiatric illness in the perinatal period alongside their baby," Sydney Local Health District Chief Executive Dr Teresa Anderson said. The Mother and Baby Unit is part of the NSW Government's $700 million Statewide Mental Health Infrastructure Program – the single biggest investment in mental health infrastructure in NSW to date. A second state-wide facility at Westmead Hospital is expected to open later in the year..

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Choice is what is kamagra 100mg oral jelly probably one of the most often discussed areas in bioethics, alongside the related concepts of informed consent and autonomy. It is generally, prima facie, portrayed as a good what is kamagra 100mg oral jelly thing. In healthcare, the 2000s saw the UK Prime Minister Tony Blair pursue the ‘Choice Agenda’ what is kamagra 100mg oral jelly where, ‘As capacity expands, so choice will grow.

Choice will fundamentally change the balance of power in the NHS.’1 In a consumerist society giving consumers more choice is seen as desirable. However, choice is not what is kamagra 100mg oral jelly a good in itself, giving people more choice in certain situations can be problematic. I.e.

Consumerism drives economic growth and this has a detrimental effect on the environment. And increasing the range of choices a patient is offered is often not the best way to improve the quality of healthcare provision.2 The assumptions behind the valuing of choice need careful unpacking and this Issue of the Journal of Medical Ethics includes papers that explore choice in a number of areas.This Issue's Editor’s choice is Tom Walker’s ‘The Value of Choice’,3 which puts forward a suggestion for the importance of the symbolic value of choice. There are a number of ways of categorising the value of choice in healthcare.

One account sees choice as valuable because it is by choosing that individuals make their life their own. Another account sees choice as valuable for instrumental reasons, people are generally, assuming they are sufficiently informed, the best judge of their own best interests. Walker argues for an additional third reason, the symbolic value of choice, originally proposed by Scanlon.

This sees choice as valuable because being given the option to choose, whether or not one takes it up, not the act of choosing is what makes choice valuable. Being offered the option to choose has a ‘communicative role’ in that it communicates that the person has standing and, for certain types of choice, being denied the opportunity to choose, ‘can be both demeaning and stigmatising.’ Walker states that denying someone the opportunity to choose in certain circumstances does not communicate anything untoward, and he goes to explore how we might determine when not allowing someone a choice would be demeaning. Here he stresses the importance of context in making this determination, it is not fixed by the features of a patient, but what being ‘allowed’ or ‘denied’ the opportunity to make a choice reveals about the healthcare professional’s view of the patient.

€˜It communicates that they either see those patients as competent and equal members of society, or that they do not.’ Denying a patient the opportunity to choose an ineffective treatment, for example, does not communicate a negative judgement. Walker says his account, ‘is intended to supplement existing accounts, not replace them. Because choice is valuable for more than one reason no single account can capture everything that matters.’The importance of pointing to the context of the choice is highlighted in Walker’s paper and it is only through careful examination of the context of that offering that we can determine if, in fact, this is an area where choice should be offered and to whom.

Such an examination is carried out in Cameron Beattie’s paper,4 which considers the High Court review of service provision at the youth-focussed gender identity Tavistock Clinic. Beattie disagrees with the High Court’s view that it is ’highly unlikely’ that under-13s, and ’doubtful’ that 14–15 years old, can be competent to consent to puberty blocker therapy for gender dysphoria. Beattie argues that having puberty blocker therapy is a choice that minors should be given the opportunity to make.

In principle, children of that age could be competent to make the decision and that the decision is no more complex than other medical decisions that Gillick competence has conventionally been applied to. Children of this age fall into what Walker calls a ‘transitional’ group, ‘Of particular importance here is the extent to which societal features mean members of some groups find it particularly hard to be recognised as competent and equal members of society. That includes members of groups subject to discrimination….It also includes those who are in what we might call transitional groups such as teenagers struggling to be recognised as competent.’ In the case of denying puberty blockers, the symbolic value of choice is clear.The paper by Zeljka Buturovic5 examines the debate over young childless women requesting sterilisation.

There has been a discussion in the literature that critiques doctors’ hesitancy to accede to this type of request and Buturovic argues against these criticisms. The argument is that rather than a doctor’s refusal to sterilise a young childless woman or putting up obstacles to this being examples of, variously, inconsistency, paternalism, pronatalist bias and discrimination, it is understandable that doctors should be reluctant to follow this unusual request, and such hesitancy is of potential benefit to the young woman. This hesitancy can act as a filter for women who are not seriously committed to sterilisation.

This, in essence, is the opposite argument to Beattie’s paper, that the barriers put up to prevent people exercising their choice in this case are warranted. Young childless women should have their choice scrutinised and if necessary delayed so that it can be ascertained if the choice is a genuine one, and ‘to weed out (the) confused and uncommitted.’ Ultimately, that choice should be available for young childless woman, but it is a choice, given its long-term consequences and likely lack of reversibility, that should be carefully considered.These papers show that choice is a contextually based, complex and multi-facetted concept and approaches such as Walker’s, give us tools to think more carefully about the value of choice and what that means in particular situations. A consideration of choice is not complete without thinking about the effects of our choices on others, and this needs to be at the forefront of any ethical analysis.

The ‘choice-agenda’ can often be a proxy for an individualistic conception of personal responsibility and a construction of the ‘good’ of the choice as being solely about that individual’s right to exercise a choice, rather than a more nuanced consideration of the wider, or even limited, effects of that choice on others. Although we have well-worn ways of thinking about harm – harm to others and liberty limiting principles6 – how the exercising of individual choice might harm others is often debatable and unclear, and political with a small and large P!. For instance, in July 2021 Boris Johnson, the UK prime minister, announced that mask wearing would now be one of personal choice.

The government would end the legal obligation to wear a face covering, ‘We will move away from legal restrictions and allow people to make their own informed decisions about how to manage the kamagra.’ Johnson went on to say. €˜Guidance will suggest where you might choose to do so - especially when cases are rising and where you come into contact with people you don't usually meet in enclosed spaces, such as obviously crowded public transport.’7 This mandate for ‘freedom-day’ was criticised in a number of letters in high ranking medical journals,8 9 arguing, ‘The narrative of “caution, vigilance, and personal responsibility” is an abdication of the government’s fundamental duty to protect public health. €œPersonal responsibility” does not work in the face of an airborne, highly contagious infectious disease.

Infectious diseases are a matter of collective, rather than individual, responsibility.’8 In this case, someone’s personal choice to not wear a mask on public transport, where social distancing is impossible, conflicts with someone else’s choice to travel to work as safely as they can. As the critics of this policy and work in public health ethics notes, one person’s choice can have a significant detrimental effect on others, and in situations like this, such as this mask wearing example, where not allowing choice, that is maintaining the legally mandated requirement to wear a face mask (unless there are reasons for an exemption), is an ethically acceptable restriction on ‘personal choice.’ In Walker’s terminology disallowing this choice it is not demeaning or stigmatising, as it applies to everyone, and does not fail to recognise any particular person or group as equal members of society.Choice is often portrayed as a good thing like parenthood and apple pie and the use of choice by politicians to whip up support and bolster their political agendas, as shown by the examples of Blair and Johnson, shows the rhetorical power of the concept. But to really address in what circumstances choices should be offered, to whom and what type of choice, we need theoretical tools to help us understand and be attentive to the wider implications and the papers in this Issue help us to do that.Ethics statementsPatient consent for publicationNot applicable.Ethics approvalThis study does not involve human participants.IntroductionLarge-scale, international data sharing opens the door to the study of so-called ‘Big Data’, which holds great promise for improving patient-centred care.

Big Data health research is envisioned to take precision medicine to the next level through increased understanding of disease aetiology and phenotypes, treatment effects, disease management and healthcare expenditure.1 However, lack of public trust is proven to be detrimental to the goals of data sharing.2 The case of care.data in the UK offers a blatant example of a data sharing initiative gone awry. Criticism predominantly focused on limited public awareness and lack of clarity on the goals of the programme and ways to opt out.3 Citizens are becoming increasingly aware and critical of data privacy issues, and this warrants renewed investments to maintain public trust in data-intensive health research. Here, we use the term data-intensive health research to refer to a practice of grand-scale capture, (re)use and/or linkage of a wide variety of health-related data on individuals.Within the European Union (EU), the recently adopted General Data Protection Regulation (GDPR) (EU 2016/679) addresses some of the concerns the public may have with respect to privacy and data protection.

One of the primary goals of the GDPR is to give individuals control over their personal data, most notably through consent.4 Other lawful grounds for the processing of personal data are listed, but it is unclear how these would exactly apply to scientific research. Legal norms remain open to interpretation and thus offer limited guidance to researchers.5 6 In Recital 33, the GDPR actually mentions that additional ethical standards are necessary for the processing of personal data for scientific research. This indicates a recognised need for entities undertaking activities likely to incite public unease to go beyond compliance with legal requirements.7 Complementary ethical governance then becomes a prerequisite for securing public trust in data-intensive health research.A concept that could be of use in developing ethical governance is that of a ‘social license to operate’.7 The social license captures the notion of a mandate granted by society to certain occupational groups to determine for themselves what constitutes proper conduct, under the condition that such conduct is in line with society’s expectations.

The term ‘social license’ was first used in the 1950s by American sociologist Everett Hughes to address relations between professional occupations and society.8 The concept has been used since to frame, for example, corporate social responsibility in the mining industry,9 governance of medical research in general8 and of data-intensive health research more specifically.7 10 As such, adequate ethical governance then becomes a precondition for obtaining a social license for data sharing activities.Key to an informed understanding of the social license is identifying the expectations society may hold with regard to sharing of and access to health data. Here, relevant societal actors are the subjects of Big Data health research, constituting both patients and the general public. Identification of patients’ and public views and attitudes allows for a better understanding of the elements of a socially sanctioned governance framework.

We know of the existence of research papers that have captured these views using quantitative or qualitative methods or a combination of both. So far, systematic reviews of the literature have limited their scope to citizens of specific countries,11 12 qualitative studies only13 or the sharing of genomic data.14 Therefore, we performed an up-to-date narrative review of both quantitative and qualitative studies to explore predominant patient and public views and attitudes towards data sharing for health research.MethodsWe searched the literature databases PubMed (MEDLINE), Embase, Scopus and Google Scholar in April 2019 for publications addressing patients’ and public views and attitudes towards the use of health data for research purposes. Synonyms of the following terms (connected by ‘AND’) were used to search titles and/or abstracts of indexed references.

Research (See box 1 and online supplementary appendix 1). To merit inclusion, an article had to report results from an original research study (qualitative, quantitative or mixed methods) on attitudes of individuals regarding use of data for health research. We restricted eligibility to records published in English and studies performed between 2009 and 2019.

We chose 2009 as a lower limit because we assume that patients’ and public perspectives might have changed substantially with increasing awareness and use of digital (health) technologies. Systematic reviews and meta-analyses synthesising the empirical literature on this topic also qualified for review. Reports from stakeholder meet-ups and workshops were eligible as long as they included patients or the public as participants.

Since we were only interested in empirical evidence, expert opinion and publications merely advocating for the inclusion of patients’ and public views in Big Data health research were excluded. Studies that predominantly reported on views of other stakeholders—such as clinicians, researchers, policy makers or industry—were excluded. Articles reporting on conference proceedings, or views regarding (demographic) data collection in low or middle income countries or for public health and care/quality improvement were not considered relevant to this review.

Despite our specific interest in data sharing within the European context, we broadened eligibility criteria to include studies performed in the USA, Canada, Australia and New Zealand. Additional articles were identified through consultation with experts and review of references in the manuscript identified through the literature database searches. Views and attitudes of patients and the public were identified from selected references and reviewed by means of thematic content analysis.Supplemental materialBox 1 Key search terms(patient* OR public OR citizen*)AND(attitude* OR view* OR perspective* OR opinion* OR interview* OR qualitative* OR questionnaire* OR survey*)AND(“data sharing” OR “data access” OR “data transfer”)ANDResearchResultsStudy characteristicsSearches in PubMed (MEDLINE), Embase, Scopus and Google Scholar resulted in a total of 1153 non-unique records (see online supplementary appendix 1).

We identified 27 papers for review, including 12 survey or questionnaire studies (quantitative), 8 interview or focus group studies (qualitative), 1 mixed methods study and 6 systematic reviews (see table 1). Most records were excluded because they were not relevant to our research question or because they did not report on findings from original (empirical) research studies. Ten studies reported on views of patients, 11 on views of the public/citizens and 6 studies combined views of patients, research participants and the public.View this table:Table 1 Study characteristicsWillingness to share data for health researchReviewed papers suggest widespread support for the sharing of data for health research.Four systematic reviews synthesising the views of patients and the public report that willingness for data to be linked and shared for research purposes is high11–14 and that people are generally open to and understand the benefits of data sharing.15Outpatients from a German university hospital who participated in a questionnaire study (n=503) expressed a strong willingness (93%) to give broad consent for secondary use of data,16 and 93% of a sample of UK citizens with Parkinson’s disease (n=306) were willing to share their data.17 Wide support for sharing of data internationally18 19 and in multicentre studies20 was reported among patient participants.

Goodman et al found that most participants in a sample of US patients with cancer (n=228) were willing to have their data made available for ‘as many research studies as possible’.21 Regarding the use of anonymised healthcare data for research purposes, a qualitative study found UK rheumatology patients and patient representatives in support of data sharing (n=40).22Public respondents in survey studies recognised the benefits of storing electronic health information,23 and 78.8% (n=151) of surveyed Canadians felt positive about the use of routinely collected data for health research.24 The majority (55%) of a sample of older Swiss citizens (n=40) were in favour of placing genetic data at disposal for research.25 Focus group discussions convened in the UK showed that just over 50% of the members of the Citizens Council of The National Institute for Health and Care Excellence (NICE) said they would have no concerns about NICE using anonymised data derived from personal care records to evaluate treatments,26 and all participants in one qualitative study were keen to contribute to the National Healthcare Service (NHS)-related research.27Motivations to share dataPatients and public participants expressed similar reasons and motivations for their willingness to share data for health research, including contributing to advancements in healthcare, returning incurred benefits and the hope of future personal health benefits (tables 2–4).View this table:Table 2 Patients’ views and attitudes towards the sharing of health data for researchView this table:Table 3 Public views and attitudes towards the sharing of health data for researchView this table:Table 4 Patients’ and public views and attitudes towards the sharing of health data for researchIn the two systematic reviews that addressed this topic, sharing data for ‘the common good’ or ‘the greater good’ was identified as one of the most prevalent motivations.12 14For patients specifically, to help future patients or people with similar health problems was an important reason.14 16 One survey study conducted among German outpatients found that 72% listed returning their own benefits incurred from research as a driver for sharing clinical data.16 Patients with rare disease were also motivated by ‘great hope and trust’ in the development of international databases for health research.19 Among patients, support of research in general,16 the value attached to answering ‘important’ research questions,20 and a desire to contribute to advancements in medicine14 were prevalent reasons in favour of data sharing. Ultimately, the belief that data sharing could lead to improvements in health outcome and care was reported.20Only one original study research paper addressed public motivations. This study found that older citizens mentioned auistic reasons and the greater good in a series of interviews as reasons to share genetic data for research.25 In these interviews, citizens expressed no expectations of an immediate impact or beneficial return but ultimately wanted to help the next generation.Perceived benefits of data sharingPatients and the public perceive that data sharing could lead to better patient care through improved diagnosis and treatment options and more efficient use of resources.

Patients seem to also value the potential of (direct) personal health benefits.Two systematic reviews reported on perceived benefits of data sharing for health research purposes. Howe et al mentioned perceived benefits to research participants or the immediate community, benefits to the public and benefits to research and science.15 Shabani et al also listed accelerating research advancement and maximising the value of resources as perceived benefits.14Surveyed patients perceived that data sharing could help their doctor ‘make better decisions’ about their health (94%, n=3516)28 or result in an increased chance of receiving personalised health information (n=228).21In the original studies reviewed, advantages and potential benefits of data sharing were generally recognised by public and patient participants.22 29 Data sharing was believed to enable the study of long-term treatment effects and rare events, as well as the study of large numbers of people,24 to improve diagnosis25 and treatment quality,20 23 as well as to stimulate innovation30 and identify new treatment options.25 A cross-sectional online survey among patient and citizen groups in Italy (n=280) also identified the perception that data sharing could reduce waste in research.30Perceived risks of data sharingThe most significant risks of data sharing were perceived to results from breaches of confidentiality, commercial use and potential abuse of the data.Systematic reviews report on patients’ and public concerns about confidentiality in general,13 15 sometimes linked to the risk of reidentification,14 concerns about a party's competence in keeping data secure,12 and concerns that personal information could be mined from genomic data.14 A systematic review by Stockdale et al identified concerns among the public (UK and Ireland) about the motivation a party might have to use the data.14Patients in a UK qualitative study (n=40) perceived ‘detrimental’ consequences of data ‘falling into the wrong hands’, such as insurance companies.22 Respondents from the online patient community PatientsLikeMe were fearful of health data being ‘stolen by hackers’ (87%, n=3516).28Original research studies flagged data security and privacy as major public concerns.16 18 20 25 26 29–32 More specifically, many studies found that participants worried about who would have access to the data and about risk of misuses or abuses.13 15 18 25 27 33 A large pan-European survey among respondents from 27 EU member states revealed public concerns about different levels of access by third parties (48.9%–60.6%, n=20 882).23 Overall, reviewed papers suggest that patients and the public are concerned about the use of their data for commercial purposes.14 27 For example, the NICE Citizens Council expressed concerns about the potential for data to be sold to other organisations and used for profit and for purposes other than research.26 The Citizens Council also highlighted the need for transparency about how data are used and how it might be used in the future and for ensuring the research is conducted according to good scientific practice and that data are used to benefit society. Concerns about control and ownership of data were identified13 33 and about re-use of data for purposes that participants do not agree on.30 Fear of discrimination, stigmatisation, exploitation or other repercussions as a consequence of data being shared was widely cited by individuals.14 15 18Barriers to share dataStudies showed that patients and the public rarely mention barriers to data sharing in absolute terms.

Rather, acceptance seemed to decrease if data sharing was financially motivated, and if people did not know how and with whom their data would be shared.First, individuals often opposed data sharing if it was motivated by financial gain or profit20 or if the data were shared with commercial/private companies.14 15 In one large pan-European survey (n=20 882), respondents were found to be strongly averse to health insurance companies and private sector pharmaceutical companies viewing their data.23 Second, lack of understanding and awareness around the use of data was viewed as a barrier to data sharing.15 22 Third, lack of transparency and controllability in releasing data were mentioned as factors compromising public trust in data sharing activities.14 22Factors affecting willingness to share dataA wide range of factors were identified from the literature that impacted individuals’ willingness to share data for health research, including geographical factors, age, individual-specific and research-specific characteristics.Geographical factorsMcCormack et al found that European patients’ expressions of trust and attitudes to risk were often affected by the regulatory and cultural practices in their home countries, as well as by the nature of the (rare) disease the patient participant had.18 Shah et al conducted a survey among patients in four Northern European countries (n=855) and found a significant association between country and attitudes towards sharing of deidentified data.34 Interestingly, Dutch respondents were less likely to support sharing of their deidentified data compared with UK citizens.AgeAmong a sample of surveyed patients with Parkinson’s disease (UK), a significant association was found between higher age and increased support for data sharing.17 According to a study based on semistructured interviews with older Swiss citizens, generational differences impacted willingness to share.25 With respect to public attitudes towards data sharing, findings of one systematic review suggest that males and older people are more likely to consent to sharing their medical data.27 A systematic review by Shabani et al suggests that patient and public participants with higher mean age are substantially less worried about privacy and confidentiality than other groups.14Individual-specific characteristicsA systematic review into patients’ and public perspectives on data sharing in the USA suggests that individuals from under-represented minorities are less willing to share data.11 A large multisite survey (n=13 000) among the US public found that willingness to share was associated with self-identified white race, higher educational attainment and lower religiosity.31 In another systematic review, race, gender, age, marital status and/or educational level all seemed to influence how people perceived sensitivity of genomic data and the sharing thereof.14 However, a UK study among patients with Parkinson’s disease found no clear relationship between data sharing and the number of years diagnosed, sex, medication class or health confidence.17Factors that clearly positively affected attitudes towards data sharing were perceptions of the (public) benefits and value of the research,13 20 fewer concerns and fewer information needs,31 and higher trust in and reputation of individuals or organisations conducting and/or overseeing data sharing.12–14 35 Conversely, willingness decreased with higher privacy and confidentiality concerns11 and higher distrust of the government as an oversight body for (genetic) research data.35Research-specific characteristicsPrivacy measures increased people’s willingness to share their data for health research, such as removal of social security numbers (90%, n=3516) and insurance ID (82%, n=3516), the sharing of only summary-level or aggregate data20 and deposition of data in a restricted access online database.29 Expressions of having control over what data are shared and with whom positively affected attitudes towards data sharing.34 In one study, being asked for consent for each study made participants (81%) feel ‘respected and involved’, and 74% agreed that they would feel that they ‘had control’.14 With respect to data sharing without prospective consent, participants became more accepting after being given information about the research processes and selection bias.27 Less support was observed for data sharing due to financial incentives25 and, more specifically, if data would be shared with private companies, such as insurance or pharmaceutical companies.11 25Conditions for sharingWidespread willingness to share data for health research very rarely led to participants’ unconditional support. Studies showed agreement on the following conditions for responsible data sharing. Value, privacy, minimising risks, data security, transparency, control, information, trust, responsibility and accountability.ValueOne systematic review found that participants found it important that the research as a result of data sharing should be in the public’s interest and should reflect participants’ values.15 The NICE Citizens Council advocated for appropriate systems and good working practices to ensure a consistent approach to research planning, data capture and analysis.26Privacy, risks and data securityThe need to protect individuals’ privacy was considered paramount11 14 21 34 and participants often viewed deidentification of personal data as a top privacy measure.11 24 30 36 One survey among US patients with cancer found that only 20% (n=228) of participants found linkage of individuals with their deidentified data acceptable for return of individual health results and to support further research.21 Secured access to databases was considered an important measure to ensure data security in data sharing activities.30 34 A systematic review of participants’ attitudes towards data sharing showed that people established risk minimisation as another condition for data sharing.15 Findings by Mazor et al suggest that patients only support studies that offer value and minimise security risks.20Transparency and controlConditions regarding transparency were information about how data will be shared and with whom,14 35 the type of research that is to be performed, by whom the research will be performed,16 information on data sharing and monitoring policies and database governance,35 conditions framing access to data and data access agreements,24 28 30 and any partnerships with the pharmaceutical industry.19 More generally, participants expressed the desire to be involved in the data sharing process,35 to be notified when their data are (re)used and to be informed of the results of studies using their data.15 Spencer et al identified use of an electronic interface as a highly valued means to enable greater control over consent choices.22 When asked about the use of personal data for health research by the NHS, UK citizens were typically willing to accept models of consent other than the ones they would prefer.37 Acceptance of consent models with lower levels of individual control was found to be dependent on a number of factors, including adequate transparency, control over detrimental use and commercialisation, and the ability to object, particularly to any processing considered to be inappropriate or particularly sensitive.37Information and trustOne systematic review identified trust in the ability of the original institution to carry out the oversight tasks as a major condition for responsible data sharing.14 Appropriate education and information about data sharing was thought to include public campaigns to inform stakeholders about Big Data32 and information communicated at open days of research institutions (such as NICE) to ensure people understand what their data are being used for and to reassure them that personal data will not be passed on or sold to other organisations.26 The informed consent process for study participation was believed to include information about the fact that individuals’ data could potentially be shared,15 30 the objectives of data sharing and (biobank) research, the study’s data sharing plans,29 governance structure, logistics and accountability.33Responsibility and accountabilityParticipants often placed the responsibility for data sharing practices on the shoulders of researchers.

Secondary use of data collected earlier for scientific research was viewed to require a data access committee that involves a researcher from the original research project, a clinician, patient representative and a participant in the original study.36 Researchers of the original study were required to monitor data used by other researchers.36 In terms of accountability, patient and public groups in Italy (n=280) placed high value on sanctions for misuse of data.30 Information on penalties or other consequences of a breach of protection or misuse was considered important by many.31 35DiscussionIn this study, we narratively reviewed 27 papers on patients’ and public views on and attitudes towards the use of health data for scientific research. Studies reported a widespread—though conditional—support for the linkage and sharing of data for health research. The only outlier seems to be the finding that just over half (n=25) of the NICE Citizens Council answered ‘no’ to the question whether they had any concerns if NICE used anonymised data to fill in the gaps if NICE was not getting enough evidence in ‘the usual ways’.26 However, we hasten to point out that the question about willingness to share is different from the question whether people have concerns or not.

In addition, after a 2-day discussion meeting Council members were perhaps more sensitised to the potential concerns regarding data sharing. Therefore, we suggest that the way and context within which questions are phrased may influence the answers people give.Overall, people expressed similar motivations to share their data, perceived similar benefits (despite some variation between patients and citizens), yet at the same time displayed a range of concerns, predominantly relating to confidentiality and data security, awareness about access and control, and potential harms resulting from these risks. Both patient and public participants conveyed that certain factors would increase or reduce their willingness to have their data shared.

For example, the presence of privacy-protecting measures (eg, data deidentification and the use of secured databases) seemed to increase willingness to share, as well as transparency and information about data sharing processes and responsibilities. The identified views and attitudes appeared to come together in the conditions stipulated by participants. Value, privacy and confidentiality, minimising risks, data security, transparency, control, information, trust, responsibility and accountability.In our Introduction, we mentioned that identifying patients’ and public views and attitudes allows for a better understanding of the elements of a socially sanctioned governance framework.

In other words, what work should our governance framework be doing in order to obtain a social license?. This review urges researchers and institutions to address people’s diverse concerns and to make an effort to meet the conditions identified. Without these conditions, institutions lack trustworthiness, which is vital for the proceedings of medicine and biomedical science.

As such, a social license is not a ‘nice to have’ but a ‘need to have’. Our results also confirm that patients and the public indeed care about more than legal compliance alone, and wish to be engaged through information, transparency and control. This work supports the findings of a recent systematic review into ethical principles of data sharing as specified in various international ethical guidelines and literature.38 What this body of research implies is considerable diversity of values and beliefs both between and within countries.The goal of this narrative review was to identify the most internationally dominant, aggregated patient and public views about the broad topic of data sharing for health research.

We deliberately opted for the methodology of a narrative review rather than a systematic review. Most narrative reviews deal with a broad range of issues to a given topic rather than addressing a particular topic in depth.39 This means narrative reviews may be most useful for obtaining a broad perspective on a topic, and that they often are less useful in generating quantitative answers to specific clinical questions. However, because narrative reviews do not require specification of the search and selection strategy and the way of critically appraising literature can be variable, the connection between evidence generated by narrative reviews and (clinical) recommendations is less rigorous and risk of bias exists.

This is something to take into account in this study. A risk of bias assessment was not possible due to the heterogeneity of the findings. We acknowledge that our methodological choices may have affected the discriminative power or granularity of our findings.

For example, there is a difference between sharing of routinely collected health data versus secondary use of health data collected for research purposes. And we can only make loose assumptions about potential differences between patient and public views.In addition, we should mention that this work is centred around studies conducted in Western countries as the whole Big Data space and literature is dominated by Western countries, higher socioeconomic status and Caucasians. However, most of the disease burden globally and within countries is most probably not represented in the ‘Big Data’ and so we have to stress the lack of generalisability to large parts of the world.Nevertheless, we believe our findings point towards essential elements of a governance framework for data sharing for health research purposes.

If we are to conclude that the identified conditions ought to act as the pillars of a governance framework, the next step is to identify how these conditions could be practically operationalised. For example, if people value information, transparency and control, what type of consent is most likely to valorise these conditions?. And what policy for returning research results would be desirable?.

Once we know what to value, we can start thinking about the ways to acknowledge that value. A new challenge arising here, however, is what to do when people hold different or even conflicting values or preferences. Discrete choice experiments could help to test people’s preferences regarding specific topics, such as preferred modes of informed consent.

Apart from empirical work, conceptual analysis is needed to clarify how public trust, trustworthiness of institutions and accountability are interconnected.ConclusionThis narrative review suggests widespread—though conditional—support among patients and the public for data sharing for health research. Despite the fact that participants recognise actual or potential benefits of health research, they report a number of significant concerns and related conditions. We believe identified conditions (eg, social value, data security, transparency and accountability) ought to be operationalised in a value-based governance framework that incorporates the diverse patient and public values, needs and interests, and which reflects the way these same conditions are met, to strengthen the social license for Big Data health research.Ethics statementsPatient consent for publicationNot required.AcknowledgmentsWe thank Susanne Løgstrup (European Heart Network) and Evert-Ben van Veen (Medlaw) for their valuable feedback during various stages in drafting the manuscript..

Choice is probably one of http://cassiausa.com/where-can-i-buy-viagra-over-the-counter/ the buy kamagra 100mg oral jelly uk most often discussed areas in bioethics, alongside the related concepts of informed consent and autonomy. It is generally, prima facie, portrayed buy kamagra 100mg oral jelly uk as a good thing. In healthcare, the 2000s saw the UK Prime Minister Tony Blair pursue the ‘Choice Agenda’ where, ‘As buy kamagra 100mg oral jelly uk capacity expands, so choice will grow. Choice will fundamentally change the balance of power in the NHS.’1 In a consumerist society giving consumers more choice is seen as desirable. However, choice is not a good in itself, giving buy kamagra 100mg oral jelly uk people more choice in certain situations can be problematic.

I.e. Consumerism drives economic growth and this has a detrimental effect on the environment. And increasing the range of choices a patient is offered is often not the best way to improve the quality of healthcare provision.2 The assumptions behind the valuing of choice need careful unpacking and this Issue of the Journal of Medical Ethics includes papers that explore choice in a number of areas.This Issue's Editor’s choice is Tom Walker’s ‘The Value of Choice’,3 which puts forward a suggestion for the importance of the symbolic value of choice. There are a number of ways of categorising the value of choice in healthcare. One account sees choice as valuable because it is by choosing that individuals make their life their own.

Another account sees choice as valuable for instrumental reasons, people are generally, assuming they are sufficiently informed, the best judge of their own best interests. Walker argues for an additional third reason, the symbolic value of choice, originally proposed by Scanlon. This sees choice as valuable because being given the option to choose, whether or not one takes it up, not the act of choosing is what makes choice valuable. Being offered the option to choose has a ‘communicative role’ in that it communicates that the person has standing and, for certain types of choice, being denied the opportunity to choose, ‘can be both demeaning and stigmatising.’ Walker states that denying someone the opportunity to choose in certain circumstances does not communicate anything untoward, and he goes to explore how we might determine when not allowing someone a choice would be demeaning. Here he stresses the importance of context in making this determination, it is not fixed by the features of a patient, but what being ‘allowed’ or ‘denied’ the opportunity to make a choice reveals about the healthcare professional’s view of the patient.

€˜It communicates that they either see those patients as competent and equal members of society, or that they do not.’ Denying a patient the opportunity to choose an ineffective treatment, for example, does not communicate a negative judgement. Walker says his account, ‘is intended to supplement existing accounts, not replace them. Because choice is valuable for more than one reason no single account can capture everything that matters.’The importance of pointing to the context of the choice is highlighted in Walker’s paper and it is only through careful examination of the context of that offering that we can determine if, in fact, this is an area where choice should be offered and to whom. Such an examination is carried out in Cameron Beattie’s paper,4 which considers the High Court review of service provision at the youth-focussed gender identity Tavistock Clinic. Beattie disagrees with the High Court’s view that it is ’highly unlikely’ that under-13s, and ’doubtful’ that 14–15 years old, can be competent to consent to puberty blocker therapy for gender dysphoria.

Beattie argues that having puberty blocker therapy is a choice that minors should be given the opportunity to make. In principle, children of that age could be competent to make the decision and that the decision is no more complex than other medical decisions that Gillick competence has conventionally been applied to. Children of this age fall into what Walker calls a ‘transitional’ group, ‘Of particular importance here is the extent to which societal features mean members of some groups find it particularly hard to be recognised as competent and equal members of society. That includes members of groups subject to discrimination….It also includes those who are in what we might call transitional groups such as teenagers struggling to be recognised as competent.’ In the case of denying puberty blockers, the symbolic value of choice is clear.The paper by Zeljka Buturovic5 examines the debate over young childless women requesting sterilisation. There has been a discussion in the literature that critiques doctors’ hesitancy to accede to this type of request and Buturovic argues against these criticisms.

The argument is that rather than a doctor’s refusal to sterilise a young childless woman or putting up obstacles to this being examples of, variously, inconsistency, paternalism, pronatalist bias and discrimination, it is understandable that doctors should be reluctant to follow this unusual request, and such hesitancy is of potential benefit to the young woman. This hesitancy can act as a filter for women who are not seriously committed to sterilisation. This, in essence, is the opposite argument to Beattie’s paper, that the barriers put up to prevent people exercising their choice in this case are warranted. Young childless women should have their choice scrutinised and if necessary delayed so that it can be ascertained if the choice is a genuine one, and ‘to weed out (the) confused and uncommitted.’ Ultimately, that choice should be available for young childless woman, but it is a choice, given its long-term consequences and likely lack of reversibility, that should be carefully considered.These papers show that choice is a contextually based, complex and multi-facetted concept and approaches such as Walker’s, give us tools to think more carefully about the value of choice and what that means in particular situations. A consideration of choice is not complete without thinking about the effects of our choices on others, and this needs to be at the forefront of any ethical analysis.

The ‘choice-agenda’ can often be a proxy for an individualistic conception of personal responsibility and a construction of the ‘good’ of the choice as being solely about that individual’s right to exercise a choice, rather than a more nuanced consideration of the wider, or even limited, effects of that choice on others. Although we have well-worn ways of thinking about harm – harm to others and liberty limiting principles6 – how the exercising of individual choice might harm others is often debatable and unclear, and political with a small and large P!. For instance, in July 2021 Boris Johnson, the UK prime minister, announced that mask wearing would now be one of personal choice. The government would end the legal obligation to wear a face covering, ‘We will move away from legal restrictions and allow people to make their own informed decisions about how to manage the kamagra.’ Johnson went on to say. €˜Guidance will suggest where you might choose to do so - especially when cases are rising and where you come into contact with people you don't usually meet in enclosed spaces, such as obviously crowded public transport.’7 This mandate for ‘freedom-day’ was criticised in a number of letters in high ranking medical journals,8 9 arguing, ‘The narrative of “caution, vigilance, and personal responsibility” is an abdication of the government’s fundamental duty to protect public health.

€œPersonal responsibility” does not work in the face of an airborne, highly contagious infectious disease. Infectious diseases are a matter of collective, rather than individual, responsibility.’8 In this case, someone’s personal choice to not wear a mask on public transport, where social distancing is impossible, conflicts with someone else’s choice to travel to work as safely as they can. As the critics of this policy and work in public health ethics notes, one person’s choice can have a significant detrimental effect on others, and in situations like this, such as this mask wearing example, where not allowing choice, that is maintaining the legally mandated requirement to wear a face mask (unless there are reasons for an exemption), is an ethically acceptable restriction on ‘personal choice.’ In Walker’s terminology disallowing this choice it is not demeaning or stigmatising, as it applies to everyone, and does not fail to recognise any particular person or group as equal members of society.Choice is often portrayed as a good thing like parenthood and apple pie and the use of choice by politicians to whip up support and bolster their political agendas, as shown by the examples of Blair and Johnson, shows the rhetorical power of the concept. But to really address in what circumstances choices should be offered, to whom and what type of choice, we need theoretical tools to help us understand and be attentive to the wider implications and the papers in this Issue help us to do that.Ethics statementsPatient consent for publicationNot applicable.Ethics approvalThis study does not involve human participants.IntroductionLarge-scale, international data sharing opens the door to the study of so-called ‘Big Data’, which holds great promise for improving patient-centred care. Big Data health research is envisioned to take precision medicine to the next level through increased understanding of disease aetiology and phenotypes, treatment effects, disease management and healthcare expenditure.1 However, lack of public trust is proven to be detrimental to the goals of data sharing.2 The case of care.data in the UK offers a blatant example of a data sharing initiative gone awry.

Criticism predominantly focused on limited public awareness and lack of clarity on the goals of the programme and ways to opt out.3 Citizens are becoming increasingly aware and critical of data privacy issues, and this warrants renewed investments to maintain public trust in data-intensive health research. Here, we use the term data-intensive health research to refer to a practice of grand-scale capture, (re)use and/or linkage of a wide variety of health-related data on individuals.Within the European Union (EU), the recently adopted General Data Protection Regulation (GDPR) (EU 2016/679) addresses some of the concerns the public may have with respect to privacy and data protection. One of the primary goals of the GDPR is to give individuals control over their personal data, most notably through consent.4 Other lawful grounds for the processing of personal data are listed, but it is unclear how these would exactly apply to scientific research. Legal norms remain open to interpretation and thus offer limited guidance to researchers.5 6 In Recital 33, the GDPR actually mentions that additional ethical standards are necessary for the processing of personal data for scientific research. This indicates a recognised need for entities undertaking activities likely to incite public unease to go beyond compliance with legal requirements.7 Complementary ethical governance then becomes a prerequisite for securing public trust in data-intensive health research.A concept that could be of use in developing ethical governance is that of a ‘social license to operate’.7 The social license captures the notion of a mandate granted by society to certain occupational groups to determine for themselves what constitutes proper conduct, under the condition that such conduct is in line with society’s expectations.

The term ‘social license’ was first used in the 1950s by American sociologist Everett Hughes to address relations between professional occupations and society.8 The concept has been used since to frame, for example, corporate social responsibility in the mining industry,9 governance of medical research in general8 and of data-intensive health research more specifically.7 10 As such, adequate ethical governance then becomes a precondition for obtaining a social license for data sharing activities.Key to an informed understanding of the social license is identifying the expectations society may hold with regard to sharing of and access to health data. Here, relevant societal actors are the subjects of Big Data health research, constituting both patients and the general public. Identification of patients’ and public views and attitudes allows for a better understanding of the elements of a socially sanctioned governance framework. We know of the existence of research papers that have captured these views using quantitative or qualitative methods or a combination of both. So far, systematic reviews of the literature have limited their scope to citizens of specific countries,11 12 qualitative studies only13 or the sharing of genomic data.14 Therefore, we performed an up-to-date narrative review of both quantitative and qualitative studies to explore predominant patient and public views and attitudes towards data sharing for health research.MethodsWe searched the literature databases PubMed (MEDLINE), Embase, Scopus and Google Scholar in April 2019 for publications addressing patients’ and public views and attitudes towards the use of health data for research purposes.

Synonyms of the following terms (connected by ‘AND’) were used to search titles and/or abstracts of indexed references. Patient or public. Views. Data sharing. Research (See box 1 and online supplementary appendix 1).

To merit inclusion, an article had to report results from an original research study (qualitative, quantitative or mixed methods) on attitudes of individuals regarding use of data for health research. We restricted eligibility to records published in English and studies performed between 2009 and 2019. We chose 2009 as a lower limit because we assume that patients’ and public perspectives might have changed substantially with increasing awareness and use of digital (health) technologies. Systematic reviews and meta-analyses synthesising the empirical literature on this topic also qualified for review. Reports from stakeholder meet-ups and workshops were eligible as long as they included patients or the public as participants.

Since we were only interested in empirical evidence, expert opinion and publications merely advocating for the inclusion of patients’ and public views in Big Data health research were excluded. Studies that predominantly reported on views of other stakeholders—such as clinicians, researchers, policy makers or industry—were excluded. Articles reporting on conference proceedings, or views regarding (demographic) data collection in low or middle income countries or for public health and care/quality improvement were not considered relevant to this review. Despite our specific interest in data sharing within the European context, we broadened eligibility criteria to include studies performed in the USA, Canada, Australia and New Zealand. Additional articles were identified through consultation with experts and review of references in the manuscript identified through the literature database searches.

Views and attitudes of patients and the public were identified from selected references and reviewed by means of thematic content analysis.Supplemental materialBox 1 Key search terms(patient* OR public OR citizen*)AND(attitude* OR view* OR perspective* OR opinion* OR interview* OR qualitative* OR questionnaire* OR survey*)AND(“data sharing” OR “data access” OR “data transfer”)ANDResearchResultsStudy characteristicsSearches in PubMed (MEDLINE), Embase, Scopus and Google Scholar resulted in a total of 1153 non-unique records (see online supplementary appendix 1). We identified 27 papers for review, including 12 survey or questionnaire studies (quantitative), 8 interview or focus group studies (qualitative), 1 mixed methods study and 6 systematic reviews (see table 1). Most records were excluded because they were not relevant to our research question or because they did not report on findings from original (empirical) research studies. Ten studies reported on views of patients, 11 on views of the public/citizens and 6 studies combined views of patients, research participants and the public.View this table:Table 1 Study characteristicsWillingness to share data for health researchReviewed papers suggest widespread support for the sharing of data for health research.Four systematic reviews synthesising the views of patients and the public report that willingness for data to be linked and shared for research purposes is high11–14 and that people are generally open to and understand the benefits of data sharing.15Outpatients from a German university hospital who participated in a questionnaire study (n=503) expressed a strong willingness (93%) to give broad consent for secondary use of data,16 and 93% of a sample of UK citizens with Parkinson’s disease (n=306) were willing to share their data.17 Wide support for sharing of data internationally18 19 and in multicentre studies20 was reported among patient participants. Goodman et al found that most participants in a sample of US patients with cancer (n=228) were willing to have their data made available for ‘as many research studies as possible’.21 Regarding the use of anonymised healthcare data for research purposes, a qualitative study found UK rheumatology patients and patient representatives in support of data sharing (n=40).22Public respondents in survey studies recognised the benefits of storing electronic health information,23 and 78.8% (n=151) of surveyed Canadians felt positive about the use of routinely collected data for health research.24 The majority (55%) of a sample of older Swiss citizens (n=40) were in favour of placing genetic data at disposal for research.25 Focus group discussions convened in the UK showed that just over 50% of the members of the Citizens Council of The National Institute for Health and Care Excellence (NICE) said they would have no concerns about NICE using anonymised data derived from personal care records to evaluate treatments,26 and all participants in one qualitative study were keen to contribute to the National Healthcare Service (NHS)-related research.27Motivations to share dataPatients and public participants expressed similar reasons and motivations for their willingness to share data for health research, including contributing to advancements in healthcare, returning incurred benefits and the hope of future personal health benefits (tables 2–4).View this table:Table 2 Patients’ views and attitudes towards the sharing of health data for researchView this table:Table 3 Public views and attitudes towards the sharing of health data for researchView this table:Table 4 Patients’ and public views and attitudes towards the sharing of health data for researchIn the two systematic reviews that addressed this topic, sharing data for ‘the common good’ or ‘the greater good’ was identified as one of the most prevalent motivations.12 14For patients specifically, to help future patients or people with similar health problems was an important reason.14 16 One survey study conducted among German outpatients found that 72% listed returning their own benefits incurred from research as a driver for sharing clinical data.16 Patients with rare disease were also motivated by ‘great hope and trust’ in the development of international databases for health research.19 Among patients, support of research in general,16 the value attached to answering ‘important’ research questions,20 and a desire to contribute to advancements in medicine14 were prevalent reasons in favour of data sharing.

Ultimately, the belief that data sharing could lead to improvements in health outcome and care was reported.20Only one original study research paper addressed public motivations. This study found that older citizens mentioned auistic reasons and the greater good in a series of interviews as reasons to share genetic data for research.25 In these interviews, citizens expressed no expectations of an immediate impact or beneficial return but ultimately wanted to help the next generation.Perceived benefits of data sharingPatients and the public perceive that data sharing could lead to better patient care through improved diagnosis and treatment options and more efficient use of resources. Patients seem to also value the potential of (direct) personal health benefits.Two systematic reviews reported on perceived benefits of data sharing for health research purposes. Howe et al mentioned perceived benefits to research participants or the immediate community, benefits to the public and benefits to research and science.15 Shabani et al also listed accelerating research advancement and maximising the value of resources as perceived benefits.14Surveyed patients perceived that data sharing could help their doctor ‘make better decisions’ about their health (94%, n=3516)28 or result in an increased chance of receiving personalised health information (n=228).21In the original studies reviewed, advantages and potential benefits of data sharing were generally recognised by public and patient participants.22 29 Data sharing was believed to enable the study of long-term treatment effects and rare events, as well as the study of large numbers of people,24 to improve diagnosis25 and treatment quality,20 23 as well as to stimulate innovation30 and identify new treatment options.25 A cross-sectional online survey among patient and citizen groups in Italy (n=280) also identified the perception that data sharing could reduce waste in research.30Perceived risks of data sharingThe most significant risks of data sharing were perceived to results from breaches of confidentiality, commercial use and potential abuse of the data.Systematic reviews report on patients’ and public concerns about confidentiality in general,13 15 sometimes linked to the risk of reidentification,14 concerns about a party's competence in keeping data secure,12 and concerns that personal information could be mined from genomic data.14 A systematic review by Stockdale et al identified concerns among the public (UK and Ireland) about the motivation a party might have to use the data.14Patients in a UK qualitative study (n=40) perceived ‘detrimental’ consequences of data ‘falling into the wrong hands’, such as insurance companies.22 Respondents from the online patient community PatientsLikeMe were fearful of health data being ‘stolen by hackers’ (87%, n=3516).28Original research studies flagged data security and privacy as major public concerns.16 18 20 25 26 29–32 More specifically, many studies found that participants worried about who would have access to the data and about risk of misuses or abuses.13 15 18 25 27 33 A large pan-European survey among respondents from 27 EU member states revealed public concerns about different levels of access by third parties (48.9%–60.6%, n=20 882).23 Overall, reviewed papers suggest that patients and the public are concerned about the use of their data for commercial purposes.14 27 For example, the NICE Citizens Council expressed concerns about the potential for data to be sold to other organisations and used for profit and for purposes other than research.26 The Citizens Council also highlighted the need for transparency about how data are used and how it might be used in the future and for ensuring the research is conducted according to good scientific practice and that data are used to benefit society. Concerns about control and ownership of data were identified13 33 and about re-use of data for purposes that participants do not agree on.30 Fear of discrimination, stigmatisation, exploitation or other repercussions as a consequence of data being shared was widely cited by individuals.14 15 18Barriers to share dataStudies showed that patients and the public rarely mention barriers to data sharing in absolute terms.

Rather, acceptance seemed to decrease if data sharing was financially motivated, and if people did not know how and with whom their data would be shared.First, individuals often opposed data sharing if it was motivated by financial gain or profit20 or if the data were shared with commercial/private companies.14 15 In one large pan-European survey (n=20 882), respondents were found to be strongly averse to health insurance companies and private sector pharmaceutical companies viewing their data.23 Second, lack of understanding and awareness around the use of data was viewed as a barrier to data sharing.15 22 Third, lack of transparency and controllability in releasing data were mentioned as factors compromising public trust in data sharing activities.14 22Factors affecting willingness to share dataA wide range of factors were identified from the literature that impacted individuals’ willingness to share data for health research, including geographical factors, age, individual-specific and research-specific characteristics.Geographical factorsMcCormack et al found that European patients’ expressions of trust and attitudes to risk were often affected by the regulatory and cultural practices in their home countries, as well as by the nature of the (rare) disease the patient participant had.18 Shah et al conducted a survey among patients in four Northern European countries (n=855) and found a significant association between country and attitudes towards sharing of deidentified data.34 Interestingly, Dutch respondents were less likely to support sharing of their deidentified data compared with UK citizens.AgeAmong a sample of surveyed patients with Parkinson’s disease (UK), a significant association was found between higher age and increased support for data sharing.17 According to a study based on semistructured interviews with older Swiss citizens, generational differences impacted willingness to share.25 With respect to public attitudes towards data sharing, findings of one systematic review suggest that males and older people are more likely to consent to sharing their medical data.27 A systematic review by Shabani et al suggests that patient and public participants with higher mean age are substantially less worried about privacy and confidentiality than other groups.14Individual-specific characteristicsA systematic review into patients’ and public perspectives on data sharing in the USA suggests that individuals from under-represented minorities are less willing to share data.11 A large multisite survey (n=13 000) among the US public found that willingness to share was associated with self-identified white race, higher educational attainment and lower religiosity.31 In another systematic review, race, gender, age, marital status and/or educational level all seemed to influence how people perceived sensitivity of genomic data and the sharing thereof.14 However, a UK study among patients with Parkinson’s disease found no clear relationship between data sharing and the number of years diagnosed, sex, medication class or health confidence.17Factors that clearly positively affected attitudes towards data sharing were perceptions of the (public) benefits and value of the research,13 20 fewer concerns and fewer information needs,31 and higher trust in and reputation of individuals or organisations conducting and/or overseeing data sharing.12–14 35 Conversely, willingness decreased with higher privacy and confidentiality concerns11 and higher distrust of the government as an oversight body for (genetic) research data.35Research-specific characteristicsPrivacy measures increased people’s willingness to share their data for health research, such as removal of social security numbers (90%, n=3516) and insurance ID (82%, n=3516), the sharing of only summary-level or aggregate data20 and deposition of data in a restricted access online database.29 Expressions of having control over what data are shared and with whom positively affected attitudes towards data sharing.34 In one study, being asked for consent for each study made participants (81%) feel ‘respected and involved’, and 74% agreed that they would feel that they ‘had control’.14 With respect to data sharing without prospective consent, participants became more accepting after being given information about the research processes and selection bias.27 Less support was observed for data sharing due to financial incentives25 and, more specifically, if data would be shared with private companies, such as insurance or pharmaceutical companies.11 25Conditions for sharingWidespread willingness to share data for health research very rarely led to participants’ unconditional support. Studies showed agreement on the following conditions for responsible data sharing. Value, privacy, minimising risks, data security, transparency, control, information, trust, responsibility and accountability.ValueOne systematic review found that participants found it important that the research as a result of data sharing should be in the public’s interest and should reflect participants’ values.15 The NICE Citizens Council advocated for appropriate systems and good working practices to ensure a consistent approach to research planning, data capture and analysis.26Privacy, risks and data securityThe need to protect individuals’ privacy was considered paramount11 14 21 34 and participants often viewed deidentification of personal data as a top privacy measure.11 24 30 36 One survey among US patients with cancer found that only 20% (n=228) of participants found linkage of individuals with their deidentified data acceptable for return of individual health results and to support further research.21 Secured access to databases was considered an important measure to ensure data security in data sharing activities.30 34 A systematic review of participants’ attitudes towards data sharing showed that people established risk minimisation as another condition for data sharing.15 Findings by Mazor et al suggest that patients only support studies that offer value and minimise security risks.20Transparency and controlConditions regarding transparency were information about how data will be shared and with whom,14 35 the type of research that is to be performed, by whom the research will be performed,16 information on data sharing and monitoring policies and database governance,35 conditions framing access to data and data access agreements,24 28 30 and any partnerships with the pharmaceutical industry.19 More generally, participants expressed the desire to be involved in the data sharing process,35 to be notified when their data are (re)used and to be informed of the results of studies using their data.15 Spencer et al identified use of an electronic interface as a highly valued means to enable greater control over consent choices.22 When asked about the use of personal data for health research by the NHS, UK citizens were typically willing to accept models of consent other than the ones they would prefer.37 Acceptance of consent models with lower levels of individual control was found to be dependent on a number of factors, including adequate transparency, control over detrimental use and commercialisation, and the ability to object, particularly to any processing considered to be inappropriate or particularly sensitive.37Information and trustOne systematic review identified trust in the ability of the original institution to carry out the oversight tasks as a major condition for responsible data sharing.14 Appropriate education and information about data sharing was thought to include public campaigns to inform stakeholders about Big Data32 and information communicated at open days of research institutions (such as NICE) to ensure people understand what their data are being used for and to reassure them that personal data will not be passed on or sold to other organisations.26 The informed consent process for study participation was believed to include information about the fact that individuals’ data could potentially be shared,15 30 the objectives of data sharing and (biobank) research, the study’s data sharing plans,29 governance structure, logistics and accountability.33Responsibility and accountabilityParticipants often placed the responsibility for data sharing practices on the shoulders of researchers. Secondary use of data collected earlier for scientific research was viewed to require a data access committee that involves a researcher from the original research project, a clinician, patient representative and a participant in the original study.36 Researchers of the original study were required to monitor data used by other researchers.36 In terms of accountability, patient and public groups in Italy (n=280) placed high value on sanctions for misuse of data.30 Information on penalties or other consequences of a breach of protection or misuse was considered important by many.31 35DiscussionIn this study, we narratively reviewed 27 papers on patients’ and public views on and attitudes towards the use of health data for scientific research. Studies reported a widespread—though conditional—support for the linkage and sharing of data for health research.

The only outlier seems to be the finding that just over half (n=25) of the NICE Citizens Council answered ‘no’ to the question whether they had any concerns if NICE used anonymised data to fill in the gaps if NICE was not getting enough evidence in ‘the usual ways’.26 However, we hasten to point out that the question about willingness to share is different from the question whether people have concerns or not. In addition, after a 2-day discussion meeting Council members were perhaps more sensitised to the potential concerns regarding data sharing. Therefore, we suggest that the way and context within which questions are phrased may influence the answers people give.Overall, people expressed similar motivations to share their data, perceived similar benefits (despite some variation between patients and citizens), yet at the same time displayed a range of concerns, predominantly relating to confidentiality and data security, awareness about access and control, and potential harms resulting from these risks. Both patient and public participants conveyed that certain factors would increase or reduce their willingness to have their data shared. For example, the presence of privacy-protecting measures (eg, data deidentification and the use of secured databases) seemed to increase willingness to share, as well as transparency and information about data sharing processes and responsibilities.

The identified views and attitudes appeared to come together in the conditions stipulated by participants. Value, privacy and confidentiality, minimising risks, data security, transparency, control, information, trust, responsibility and accountability.In our Introduction, we mentioned that identifying patients’ and public views and attitudes allows for a better understanding of the elements of a socially sanctioned governance framework. In other words, what work should our governance framework be doing in order to obtain a social license?. This review urges researchers and institutions to address people’s diverse concerns and to make an effort to meet the conditions identified. Without these conditions, institutions lack trustworthiness, which is vital for the proceedings of medicine and biomedical science.

As such, a social license is not a ‘nice to have’ but a ‘need to have’. Our results also confirm that patients and the public indeed care about more than legal compliance alone, and wish to be engaged through information, transparency and control. This work supports the findings of a recent systematic review into ethical principles of data sharing as specified in various international ethical guidelines and literature.38 What this body of research implies is considerable diversity of values and beliefs both between and within countries.The goal of this narrative review was to identify the most internationally dominant, aggregated patient and public views about the broad topic of data sharing for health research. We deliberately opted for the methodology of a narrative review rather than a systematic review. Most narrative reviews deal with a broad range of issues to a given topic rather than addressing a particular topic in depth.39 This means narrative reviews may be most useful for obtaining a broad perspective on a topic, and that they often are less useful in generating quantitative answers to specific clinical questions.

However, because narrative reviews do not require specification of the search and selection strategy and the way of critically appraising literature can be variable, the connection between evidence generated by narrative reviews and (clinical) recommendations is less rigorous and risk of bias exists. This is something to take into account in this study. A risk of bias assessment was not possible due to the heterogeneity of the findings. We acknowledge that our methodological choices may have affected the discriminative power or granularity of our findings. For example, there is a difference between sharing of routinely collected health data versus secondary use of health data collected for research purposes.

And we can only make loose assumptions about potential differences between patient and public views.In addition, we should mention that this work is centred around studies conducted in Western countries as the whole Big Data space and literature is dominated by Western countries, higher socioeconomic status and Caucasians. However, most of the disease burden globally and within countries is most probably not represented in the ‘Big Data’ and so we have to stress the lack of generalisability to large parts of the world.Nevertheless, we believe our findings point towards essential elements of a governance framework for data sharing for health research purposes. If we are to conclude that the identified conditions ought to act as the pillars of a governance framework, the next step is to identify how these conditions could be practically operationalised. For example, if people value information, transparency and control, what type of consent is most likely to valorise these conditions?. And what policy for returning research results would be desirable?.

Once we know what to value, we can start thinking about the ways to acknowledge that value. A new challenge arising here, however, is what to do when people hold different or even conflicting values or preferences. Discrete choice experiments could help to test people’s preferences regarding specific topics, such as preferred modes of informed consent. Apart from empirical work, conceptual analysis is needed to clarify how public trust, trustworthiness of institutions and accountability are interconnected.ConclusionThis narrative review suggests widespread—though conditional—support among patients and the public for data sharing for health research. Despite the fact that participants recognise actual or potential benefits of health research, they report a number of significant concerns and related conditions.

We believe identified conditions (eg, social value, data security, transparency and accountability) ought to be operationalised in a value-based governance framework that incorporates the diverse patient and public values, needs and interests, and which reflects the way these same conditions are met, to strengthen the social license for Big Data health research.Ethics statementsPatient consent for publicationNot required.AcknowledgmentsWe thank Susanne Løgstrup (European Heart Network) and Evert-Ben van Veen (Medlaw) for their valuable feedback during various stages in drafting the manuscript..

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New Veterans Crisis Line phone number WASHINGTON — Effective July 16, Veterans have buy kamagra online usa the option to Dial 988 then Press 1 to connect with caring, qualified responders for 24/7 crisis support. In response to the National Suicide Hotline Designation Act designating the 988 Suicide and Crisis Lifeline, the Department of Veterans Affairs has made it more user friendly to access the Veterans Crisis Line. €œDuring a crisis, every second counts,” said VA Secretary Denis McDonough.

€œThis new, shorter number makes it easier for Veterans and those who care about them to reach lifesaving support without having to be enrolled in VA benefits or health care.” Reducing Veteran suicide is the top clinical buy kamagra online usa priority for the Department of Veterans Affairs and a top priority for the Biden-Harris administration. Enhancing suicide prevention crisis services is a key component of the White House strategy on reducing Veteran suicide as well as President Biden’s comprehensive strategy to address the country’s national mental health crisis. VA operates the Veterans Crisis Line through the 988 Lifeline’s national network and thus collaborated to accomplish the successful transition.

During two years of preparation, the department has added hundreds of crisis line employees and responder staff, with still more hiring underway, and has strengthened call center infrastructure buy kamagra online usa. The Veterans Crisis Line is a critical component of the nation’s largest integrated suicide prevention network. It links to more than 500 suicide prevention coordinators across the VA health care system, ensuring coordination into follow-up services as part of a full continuum of care.

Individuals who call the Veterans Crisis Line are buy kamagra online usa five times more likely to have less distress and less suicidal ideation from the beginning to end of the call. While Dial 988 then Press 1 is a new option for contacting the Veterans Crisis Line, the original number. 1-800-273-8255 and press 1, remains available, and Veterans can continue to reach out via chat at VeteransCrisisLine.net/Chat or by text to 838255.

### If you or someone you know is having thoughts of suicide, contact the Veterans Crisis Line to receive free, confidential buy kamagra online usa support and crisis intervention available 24 hours a day, 7 days a week, 365 days a year. Dial 988 then Press 1, text to 838255 or chat online at VeteransCrisisLine.net/Chat. Disclaimer of HyperlinksThe appearance of external hyperlinks does not constitute endorsement by the Department of Veterans Affairs of the linked web sites, or the information, products or services contained therein.

For other than authorized VA activities, the Department does not exercise any editorial control over the information you may find at buy kamagra online usa these locations. All links are provided with the intent of meeting the mission of the Department and the VA website. Please let us know about existing external links which you believe are inappropriate and about specific additional external links which you believe ought to be included by emailing newmedia@va.gov.Start Preamble Substance Abuse and Mental Health Services Administration, Department of Health and Human Services.

Notice. The Secretary of Health and Human Services announces a meeting of the Interdepartmental Serious Mental Illness Coordinating Committee (ISMICC). The meeting will provide information on federal efforts related to serious mental illness (SMI) and serious emotional disturbance (SED).

October 28, 2022, 10 a.m.-4:30 p.m. (EDT)/Open. The meeting will be held virtually and can be accessed via Zoom at.

Https://www.zoomgov.com/​j/​1617075418?. €‹pwd=​T3RqeHFUS1p6ZFhOVUpaSFdQRno3UT09, or by dialing 669-254-5252, webinar ID. 161 707 5418, passcode.

151059. Agenda with call-in information will be posted on the SAMHSA website prior to the meeting at. Https://www.samhsa.gov/​about-us/​advisory-councils/​meetings.

Start Further Info Pamela Foote, ISMICC Designated Federal Officer, SAMHSA, 5600 Fishers Lane, 14E53C, Rockville, MD 20857. Telephone. 240-276-1279.

Email. Pamela.foote@samhsa.hhs.gov. End Further Info End Preamble Start Supplemental Information I.

Background and Authority The ISMICC was established on March 15, 2017, in accordance with section 6031 of the 21st Century Cures Act, and the Federal Advisory Committee Act, 5 U.S.C. App., as amended, to report to the Secretary, Congress, and any other relevant federal department or agency on advances in SMI and SED, research related to the prevention of, diagnosis of, intervention in, and treatment and recovery of SMIs, SEDs, and advances in access to services and supports for adults with SMI or children with SED. In addition, the ISMICC will evaluate the effect federal programs related to SMI and SED have on public health, including public health outcomes such as.

(A) rates of suicide, suicide attempts, incidence and prevalence of SMIs, SEDs, and substance use disorders, overdose, overdose deaths, emergency hospitalizations, emergency room boarding, preventable emergency room visits, interaction with the criminal justice system, homelessness, and unemployment. (B) increased rates of employment and enrollment in educational and vocational programs. (C) quality of mental and substance use disorders treatment services.

Or (D) any other criteria determined by the Secretary. Finally, the ISMICC will make specific recommendations for actions that agencies can take to better coordinate the administration of mental health services for adults with SMI or children with SED. Not later than one (1) year after the date of enactment of the 21st Century Cures Act, and five (5) years after such date of enactment, the ISMICC shall submit a report to Congress and any other relevant federal department or agency.

II. Membership This ISMICC consists of federal members listed below or their designees, and non-federal public members. Federal Membership.

Members include, The Secretary of Health and Human Services. The Assistant Start Printed Page 42200 Secretary for Mental Health and Substance Use. The Attorney General.

The Secretary of the Department of Veterans Affairs. The Secretary of the Department of Defense. The Secretary of the Department of Housing and Urban Development.

The Secretary of the Department of Education. The Secretary of the Department of Labor. The Administrator of the Centers for Medicare and Medicaid Services.

And The Commissioner of the Social Security Administration. Non-federal Membership. Members include, not less than 14 non-federal public members appointed by the Secretary, representing psychologists, psychiatrists, social workers, peer support specialists, and other providers, patients, family of patients, law enforcement, the judiciary, and leading research, advocacy, or service organizations.

The ISMICC is required to meet at least twice per year. To attend virtually, submit written or brief oral comments, or request special accommodation for persons with disabilities, contact Pamela Foote. Individuals can also register on-line at.

Https://snacregister.samhsa.gov. The public comment section will be scheduled at the conclusion of the meeting. Individuals interested in submitting a comment, must notify Pamela Foote on or before October 10, 2022, via email to.

Pamela.Foote@samhsa.hhs.gov. Up to three minutes will be allotted for each approved public comment as time permits. Written comments received in advance of the meeting will be considered for inclusion in the official record of the meeting.

Substantive meeting information and a roster of Committee members is available at the Committee's website. Https://www.samhsa.gov/​about-us/​advisory-councils/​ismicc.

Enhancing suicide prevention crisis services is a key component of the White House strategy on reducing Veteran suicide as well where to get kamagra as President Biden’s buy kamagra 100mg oral jelly uk comprehensive strategy to address the country’s national mental health crisis. VA operates the Veterans Crisis Line through the 988 Lifeline’s national network and thus collaborated to accomplish the successful transition. During two years of preparation, the department has added hundreds of crisis line employees and responder staff, with still more hiring underway, and has strengthened call center infrastructure. The Veterans Crisis Line is a critical component of the nation’s buy kamagra 100mg oral jelly uk largest integrated suicide prevention network.

It links to more than 500 suicide prevention coordinators across the VA health care system, ensuring coordination into follow-up services as part of a full continuum of care. Individuals who call the Veterans Crisis Line are five times more likely to have less distress and less suicidal ideation from the beginning to end of the call. While Dial 988 then Press 1 is buy kamagra 100mg oral jelly uk a new option for contacting the Veterans Crisis Line, the original number. 1-800-273-8255 and press 1, remains available, and Veterans can continue to reach out via chat at VeteransCrisisLine.net/Chat or by text to 838255.

### If you or someone you know is having thoughts of suicide, contact the Veterans Crisis Line to receive free, confidential support and crisis intervention available 24 hours a day, 7 days a week, 365 days a year. Dial 988 then Press 1, text to buy kamagra 100mg oral jelly uk 838255 or chat online at VeteransCrisisLine.net/Chat. Disclaimer of HyperlinksThe appearance of external hyperlinks does not constitute endorsement by the Department of Veterans Affairs of the linked web sites, or the information, products or services contained therein. For other than authorized VA activities, the Department does not exercise any editorial control over the information you may find at these locations.

All links are provided with the intent buy kamagra 100mg oral jelly uk of meeting the mission of the Department and the VA website. Please let us know about existing external links which you believe are inappropriate and about specific additional external links which you believe ought to be included by emailing newmedia@va.gov.Start Preamble Substance Abuse and Mental Health Services Administration, Department of Health and Human Services. Notice. The Secretary of Health and Human Services announces a meeting of the Interdepartmental buy kamagra 100mg oral jelly uk Serious Mental Illness Coordinating Committee (ISMICC).

The meeting will provide information on federal efforts related to serious mental illness (SMI) and serious emotional disturbance (SED). October 28, 2022, 10 a.m.-4:30 p.m. (EDT)/Open. The meeting will be held virtually and can be accessed via Zoom at.

Https://www.zoomgov.com/​j/​1617075418?. €‹pwd=​T3RqeHFUS1p6ZFhOVUpaSFdQRno3UT09, or by dialing 669-254-5252, webinar ID. 161 707 5418, passcode. 151059.

Agenda with call-in information will be posted on the SAMHSA website prior to the meeting at. Https://www.samhsa.gov/​about-us/​advisory-councils/​meetings. Start Further Info Pamela Foote, ISMICC Designated Federal Officer, SAMHSA, 5600 Fishers Lane, 14E53C, Rockville, MD 20857. Telephone.

240-276-1279. Email. Pamela.foote@samhsa.hhs.gov. End Further Info End Preamble Start Supplemental Information I.

Background and Authority The ISMICC was established on March 15, 2017, in accordance with section 6031 of the 21st Century Cures Act, and the Federal Advisory Committee Act, 5 U.S.C. App., as amended, to report to the Secretary, Congress, and any other relevant federal department or agency on advances in SMI and SED, research related to the prevention of, diagnosis of, intervention in, and treatment and recovery of SMIs, SEDs, and advances in access to services and supports for adults with SMI or children with SED. In addition, the ISMICC will evaluate the effect federal programs related to SMI and SED have on public health, including public health outcomes such as. (A) rates of suicide, suicide http://guitarskool.com/downloads/ attempts, incidence and prevalence of SMIs, SEDs, and substance use disorders, overdose, overdose deaths, emergency hospitalizations, emergency room boarding, preventable emergency room visits, interaction with the criminal justice system, homelessness, and unemployment.

(B) increased rates of employment and enrollment in educational and vocational programs. (C) quality of mental and substance use disorders treatment services. Or (D) any other criteria determined by the Secretary. Finally, the ISMICC will make specific recommendations for actions that agencies can take to better coordinate the administration of mental health services for adults with SMI or children with SED.

Not later than one (1) year after the date of enactment of the 21st Century Cures Act, and five (5) years after such date of enactment, the ISMICC shall submit a report to Congress and any other relevant federal department or agency. II. Membership This ISMICC consists of federal members listed below or their designees, and non-federal public members. Federal Membership.

Members include, The Secretary of Health and Human Services. The Assistant Start Printed Page 42200 Secretary for Mental Health and Substance Use. The Attorney General. The Secretary of the Department of Veterans Affairs.

The Secretary of the Department of Defense. The Secretary of the Department of Housing and Urban Development. The Secretary of the Department of Education. The Secretary of the Department of Labor.

The Administrator of the Centers for Medicare and Medicaid Services. And The Commissioner of the Social Security Administration. Non-federal Membership. Members include, not less than 14 non-federal public members appointed by the Secretary, representing psychologists, psychiatrists, social workers, peer support specialists, and other providers, patients, family of patients, law enforcement, the judiciary, and leading research, advocacy, or service organizations.

The ISMICC is required to meet at least twice per year. To attend virtually, submit written or brief oral comments, or request special accommodation for persons with disabilities, contact Pamela Foote. Individuals can also register on-line at. Https://snacregister.samhsa.gov.

The public comment section will be scheduled at the conclusion of the meeting. Individuals interested in submitting a comment, must notify Pamela Foote on or before October 10, 2022, via email to. Pamela.Foote@samhsa.hhs.gov. Up to three minutes will be allotted for each approved public comment as time permits.

Written comments received in advance of the meeting will be considered for inclusion in the official record of the meeting. Substantive meeting information and a roster of Committee members is available at the Committee's website. Https://www.samhsa.gov/​about-us/​advisory-councils/​ismicc. Start Signature Dated.

July 8, 2022. Carlos Castillo, Committee Management Officer. End Signature End Supplemental Information.