The relationship between a doctor and a patient today is based on the principle of freedom of choice (of doctor, treatment type) which is characteristic of informational relationship model. A new concept has replaced the previously prevailing in medical practice paternalism, when doctor individually, not considering patient’s opinion, made the decision on the examination and treatment.

In the modern system of doctor-patient relationship, a patient’s right to voluntary informed consent plays an important role. Informed consent, which is a prerequisite for any medical intervention, is a patient’s voluntary acceptance of treatment after being sufficiently informed by the doctor.

The process of obtaining informed consent can be divided into two stages: 1) providing patient with information on the basis of voluntariness and competence and 2) the getting and proper registration of the patient’s consent (Cohn & Larson, 2007).

Under the current law a patient has the right to be fully informed (Hoeyer, 2009):

about his or her health status (including medical indicators of that state);

about the doctor’s assumed actions, potential risks and benefits of each procedure;

about alternatives to the proposed treatment;

about the diagnosis, prognosis and course of treatment.

When informing a patient, particular attention should be given to the possible risks associated with the course of the recommended treatment.

In addition, to make conscious decisions about medical intervention the patient has the right to consult with a disinterested person and get an additional independent opinion on the state of his or her health. The patient also has the right to obtain information about the professional qualities of the person providing medical aid or special care, about the rules that the patient must follow when undergoing treatment and immediately after. The data provided to the patient by the doctor should contain all the necessary information (Schenker, 2011; Sugarman, 2005).

Taking into account the principle of voluntariness of obtaining information, the patient has the right to refuse from receiving information about his or her health status or indicate a person who should be informed instead (Felt, 2009).

When informing, an important issue is the patient’s competence and ability to understand the received special medical information. Obviously, information should be communicated to patient in a way consistent with his or her ability to comprehend. It should be differentiated depending on patient’s individualities and specific circumstances (general health state, educational level, etc.). Explaining the nature of the forthcoming treatment to the patient, it is desirable to use a minimum of medical or technical terms. If necessary, an interpreter should be provided for adequate communication and perception of information about treatment by the patient (Cohn & Larson, 2007).

At the time of receiving the information the patient should be able to perceive it in order to make conscious decisions about voluntary consent to medical intervention. Informed consent means that the decision should be made on patient’s own free will without such external factors as coercion; deception; threat; career, financial or other dependency (Cohn & Larson, 2007; Sugarman, 2005).

The obtained patient’s consent to medical intervention should be properly recorded. The current law on health care does not provide as a norm a written form of consent, but since getting informed consent is regarded as the right of the patient and therefore implies corresponding obligations of the doctor, the written form of consent is advisable as evidence of doctor’s execution of his duties. In case of a court issue or a conflict between patient and doctor, the written informed consent of the patient will guarantee objective consideration of the dispute.

Literature review

In medical literature, an opinion is expressed that informed consent is a doctor’s means of legal protection, greatly weakening patient’s legal position and not representing his or her interests fully.

Any treatment carried out without patient’s informed consent is considered illegal, and if it causes harm, the question of obtaining a refund is solved uniquely. The situation changes when a damage occurs after fulfilling the obligation of providing the necessary information to the patient and obtaining the consent. In this situation the plaintiff-patient has to prove the relationship between treatment and harm beyond the limits of informed consent, or disclose the poor quality, insufficiency, or incompleteness of information, only in this case his or her verbal or written consent loses its meaning (Cockcroft, 2009; Felt, 2009; Sugarman, 2005). The current court practice of the dispute between patients and hospitals fully confirms this thesis.

The problem can be solved by developing a certain standard of informing a patient about each type of medical intervention taking into account the existing medical standards for the provision of various forms of aid (Cockcroft, 2009). Standard of informing and the unified form of the document for this type of medical intervention can help to prevent or significantly reduce the number of legal disputes over the insufficiency and incompleteness of information provided to the patient. The lack of standard of informing the patient and the unified mechanism of regulation of issues related to its obtaining and registration prevents both the full implementation of the respective rights of a citizen and the protection of medical employees in case of conflict situations (Hoeyer, 2009).

Moreover, in recent years a lot of information has appeared that team paternalistic attitude to the patient reduces the effect of therapeutic measures, that openness and collaboration between doctor and patient in making treatment decisions increase patient’s chances to survive even with the direst diagnoses, including cancer (Cohn & Larson, 2007; Schenker, 2011). There is an article (Cunningham & Watson, 2004) about the married couple of Simontons, the administrators of Dallas Cancer Center, who have achieved obvious success in treating malignant tumors by developing in patients the attitudes and belief in the possibility of nonspecific treatment of physiotherapy and occupational therapy. Practicing since 1971, the authors of the method managed in 63 out of 159 people condemned by the official medicine to maximum of one year of dying to completely remove the cancer stress (still alive), and help others to at least double their life span making it 24.4 months against 12 in the control group of patients treated by standard methods. That is a polar case of a high efficiency of cooperation of doctors and patients (Cunningham & Watson, 2004).

Due to the increasing number of lawsuits related to poor-quality medical care, unfavorable outcome of medical intervention, many hospitals are developing their own form of the document that displays the patient’s consent to medical intervention. Practice shows that the most commonly proof of voluntary consent of the patient to medical intervention is registered in case of delivery paid medical services or performing complex interventions, as well as in outpatient clinics that provide dental care. Lately, the principle of informed consent has been actively used in carrying out such interventions as preventive vaccinations.

Further, we’ll analyze the concept of informed consent, figuring out its main elements and effects, as well as discuss the implication of the concept in nursing practice.

Antecedents, attributes, and consequences of the concept of informed consent

The concept of informed consent was born in the fight against paternalism in the relationship between doctor and patient when it was believed that the doctor was all-knowing, wise, stern father, and the patient was an innocent child, who should unquestioningly obey the opinion of elders. Its appearance is associated with two global processes: the development of universal human rights, when with increasing educational and cultural level of the population each individual as a personality has become aware of his uniqueness and value, and the dissemination of market relations in the sphere of medical care, when a doctor gets into the position of the person who sells medical service, and the patient – the person buying it (Sugarman, 2005).

The bargaining parties are legally equal. In these circumstances, the seller (doctor) should prove himself that the choice made for the patient is the best available and be able to convince the buyer (patient), conveying his own logic of decision in a way that the latter would understand and believe that doctor’s actions are intended to cure, rather than just pulling the money. Thus, the risk is shared between the parties: the doctor puts his reputation and professional responsibility at risk, and patients put their health and sometimes their life.

In general, the concept of informed consent derives from the general concept of individual rights, formulated at the beginning of the century. In particular, it refers to the right of a free citizen (the first and superior to other rights) to the inviolability of his personality, the right to himself implicitly recognized by all the rest (Steinberg, 2009). This law prohibits a doctor to break out his patient’s bodily integrity without having the permission. By this we mean that the patient is a person who will continue to live after medical penetration with all the consequences produced by it. And there is no legal obligation to the patient to accept the proposed treatment; in addition, laws do not mention that the patient can be subjected to any curative effects without his informed consent.

The rights of doctors also do not include mandate to treat someone who is in need of treatment just in the opinion of doctor. The work of a doctor is certainly complicated by the conditions of the legal protection of personality, but the lack of such protection is not good too. For example, a Muslim fundamentalist will die of the idea that he was poured another person’s blood when he was in a severe coma, and his relatives will regard it as lethal sacrilege.

Thus, the doctrine of informed consent lies in the fact that before the doctor asks the patient to give consent on implementing an individual course of treatment or procedures that are risky, but have alternative options, especially where the chances of success are low, the patient must be provided with the following information (Cohn & Larson, 2007; Hoeyer, 2009):

– what the proposed procedures are, and what they involve;

– what the risks and benefits of recommended measures are, specifically emphasizing the danger level of the most adverse outcomes (death or severe disability);

– what alternative ways of treatment and their risks are;

– what will happen if a patient do not start or delay treatment;

– which the probability of success is and what kind of success is expected by the doctor;

– what possible difficulties and duration of rehabilitation are;

– what other related information can be provided (answers to patient’s questions, posing similar cases from doctor’s experience, etc.)

The patients are to be informed about the serious risks that increase their liability in the choice of consent to treatment or alternative treatment or in the direction of the full withdrawal from it. For example, the probability of death 1:10 000 should be mentioned, and the probability of postoperative non-threatening complications may not be mentioned.

From a legal point of view, the doctrine increases patient’s self-involvement and self-determination in decision making and thus, increases its validity. The market “buyer-seller” relations are supplemented by the specific component of personal trust of the patient towards the doctor. The patient believes that the doctor gives him the full amount of information needed for the success of treatment. Thus, the relationship may assume the character of paternalism: the patient entrusts his fate to doctor at a level children entrust themselves to the care of parents. But this is no longer the same command paternalism that was specific for the past soulless administrative management systems.

Still, a lot of discussions are focused around the question on how often patients need to be asked for permission. Courts consider that patients are to be asked in all cases fraught with any serious complications, infection, changes in appearance, etc. For example, a pregnant woman was treated by a dermatologist on a case of spots on her face. The doctor applied the traditional methods, without considering pregnancy, and the spots became more vivid on therapy. The court found the doctor guilty, as he did not see a serious reason for treatment and exposed a pregnant woman to unnecessary risk. First of all, courts ask their experts how necessary the treatment was and whether it did not involve additional risks which could be more significant than the expected success (Walker, 2008).

Lawyers also in all cases try to find out whether the patient’s consent was competent, voluntary, and based on clear information.

The problem the competence of concerns both parties. The doctor should not go beyond his competence in explanations. For example, the risk for complex anesthesia should be explained by an anesthesiologist. At the same time, every adult patient should a priori be considered legally competent listener, if he has no restrictions on capacity and is not under the acute influence of alcohol, drugs, etc. The question of the competence of the decision often arises in cases of deliberate incompetence of patients (children, persons found legally incapable because of mental disorders, moronity, senile dementia, etc.). Here, a decision is made by the same schemes with the participation of parents or guardians. For example, regarding homelessness people, the decisions are made by specially authorized social workers. If the family or of the guardianship have no consensus, the question of a single custodian is decided by court (Steinberg, 2009).

Voluntariness lies in the fact that when making decisions, especially when signing a written consent or refusal, the patient was not subject to any external pressure (threats, bribery, onerous financial terms). Understanding of the provided information can be difficult to prove, which in judicial practice is known as an example of denial of earlier given evidence. Often the patient finally remembers that the choice was made by him voluntarily (Felt, 2009). But if the doctor initially failed to reconcile the expectations of the patient from treatment with the possibilities of modern therapy, it becomes difficult to resolve such conflicts.

There are 4 main cases when the doctrine of informed consent may not be applied:

1. In case of emergency care, where any delay threatens the life or preservation of the health of the patient;

2. If the risks are negligibly low and are well known to all the citizens (e.g., risks of blood test);

3. If the patient knowingly refuses to listen to information about the likelihood of death or severe disability (such a refusal is preferably set down).

4. If the doctor believes that the patient cannot psychologically bear the informational trauma from the message on the discovered disease or health state. In this case, the doctor should ask the patient to whom he entrusts the discussion of health problems and future treatment. In modern terms, this occasion is resorted rarely.

It would also be wrong to introduce the patient to treatment, allowing him to read professional literature (Schenker, 2011). Such reading could cause “the effect of Mark Twain”, who, reading the Encyclopaedia Britannica, discovered he had all the diseases, except for puerperal fever. Besides, the language of medical literature is complicated for an average patient. It can only complexity the understanding of what the patient has to move through and what results he has to wait for and when.

However, hospitals and clinics have an internal profilization, and for each doctor, there is a small collection of some standardized technologies and procedures, the description of which is easy in the framework of adopted treatment schemes and within the language understandable to an average literate competent patient. In these booklets of internal use, a patient can find the information on risks, alternatives, and consequences of refusing from treatment. Literate patients are provided with booklets and others come through interviews with nurses (Cohn & Larson, 2007; Schenker, 2011).

Conclusion. Implications for nursing

Nursing personnel makes up the largest category of health workers, and the effectiveness of health care institutions largely depends on their professional knowledge and skills.

Important functions of the nursing staff are informing patients about their rights and responsibilities when receiving medical aid, about medical interventions conducted by nursing staff including information about the associated risks, options for medical intervention, their consequences and outcomes of treatment (Higgins & Daly, 2002).

Discussing situation with the patient and possible ways of its improvement, the nurse should consider the significant point that the patient has the right to accept or reject the suggested treatment and care after receiving the necessary information. Therefore, he should be informed about everything that happened to him, everything that will be done, that he himself or his relatives will have to do, and give the consent. Further, the plan can only include the problems, goals and interventions agreed by the patient. It is desirable that the informed consent of the patient was recorded in nursing documentation. In our case the patient cannot speak, but he understands everything and can by any gesture confirm his consent. The nurse must not only respect the rights of the patient but also tell him about his rights (Higgins & Daly, 2002; Informed consent for research in critical care: implications for nursing, 2006).

The nurse should write down all nursing interventions, actions on addressing the problem, into a report (usually on the reverse side of the page with the plan). This helps to monitor the activities of nurses and to provide continuity, so that the next shift nurse knew what has been done and what needs to be done. The plan of nursing interventions is made by the nurse, who was on the shift when the patient arrived, but during a shift of some other nurse some additional problems may occur. Then the nurse formulates goals and nursing interventions, and inserts an extra sheet into the folder kept for each patient. If the problem is solved, the corresponding sheet is replaced to the bottom of the folder (Ulrich, 2010).

It is recognized around the world that the quality of health care depends not only on doctors, but also on the professional nursing care. Therefore after discharging a patient, all the documentation on the nursing process is stored in the archive together with patient record. It is desirable that a patient had a copy of the plan of nursing interventions, so that he could estimate progress on the way to recovery. In any case, the nurse should discuss the situation with the patient and his relatives, show positive changes, etc. (Higgins & Daly, 2002; Ulrich, 2010)

In any case, nursing interventions can be very diverse, but one of the major responsibilities of nurses is to clarify the patient’s understanding of purpose and progress of the upcoming treatment and his consent to the procedure.

In general, the doctrine of informed consent is the most modern form of the union of medicine with the people, the reflection of the most humane inclusion of medicine for the benefit of living, constantly renewing humanity. Only the further development of the principle of voluntary informed consent to medical intervention, its wide application in medical institutions can help to protect the legal rights and interests of both patients and medical professionals.

ACE Alzheimer’s: An adjuvant strategy of treating Alzheimer’s disease with Vitamin A, C & E (ACE)

ABSTRACT

Alzheimer’s disease (AD) is a chronic and slowly progressing neurodegenerative disorder which has become a major concern with regards to health, worldwide. This disorder is characterised by progressive dementia and cognitive decline. Pathologically, AD is characterised by the presence of Aβ plaques and tau neurofibrils. However, literature has shown that oxidative stress is one of the most important risk factor behind the cause of AD. Oxidative stress often leads to production of Reactive Oxygen Species (ROS), which further increases structural and functional abnormalities in neurons of the brain, which subsequently, presents as dementia and cognitive decline.

In order, to curb the oxidative stress, antioxidants can be of great help. There have been many evidences that supports the use of antioxidants in the treatment for AD. Vitamins A, C and E are an example of antioxidants that can be used as adjuvants in the treatment of AD. This article will focus on current literature and will present forward the evidence based advantages of using Vitamin A, C and E as an adjuvant treatment for AD.

Keywords:

Antioxidants, ACE, Adjuvant therapy.

INTRODUCTION

A clinical psychiatrist and neuroanatomist, Alois Alzheimer, reported “A peculiar severe disease process of the cerebral cortex” to the 37th Meeting of South-West German Psychiatrists in Tubingen, thus marking the discovery of one of the most interesting pathologies in medicine – Alzheimer’s disease. His invention was based on the observations in one his patient named Auguste D, suffering from profound memory loss, unfounded suspicions about her family, and additional worsening psychological changes. Her post mortem findings further revealed dramatic shrinkage of the brain and abnormal deposits in and encircling the nerve cells

[1].

AD has proven to be a significant public health issue, as it consumes a major amount of heath budget in developed as well as developing countries. AD has become one of the leading causes of dementia in patients less than 65 years, other causes being Lewy body dementia (LBD), frontotemporal dementia (FTD), vascular dementia (VaD) and alcohol associated dementia [

2

].

United States alone has documented a $200 billion annual expenditure on patients affected by AD. Moreover, one person develops Alzheimer’s dementia every 68 seconds emphasizing the incidence of the disease [

3

]. Dementia can be defined as a chronic progressive disorder marked by memory deficits, personality changes, and impaired reasoning.

Results from population-based studies have shown a significant relationship between the certain risk factors and development of AD. Increased risk was shown with an increase in age, fewer years of education, and head trauma. Genetic factors do contribute to the early development of AD – increased risk with mutations on chromosome 21 (cases of down’s syndrome) as it carries the amyloid precursor protein, the presence of apolipoprotein E epsilon 4 allele and the presenilin 1 and 2 genes. The strongest factor identified till date are the apolipoprotein E genes located on chromosome 19 which exists in three forms – ε2, ε3, and ε4. ε2 has been found to reduce the risk, ε3 is found to be neutral whereas ε4 has been associated with a tremendous increase in risk as well as early development of symptoms (Figure 1) [

4

].

Figure 1.

Genetic factors causing a risk to develop Alzheimer’s

Ad is difficult to differentiate from other causes of dementia like LBD, FTD and Vad [

5

]. It may present with dysfunction of various fields such as vision, touch – voluntary movements, personality deficits and judgemental disorders depending upon the area of the brain affected [

6

].The National Institute of Neurological and Communicative Disorders and Stroke and the Alzheimer’s disease and Related Disorders Association (NINCDS/ADRDA) has proposed a diagnostic criteria for differentiating between AD and other known causes of dementia. In compliance with NINCDS/ADRDA , AD is diagnosed if: (I) Cognitive functions decline progressively over a period of time including/ not including memory impairment or (Ia) Inability to understand language and verbal commands (aphasia); (Ib) Loss of ability to accomplish tasks due to incoordination of muscles (apraxia); (Ic) Failure to recognise previously known objects and loss of ability to use them(agnosia); (Id) Unable to plan, organise and execute daily chores; (II) All above mentioned under ‘I’ do get progressively deteriorated with time; (III) Other known causes of dementia as well as cognitive deterioration must be eliminated [

6,7

].

Neurofibrillatory tangles and extracellular amyloid plaques have been the initial histopathological findings associated with AD. Recently several other features have been recognised which include degeneration of neuronal synapses, aneuploidy and loss of neurons in the hippocampus. Despite the recent inventions, presence of extracellular amyloid plaques and intracellular NFT have been taken into account as the main histopathological criteria for establishment of AD [

8

]. Among all the different hypothesis, Aβ cascade has been the most accepted. Previously, a mutation in beta-Amyloid Precursor Protein (APP), which contributes to the normal function of neurons and cerebral development, was thought to be the sole culprit since the accumulation of Aβ proteins had lead to the pathogenesis of AD [

9

]. Eventually, mutated presenilin genes (both 1 and 2) have been discovered to play a role in the formation of Aβ pools [

10

]. But the exact mechanism underlying how Aβ aggregation contributes to the pathophysiology of AD largely remains unclear. Formerly, toxicity of neurons was believed to be caused by intracellular plaques. But recent data has suggested the role of intracellular Aβ proteins, which do not become sequestered into the extracellular plaques, as the toxic triggers stimulating the progression of AD [

11

]. Recently, it has also been shown that intracellular accumulation of Aβ proteins precedes the formation of extracellular Aβ protein plaques and NFT formation [

12

]. The role of intracellular Aβ protein in the progression of AD has also been demonstrated in recent experiments on transgenic mice. Results of these experiments indicate that increased deposits of Aβ proteins within the cells are associated with accelerated cell death [

13

].

Other important causative factors in the development of AD include oxidative stress and Reactive Oxygen Species (ROS) [

14

]. Susceptibility to oxidative damage is due to several factors which include relatively lower levels of antioxidants, significantly higher levels of polyunsaturated fatty acids, (these fatty acids rapidly fall prey to ROS), the presence of metallic ions and high oxygen utilisation [

15

]. Oxidation have been prove to be fatal for several constituents of the cells including carbohydrates, lipids, proteins, RNA and DNA [

16

]. Indirect mechanisms do play a vital role in the damaging process. Oxidation has been proven to accelerate the expression of inducible nitric oxide (iNOS) and accentuate the activity of neuronal NOS (nNOS). This leads to increased production of nitric oxide (NO). NO is known to interact with super oxide anions thus forming a highly reactive peroxynitrite anion. These transient molecules exerts their effects mainly on sulfhydryl groups of cells. [

17

]. The entire process has been depicted in figure 2.

Figure 2

. Nitric Oxide Pathogenesis

In addition to the indirect mechanisms, oxidative stress alters the protein structure. Impaired proteins are known to accelerate oxidative damage, thus proven to be interrelated. ROS causes the protein to be oxidised leading to a modified structure and causing them to be dimerized and aggregated [

18

]. Thus the oxidised protein which is both structurally and functionally abnormal gather as inclusions within the cytoplasm of the neurons, seen in the form of NFT (tau aggregates) and Aβ plaques [

19

]. Alternatively, Aβ plaques can also lead to the increased production of ROS. The entire process has been depicted in figure 3.

OXIDATION


ALTERED PROTEIN STRUCTURE

CYTOPLASMIC INCLUSIONS DIMERISATION & AGGREGATION

Figure 3.

Displaying Correlation between Oxidation and Protein Dimerization, thus forming a Vicious Cycle

Aβ (1-42) is an abundant species of Aβ proteins seen in AD [

20

]. Aβ (1-42) peptides is known for its toxicity which can be attributed to a residue of methionine at position 35 [

21

]. Oxidation of methionine contributes to the formation of methionine sulfoxide, which generally leads to irreversible oxidation and subsequently, forming methionine sulfone [

22

]. Methionine sulfoxide reductase (MSR) can even help the reduction of methionine sulfoxide into methionine [

23

]. However, the activity of MSR is also observed to be impaired in AD [

24

]. Methionine peroxide plays an important role in oxidative stress and toxicity caused by Aβ (1-42) peptides. The lone-pair of electrons present on the S atom of methionine undergoes oxidation of one atom and as a result, sulfuranyl radicals (MetS.+) are generated [

21

,

25

]. Sulfuranyl radicals are known to trigger the generation of other ROS like sulfoxides and superoxides by interacting with molecular oxygen [

26

].

The reason behind this intense oxidative damage could be attributed to the relative absence or decreased function of different antioxidant mechanisms of the body. Glutathione is one of the major antioxidant which can protect the brain tissues by causing detoxification of damaging ROS [

27

]. One of the main reasons of increase in oxidative stress in AD is the decreased glutathione levels in the brain [

28

]. The other members of the cellular antioxidant mechanism which plays a pivotal role includes Superoxide Dismutase (SOD) and Catalase (CAT). SOD is an antioxidant which is responsible for converting toxic superoxide ions into far less toxic hydrogen peroxide [

29

]. CAT evolves this reaction in to one step further and turns hydrogen peroxide into water [

30

].

Investigations have revealed that the levels of SOD and CAT decline in patients with AD [31]. Glutathione reductase (GR) and Glutathione peroxidase (GPx) represent the other crucial parts of the cellular defence mechanism which acts against oxidative stress. GPx is responsible for the metabolism of hydrogen peroxide and lipid hydroperoxides [32] and GR accelerates the reaction which helps in the regeneration of Glutathione (GSH) [33]. In total, the combination of an oxidative stress with above mentioned cellular defence mechanism against ROS, leads to the pathogenesis of AD. The pathogenesis of Alzheimer’s disease is mentioned in

Figure 4

.

Figure 4

. Pathogenesis of Alzheimer’s disease (MG : Microglia ; AS: Astrocyte; AP: Amyloid protein beta; NFT: Neurofibrillary tangles)

ACE ALZEIHMERS: VITAMIN A, C & E (ACE) THERAPY

ROLE OF VITAMIN A

Vitamin A and beta carotene have been shown to have multiple benefits for people suffering from AD. Various studies have found that patients suffering from AD have significantly lower levels of Vitamin A level and beta carotene in their CSF as well as blood [

34

]. The development of neurodegenerative disorders has shown to be influenced by Vitamin A and beta-carotene. Vitamin A plays an active role in neuronal development both in early life and in the adult nervous system. It protects and assists in the regeneration of neurons during recovery from neurodegeneration [

35

].

Inhibition of formation and destabilization of Aβ fibrils is an additional effect of Vitamin A and beta-carotene [

35

]. Since oligomerization of Aβ fibrils is an important mechanism contributing to neuronal toxicity in AD, Vitamin A supplementation has been shown to decrease the aggregation and oligomerization of Aβ40 and Aβ42 fibrils [

36

]. It has also been shown that Vitamin A and beta carotene decrease the decline of cognitive function in AD. Moreover, higher levels of these vitamins have been associated with better memory performance and spatial learning in these patients [

34

–

36

].

ROLE OF VITAMIN C

Various studies both in vivo and in vitro have shown to have significant effect in the brain due to decreased levels of vitamin C. Decreased plasma levels despite adequate intake in patients further confirmed the belief of protective effects of vitamin C in the spectrum of neurodegenerative diseases [

37

]. Hence, it can be proved that oxidative stress induces damage in AD and protection against this stress is offered to a certain degree by antioxidant vitamins. The progression of AD is altered by Vitamin C by interfering with various different aspects of pathology.

Numerous studies, both in-vivo and in vitro, have shown that Vitamin C can decrease oxidative stress. The structural progression of AD is prevented by Vitamin C by hindering the oligomerization of Aβ peptides [

38

]. Brain injury induces oxidative stress and reduces the level of antioxidants like vitamin C and SOD. Vitamin C supplementation improves the level of SOD, which consecutively helps to decrease oxidative stress and subsequent brain injury [

39

].

It has been suggested that even without additional supplementation, a normal intake of Vitamin C can have a neuroprotective effect in patients with AD. Cognitive decline in AD patients has shown to decrease is patients taking adequate Vitamin C [

40

]. In addition, results from a prospective observational study (n=4740) over a period of 3 years have shown that additional supplementation with antioxidant vitamins like vitamin C and E may be associated with both decreased incidence and prevalence of AD [

41

].

ROLE OF VITAMIN E

Vitamin E represents a cluster of 8 antioxidants composed of 4 tocotrienols and 4 tocopherols. It has been reported that there is a greater risk of neurodegenerative disorders like AD and Mild Cognitive Impairment (MCI) with lower plasma levels of vitamin E. Additionally, the level of vitamin E metabolic products (5-nitro-γ-tocopherol etc.) is shown to increase significantly in AD and MCI [

42

].

Deficiency of Vitamin E can lead to the damage and destruction of neurons and has been implicated in cases of cerebellar atrophy [

43

]. Vitamin E is a potent antioxidant which can delay the progression of AD at several levels. Increased oxidative stress induced by Aβ plaques is known to be a risk factor for neuronal death and ensuing brain injury in AD. Vitamin E behaves like a scavenger for these free radicals and therefore, is neuroprotective. [

44

].

Vitamin E also provides protection against AD via various other methods. For example, the 12-lipoxygenase pathway leads to glutamate-induced neuronal cell death by inflammation. Vitamin E can reduce this inflammation induced neuronal death [

45

]. Furthermore, consumption of vitamin E has been linked with the regeneration of SOD, levels of which are shown to decline in AD [39]. Among the different forms of vitamin E, the greatest degree of protection against AD is provided by α-tocopherols and γ-tocopherols [

46

].

A population-based cohort study of 5395 individuals was conducted to evaluate the efficacy of dietary supplementation of antioxidants to provide protection against AD. Among all the antioxidants used, results showed that the most significant degree of protection (p=0.02) against dementia and AD was provided by Vitamin E [

47

]. Moreover, supplementation of 30 International Units of alpha-tocopherols can act as a valuable adjuvant in the treatment of various neurodegenerative diseases, including AD

[48].

Conclusion

Alzheimer’s disease represents one of the most significant age-related neurodegenerative disorders. Oxidative stress is one of the most important mechanisms involved in the development and progression of this condition. In order, to curb the oxidative stress, antioxidants can be of great help. The use of antioxidant vitamins A, C and E as adjuvant therapy for AD has always been given consideration. Thus, further clinical research is necessary to study the potential of these vitamins such that it can be integrated into clinical treatment to accelerate the recovery of patients afflicted by this disorder.

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Introduction.

[1]

This study takes an aim at analysing the family knowledge and perception with children living with Autism. It further takes more interesting aspect on how various members within the family contribute in caring for these children. The study will also examine how parents living with children with Autism are treated in the society. In addition, it will also try to apply the researched areas to the social care sectors within the National Health Services (NHS). In conclusion, the study will be exploring the differences between girls and boys with Autism. The method undertaken for this study will be a comprehensive evaluation of ten (10) researched articles on the subject of family knowledge and perception with children living with Autism.

Research Questions

1. What are parents’ experiences when living with an autism child?
2. The risks involvements in living with autism children?
3. How are autism children treated in society?

Rational/Added Value.

Current researched studies and knowledge have revealed that, families with children living this type of lifelong neurological disorder sometimes have little or lack knowledge about the condition and hence makes it very frustrating to cater for these children (Mukaddes , 2012). The National Health Service (NHS) and other reputable stakeholders in health like The World Health Organization (WHO), in support of this,  are putting up procedures to support health carers and families with the essential support to cater for these children (NHS Choice, 2016; WHO,2017). Report by the Centre for Disease Control and Prevention (2014) indicates that 1 out of 100 of the world population is suffering from this condition. Likewise, National Health Services (NHS, 2018) points out that 1 out of every 58 children born in the united-kingdom suffer from autism.

About 80% of people living in England, according to the NHS Choice (2018) supports that, children living with autism should be given the necessary backing needed. The results from this survey clearly indicates that, there are still about 20% of people in England who need to be enlighten on this condition and hence led to this study.

The originality of this study lies in the fact that, articles and evidences use in the study were appraised

with the help of a CAPS TOOL. Aveyard (2014) supported that, it is very essential to critically appraise articles and evidence as it helps the researcher and other reader in making a good discernment of the information that is used. This study is a competitive advantage in giving its readers a better understanding of the topic chosen. To conclude, the study is also essential for an award of a degree for Bachelor of Science in the University of Bedfordshire.

Theory’s

• Erikson’s psychological stages of developments.
• Labelling theory.
• Behavioural theory

Aim and Objectives.

1. To explore the cultural and social factors that affect the parents   living with children with autism.
2. Understanding the autistic parent’s perspective on the condition and their coping ability.

3.   To explain the psychological, financial and emotional burden that is faced by the autistic parent and its impact on employment.

4.   To identify the impact of these perceptions on the development of the Autistic child.

5. The support mechanism available to families.

A qualitative study conducted by Huws and Jones (2009) using a semi structured interview to explore the lay perception of Autism. The study aims was to provide an in-depth analysis and generalisations of the perceptions and understanding of the particular group of subjects rather than the general population, the sample size was 10 which is far below any sample size which is generalisability according to Parahoo,( 2014). Findings from these studies indicated that participants, during the interview had no knowledge on Autism and none of them tried to ask the interviewer what autism meant. From the analysis four outcomes were generated. These are autism as a transgressing normative expectancy; functional ability discourse and dependency; the discourse of mental status and autism; explanatory discourses and autism. Entirely, it was evident from the findings of the study that people drew their perceptions and understanding of a normal childhood development and had little understanding of the autistic child. It is very relevant as per the studies to encourage the exposure of children with this condition to the society so as to increase awareness and further promote knowledge.

Wade (2008); and Schreck and Mulick (2000) in their studies showed evidence of some sort in terms of the awareness and a degree of perception of parents of the autistic child. Huws and Jones contradict from their evidence on perception indicates no level of perception by participants in the study. It is very keen there should by mass media and public education to promote the awareness of the condition and parents with autistic children sharing their experience. The role of parents and support are more evident in mothers with autistic children than those without. Tunali and Power (2008) also suggested that both mothers of children with and without autism focus on their parental roles. However, Culler and Kozloff (1987) opines that it is hard for mothers with children living with autism to pursue higher jobs and careers because of increase demand of care by these children.

Methodology

As part of health professionals’ responsibility in meeting a component of clinical governance, health professionals are therefore encouraged to support their practice with current evidence-based knowledge. In view of this, there are countless research works published every year and it is the responsibility of health professionals to carry out literature search technique in order to get relevant research knowledge related to their clinical area of practice. One of the key responsibilities of nurses and social workers is searching for relevant evidence and informing them in daily practice.(NMC 2013). Similarly, Gerard(2013) supported that literature form an important part of a proposal since it helps the researcher to analysis various literatures.

The search of literature begins by identifying academic databases from the university of Bedfordshire electronic library databases such as discover, digital library catalogue and health and social science databases as this gives reliable and evidence-based data which is relevant to the research topic (Green, 2000). Academic database was preferred due to how comprehensive and organised the information there is organised for the study (Bell, 2010). Again, Polit and Beck, (2014) suggest that the use of databases as source of research information has been proven as gold standard in getting literature review.  Furthermore, the choice of words selected for the search would be done by giving much attention to details which lead to the preferred evidence expected for the study.

In searching for relevant evidence, the writer will use keywords such as Autism, attitudes of autistic parent, perception of autistic parent, psychological and social impact on autism and knowledge of parents on autism. According to Polit and Beck (2014); Ritchie (2003) using keywords in searching for information is very vital in arriving at relevant evidence in answering the research question the writer then did a more precise and focused search to trim down to the field of social sciences, psychological and health research using the recommended research database. Cumulative index to nursing and allied health (CINAHL), Medline, psycINFO, PubMed, SocINDEX with full text, ASSIA (Applied social studies index& abstract and psycARTICLES. Effective and comprehensive literature searching must be done using several databases since this helps to widen the scope and aid easy understanding of the concepts from a diverse perspective. The Boolean operator would also inculcate to ease the search process NOT, OR, AND thereby narrowing down the search items. The Boolean operator helpes to arrive at numerous useful literatures which were scrutinized to arrive at preferable results of articles that answer the research question. In all after the use of these strategies and processes there would be a lot of articles and these would be relevant to answer the research question selected.  The writer will utilize these resources with the help of the university Liberian to arrive at evidence for the purpose of this study.

ETHICAL AND FEASIBILITY ISSUES.

Ethical issues are keen to every research work involving human subjects; all research work must be approved before its commencement (Gerrish and Lacey, 2010). Ethical considerations in conducting a research study serves as a moral guide for the researcher and helps to direct the agenda of the study, also the ethical committee looks into the effects the said study has on its participant and ensure there is no harm on researched subjects (Harcort and Sargent, 2012). Parahoo (2014) opines that individual stages of the research work have their own ethical implications and associated direction of the work. All research projects must ensure proper ethical approval as well-informed consent from its participant to enhance the genuity of the work and to protect the interest of its subjects before it commences.  In conclusion the writer in this context will hence apply all available ethical considerations and all background studies to ensure that a complete work is done.

Research Plan.

McKenzie’s (2018) research cycle will be used to analysis research plan.

Reference list.

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• Bell, J. (2010) Doing Your Research Project: A guide for first time researchers in education, health and social sciences. Berkshire: OUP.
• Booth, A. Rees. A, and Beecroft, C. (2015) ‘Systematic reviews and Evidence Syntheses’, in Gerrish, K. and Lathlean, J. (eds.) The Research Process in Nursing. 7thedn. India: John Wiley & Sons, Ltd. pp. 333-351
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• Jaci C. Huws & Robert S. P. Jones (2009) Diagnosis, disclosure, and having autism: An interpretative phenomenological analysis of the perceptions of young people with autism, Journal of Intellectual & Developmental Disability, 33:2, 99-107.
• LoBiondo-Wood, G. and Haber, J.  (2014) Methods and critical Appraisal for Evidence-based practice. 8th edn, China: Elsevier Mosby.
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GLOBAL HEALTH ISSUES

Global issue is a broad description that is often used to explain matters of great social concern that affect human populations locally and that are shared among diverse human societies within our global community. Global issues koncern us all and one at the heart of many valuable learning experiences. Issues such as environment al sustainability, health, peace building and human rights focus students attention and contemporary events and how they affect our lives at a local and global level. Many people argue that globalization has Server to bring the world closer together creating a more cooperative environment. The impact of new information and communication Technologies has changed the way people learn, work and live. From the suffering of the Second World War emerged a new international organization- the United Nations.

The United Nations founding, In 1945, enabled its Member States and their peoples to work together to promote peace and cooperation, economic and social development, and a clear Visio codified by international law.

In 1981, one of the leading causes of death in our time broke upon the world scene. The new ailment was named acquired immune deficiency syndrome(AIDS) and also Human immunodeficiency virus(HIV).

HIV means that you have tested positive for the virus and it does not become AIDS usually for ten years or until immune system problems appear.

HIV/AIDS causes immense suffering to millions of people. UNAIDS (the joint United Nations programme on HIV/AIDS showed that HIV/AIDS has bee diagnosted in every continent on the globe, yeti t is distribution is far from even.

One of the many consequences of the pandemic is that it has a major impact of life expentancy among the worlds poorer countries. The impact of AIDS on life expectancy is also felt beyond Africa, albeit somewhat less dramatically. Haiti’s life expectancy is currently almost six years less than it world heve been without AIDS, in Combodia it is currently four years lower. South Africa has also been affected, in Guana, for example, the probability of becoming HIV- positive between the ages of 15 and 50 is 19% or nearly 1 in 5. North America, for example, has 950.000 people living with HIV/AIDS and Western Europe 550.000 whilst in Australia and New Zealand 15.000 people (UNAIDS, 2002).

In Africa, 28 million people are infected with HIV and 11 million African children are thought to heve been orphaned by AIDS (WHO, 2000).

Kopelan and van Niekerk (2002) suggested that the scale of the HIV/AIDS epidmic in Africa is often explained away by pre-existing notions of a diseased, corrupt and backward continent and they argue, forcefully, for international support, albeit with reather than for African countries.

Unfortunatelly biomedical and pharmaceutical responses have had a relatively small impact upon the pandemic. Attempts to devlop vaccines, for example, have had limited success and these endeavours have probably been hindered by the allocation of relatively Modest amounts of funding. Between US dollars 300-and US dollars 600-million a year have been spent on the development of HIV vaccines(UNAIDS, 2002).

There has been more success in the development of antiretroviral drugs and these are prolonging thousands of ives in high- income countries(Babiker et al., 2002).

However, these drugs continue to remain inaccessible to the majority of those infected by HIV.

Since the people most affected by HIV/AIDS are often those with the least access to economic power or political influence it is, perhaps, hardly surprising that so many governments offer such a lukewarm response( de Wall,2002).

In many of the poorer countries in which HIV/AIDS predominates, and where people with AIDS have little or no access to medical care or treatment, responsibility for the care of the dying ultimately falls on the poorest households (Ellison et al.,2001).

In countries where governments do not take the initiative in responding to HIV/AIDS, and where the disease is often shrouded in stigma and denial, there is unlikely to be widespread popular presure for change. In this way, at an individual and a social level, the enormity of AIDS and the burden of copying tend to get hidden in the lives of ordinary familie( Palloni and Lee, 1992).

UNAIDS Global Reference Group on HIV/AIDS and Human Rights (2004) ensuring rights based approach is: the global scalling up of the response to AIDS, particulary in relation HIV testing as a preveguisite to expanded access to treatment, must be grounded in sound public health practice and also respect protection, and fulfilment of human rights norms and standarts. The voluntariness of testing must remain at the heart of HIV policies and programmes, both to comply with human rights principles and to ensure sustained public health benefits. The following key factors, which are mutually reinforcing, should be addressed simultanously :

• Ensuring an ethical process for conducting the testing, including defining the purpose of the test and benefits to the individuals being tested and assurances of linages between the site where the test is conducted and relevant treatmant care and other services, in an environment that guarantees confidentiality of all medical inforamtion.
• Adressing the implications of a positive test results, including non discrimination and access to sustainable treatment and care for people who test positive.
• Reducing HIV/AIDS- related stigma and discrimination at all levels, notably within health care settings.
• Ensuring a supportive legal and policy framework within which the respons eis scaled up, including safeguarding the human rights of people seeking services.

The HV/AIDS epidemic has deep historical roots. The epidemic have to be seen against this broad background. There are lessons to be learned, not Just about this disease, but about health, well-being and development as well.It is the first global epidemic of which we have been commonly conscious. Health and well-being are not individual concerns: they are global issues. There are opportunities for innovation and for more ‘goods’ but there is only a glimmer of hope . These are:

1. Global intersectoral action through transnational co-operation and partnerships between public health and trade and finance sectors.
2. Pro vide information about comparative health status and global determinants of health and well-being.
3. Research programmes that concentrate on developing cost-effective technologies to improve the status of the poor.
4. Recognition that management of health and well-being is a common human project and that the for-profit sector can only have limited incentives to meet those needs (Alonso, 2001).

But there are many abstacles because we need to persuade people of the true cost of HIV/AIDS and business has a role to play, but the business of business is profit no welfare. Perhaps that is also an assumption that must be challenged. In the same way that HIV/AIDS is about more than health, so business has responsibilities beyond three complementary mechanisms: the market- distribution through competitive pricing, second one is the hierarchy- distribution through organisation process and the last one is values- distribution as a response to accepted ethical principles (Alonso, 2001). Through unprecedented global attention and intervention ef fors, the rate of new HIV infections has showed and prevalence rate have leveled off globally and in many regions. Despite the progress seen in some countries and regions, the total number of people living with HIV continues to rise (Barnett and Prins, 2006).

In 2007, globally about 2 million people died of AIDS, 33 million were living with HIV and 2,7 million people where newly infected with the virus (WHO, 2008).

The impact of HIV/AIDS on women and girls has been particulary devastating. Women and girls now comprise 50 percent of those aged 15 and older living with HIV but, the impact of HIV/AIDS on children and young people is a severe and growing problem. In 2007, 370,000 children underage 15 were infected with HIV and 270,000 died of AIDS and about 15 million children have lost one or both parents due to the disease (WHO, 2008). The sixth Millennium Development Goal (MDG) focuses on stopping and reversing the spread of HIV/AIDS by 2015. Global funding is increasing, but global need is growing even faster-widening the funding gap. Services and funding are disproportionately available in developed countries. HIV infections and AIDS deaths are unevenly distributed geographically and the nature of the epidemics very by region. Epidemics are abating in some coutries and burgeoning in others. More than 90 percent of people with HIV are living in the developing worl (UNICEF, 2007).

The health care systems of most African countries, already inadequate. As the serious nature of the pandemic and it is effect on the developing world came into sharper focus in the 1990’s, so did the incoherence of international policy. The nature of the crisis was given recognition in 1995 when the United Nations set up UNAIDS to co-ordinate global policy by bringing together under one heading six key international agencies: WHO, UNDP, UNICEF, UNEPA, UNESCO and the World Bank. The re-orientation of policy towards AIDS was proposed, more or less across the board, in the face of increasingly pessimistic forecasts of the effects, both short and long term of the pandemic on whole populations in Africa (Ellison et al.,2003).

In Southern Africa insurance companies are gathering such information because they routinely test people before offering cover. These data are biased to those applying for policies and are often comercially sensitive and so they tend not to be publicly available. For companies wishing to estimate how the epidemic is going to affect their workforce, the advert of saliva and urine tests mean, surreys can be carried out more easily. This is a routine procedure to test blood donations and these data can provide a picture of what is going on in what should be a low- risk group. HIV data are also collected and constructed according to political, social and other biases (UNAIDS, 2000).

HIV/AIDS is not the first global epidemic, and it won’t be the last. It is the disease that is changing human history. HIV/AIDS shows up global inqualities. It is presence and impacts are left most profundly in poor countries and communities (Bernett and Whiteside, 2006). Public health system are undefunded; politically they attract few votes, and in parts of the world they are close to collapse. For the moment, there is only a mere itimation of any system of global public health. Social and economic conditions negate many gains made by any particular intervention. Health is not any about confronting individual diseases. Well-being, of which health is a part, is a reflection of general and economic conditions (Anderson and May, 1992).

Economic impact means that families suffer major economic problems as productive adults become ill, including: loss of income as family members become sick and are unable to work, or have to give up work to care for the sick and limited income being consumed by expensive drugs and funerals. Countries suffer significiant economic impacts including: los of investment in education and the knowledge and skills of professionally trained people, reduced ability to produce food and high costs of treatment and demands on health system (Adler, 2001).

Human and social impact means that people’s who lives are affected in many ways which include: a wide variety of physical health problems , social isolation due to stigma and misunderstanding of the spread of the disease (Barnett and Prins, 2006).

The purpose of workplace policy on HIV/AIDS in South Africa (UNAIDS, 2008) is to provide clarity on TOTALs views and commitments with regard to HIV/AIDS and the comprehensive management of HIV positive employees and employees living with AIDS. TOTAL is fully committed to protect employees, create awarness, encourage behaviour changes where necessary as well as ensure that all employees are treated with the necessary dignity, fairness and equality (USAID, Global Partnership, 2004).

Some major reasons for unnecessary deaths around the world are therefore due to human decisions and politics, not just natural outcomes. Well- intentioned companies, organizations and global action show that humanisty and compassion still exists, but tackling systematic problems is parramount for effective, Universal health care that all are entitled too. Addressing health problems goes Beyond just medical treatments and policies; it goes to the heart of social, economic and political policies that not only provide for healthier lives, but a more productive and meaningful one that can benefit other areas of society.

Bibliography:

1. De Wall, A. (2006) Aids and power. South Africa
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