"Alcohol will never run out": Socio-ecological drivers of adolescent boys' alcohol use in Kilimanjaro Region, Tanzania.

Heavy alcohol use amongst adolescent boys is a major public health concern in many countries. It is associated with a range of negative physical and mental health outcomes and predicts alcohol-related problems in adulthood. In Kilimanjaro Region, adolescent boys' alcohol use is widespread, and higher than other regions in Tanzania. An understanding of causal and contextual factors that influence the use of alcohol is needed to inform the development and implementation of effective alcohol prevention interventions. This study aimed to explore these socio-ecological factors in-depth amongst adolescent boys, young men and key stakeholders in Kilimanjaro Region, Tanzania. Between August 2022 and June 2023, multi-method, participatory, qualitative methods including: ethnographic observations (8 weeks), 37 in-depth interviews, 14 focus group discussions and participatory adolescent activities were used to elicit perceptions on factors driving adolescent boys' alcohol use in two (rural/urban) settings. Data were triangulated and deductively analysed, guided by Bronfenbrenner's socio-ecological framework. This study found many dynamic and inter-related factors linked to alcohol use within adolescents' social, cultural, economic, regulatory, and physical environments. In a context of widespread availability of alcohol, low enforcement of alcohol regulation and (mis)conceptions around the benefits of alcohol use (e.g. curative and/or nutritional properties), parental and cultural influences largely determined the initiation of use in childhood and younger adolescence; employment status, peers, lack of alternative recreational activity and social norms around independence appeared to drive continued and increased use in older adolescence. Factors and their impact varied between rural and urban settings. In conclusion, a wide range of determinants and drivers of alcohol use among ABYM work at multiple socio-ecological levels especially parental, cultural and socioeconomic factors. This suggests that effective prevention requires a systems approach intervening across these levels. For example, incorporating education/awareness raising, increased law enforcement, parent-child communication and problem-solving, and income generation activities.

Participatory development of a community mental wellbeing support package for people affected by skin neglected tropical diseases in the Kasai province, Democratic Republic of Congo.

BACKGROUND: Skin neglected tropical diseases (NTDs) produce signs and symptoms that are often physically challenging, stigmatizing and have a negative impact on the mental wellbeing of people affected. In the Democratic Republic of Congo (DRC), little is known about the mental wellbeing experiences of people affected by skin NTDs and support is lacking. We collaborated with ongoing NTD programs, the Ministry of Health and people affected to evidence experiences and opportunities for change and co-developed a mental wellbeing support package for people affected and local health system actors. METHODS: This implementation research study used the photovoice method alongside key-informant interviews to evidence mental wellbeing challenges in people affected by skin NTDs and explore opportunities for change. These were used to co-develop a skin NTD mental wellbeing support package with people affected, community members and local health system actors through a participatory workshop. RESULTS: Stigma, discrimination, decreased livelihoods and mental wellbeing challenges were evidenced by people affected by skin NTDs, their communities and health system actors. Participants identified and co-established community-led peer support groups, strengthened with basic knowledge on psychosocial support, and income-generating or recreational initiatives to support mental wellbeing of people affected by skin NTDs. CONCLUSIONS: Co-developing a support package with persons affected, community members and health system actors is a step towards holistic care for people affected by skin NTDs and promotes uptake and ownership of intervention components. CONTEXTE: Les maladies tropicales négligées (MTN) cutanées produisent des signes et des symptômes qui sont souvent difficiles à supporter physiquement, ils sont également stigmatisants et ont un impact négatif sur le bien-être mental des personnes touchées. En République Démocratique du Congo (RDC), on sait peu de choses sur le bien-être mental des personnes atteintes de MTN cutanées, et le soutien fait défaut. Nous avons collaboré avec les programmes de lutte contre les MTN en cours, le ministère de la santé et les personnes touchées pour mettre en évidence les expériences et les possibilités de changement, et nous avons élaboré un programme de soutien au bien-être mental pour les personnes touchées et les acteurs du système de santé local. MÉTHODES UTILISÉES: Cette étude de recherche sur la mise en œuvre a utilisé la méthode photovoice, ainsi que des entretiens avec des informateurs clés, afin de mettre en évidence les problèmes de bien-être mental des personnes touchées par les MNT cutanées. Ces éléments ont été utilisés pour élaborer un programme de soutien au bien-être mental des MNT cutanées avec les personnes concernées, les membres de la communauté et les acteurs du système de santé local dans le cadre d'un atelier participatif. RÉSULTATS: La stigmatisation, la discrimination, la diminution des moyens de subsistance et les problèmes de bien-être mental ont été mis en évidence par les personnes atteintes de MTN cutanées, leurs communautés et les acteurs du système de santé. Les participants ont identifié et mis en place des groupes communautaires de soutien par les pairs, renforcés par des connaissances de base en matière de soutien psychosocial, et des initiatives génératrices de revenus/récréatives pour soutenir le bien-être mental des personnes touchées par les MTN cutanées. CONCLUSIONS: L'élaboration d'un ensemble de mesures de soutien en collaboration avec les personnes concernées, les membres de la communauté et les acteurs du système de santé, constitue une étape vers une prise en charge holistique des personnes atteintes de MNT cutanées et favorise l'adoption et l'appropriation des composantes de l'intervention. ANTECEDENTES: Las enfermedades tropicales desatendidas (ETDs) cutáneas producen signos y síntomas que a menudo suponen un reto físico, estigmatizan y tienen un impacto negativo en el bienestar mental de las personas afectadas. En la República Democrática del Congo (RDC), se sabe poco sobre las experiencias de bienestar mental de las personas afectadas por ETDs cutáneas, y falta apoyo. Colaboramos con los programas en curso sobre las ETDs, el Ministerio de Sanidad y las personas afectadas para poner de manifiesto las experiencias y las oportunidades de cambio, y desarrollamos de manera conjunta un paquete de apoyo al bienestar mental para las personas afectadas y los agentes del sistema sanitario local. MÉTODOS: Este estudio de investigación utilizó el método fotovoz, junto con entrevistas a informantes clave, para poner de manifiesto los desafíos de bienestar mental de las personas afectadas por ETDs cutáneas y explorar las oportunidades de cambio. Estos datos se utilizaron para desarrollar un paquete de apoyo al bienestar mental de manera conjunta con las personas afectadas por las ETDs cutáneas, los miembros de la comunidad y los actores del sistema sanitario local a través de un taller participativo. RESULTADOS: El estigma, la discriminación, la disminución de los medios de subsistencia y los problemas de bienestar mental fueron evidenciados por las personas afectadas por ETD cutáneas, sus comunidades y los agentes del sistema sanitario. Los participantes identificaron y establecieron conjuntamente grupos de apoyo entre pares dirigidos por la comunidad, fortalecidos con conocimientos básicos sobre apoyo psicosocial e iniciativasrecreativas y generadoras de ingresos para apoyar el bienestar mental de las personas afectadas por las ETD cutáneas. CONCLUSIÓNS: El desarrollo conjunto de un paquete de medidas de apoyo con las personas afectadas, los miembros de la comunidad y los actores del sistema sanitario es un paso hacia la atención holística de las personas afectadas por las NTDs a y promueve la adopción y apropiación de los componentes de la intervención.

Mental health, stigma and the quality of life of people affected by neglected tropical diseases of the skin in Kasai Province, Democratic Republic of the Congo: a sex-disaggregated analysis.

BACKGROUND: Worldwide, persons affected by skin Neglected Tropical Diseases (NTDs) may experience stigma and discrimination, which could lead to impaired societal functioning and poor mental wellbeing. Evidence of comorbidity of NTDs and mental health conditions is dominated by Leprosy, largely lacking in post-conflict areas, and rarely disaggregated by sex. METHODS: This cross-sectional survey is the first to explore depression, anxiety, stigma, and quality of life amongst people affected by Lymphatic Filariasis, Buruli Ulcer, Onchocerciasis or Leprosy in the Democratic Republic of the Congo. After a census through active case identification, the survey was completed by 118 persons (response rate 94.4%). RESULTS: In total, 58.3% of men and 80.0% of women screened positive for major depressive disorder (PHQ-9). Symptoms indicative of generalised anxiety disorder (GAD-7) were displayed by 54.8% of men and 62.2% of women. Being female, having a disability, experiencing stigma and lower physical quality of life were predictors of depression. Anxiety was predicted by age, physical quality of life, disability (for men only) and environmental quality of life (for women only). CONCLUSIONS: Integrated, intersectoral and gender-sensitive initiatives are needed to respond to the many biopsychosocial challenges that persons affected face. CONTEXTE: Dans le monde entier, les personnes atteintes de maladies tropicales négligées (MTN) peuvent faire l'objet d'une stigmatisation et d'une discrimination, ce qui peut entraîner une altération du fonctionnement de la société et un mauvais bien-être mental. Les preuves de la comorbidité des MTN et des troubles de la santé mentale sont dominées par la lèpre, manquent largement dans les zones post-conflit et sont rarement ventilées par sexe. MÉTHODES UTILISÉES: Cette enquête transversale est la première à explorer la dépression, l'anxiété, la stigmatisation et la qualité de vie chez les personnes atteintes de filariose lymphatique, d'ulcère de Buruli, d'onchocercose ou de lèpre en République démocratique du Congo. Après un recensement par identification active des cas, 118 personnes ont répondu à l'enquête (taux de réponse 94,4%). RÉSULTATS: Au total, 58,3% des hommes et 80,0% des femmes ont été dépistés positifs pour un trouble dépressif majeur (PHQ-9). Des symptômes indiquant un trouble anxieux généralisé (GAD-7) ont été observés chez 54,8 % des hommes et 62,2 % des femmes. Le fait d'être une femme, d'avoir un handicap, d'être stigmatisé et d'avoir une qualité de vie physique inférieure était un facteur prédictif de la dépression. L'anxiété était prédite par l'âge, la qualité de vie physique, le handicap (pour les hommes uniquement) et la qualité de vie environnementale (pour les femmes uniquement). CONCLUSIONS: Des initiatives intégrées, intersectorielles et sensibles au genre sont nécessaires pour répondre aux nombreux défis biopsychosociaux auxquels sont confrontées les personnes touchées. ANTECEDENTES: En todo el mundo, las personas afectadas por Enfermedades Tropicales Desatendidas (ETD) cutáneas pueden sufrir estigmatización y discriminación, lo que podría conducir a un deterioro del funcionamiento social y a un bienestar mental deficiente. La evidencia científica sobre la comorbilidad de las ETD y las afecciones mentales está dominada por la lepra, en general insuficiente en zonas post-conflicto y rara vez se desglosan por sexo. MÉTODOS: Esta encuesta transversal es la primera que explora la depresión, la ansiedad, el estigma y la calidad de vida entre las personas afectadas por la filariasis linfática, la úlcera de Buruli, la oncocercosis o la lepra en la República Democrática del Congo. Tras un censo mediante identificación activa de casos, la encuesta fue completada por 118 personas (tasa de respuesta del 94,4%). RESULTADOS: En total, el 58,3% de los hombres y el 80,0% de las mujeres arrojaron resultados positivos para el trastorno depresivo mayor (PHQ-9). El 54,8% de los hombres y el 62,2% de las mujeres presentaban síntomas indicativos de trastorno de ansiedad generalizada (TAG-7). Ser mujer, tener una discapacidad, sufrir estigmatización y una menor calidad de vida física fueron factores predictivos de la depresión. La edad, la calidad de vida física, la discapacidad (sólo en el caso de los hombres) y la calidad de vida ambiental (sólo en el caso de las mujeres) fueron factores predictivos de la ansiedad. CONCLUSIONES: Se necesitan iniciativas integradas, intersectoriales y con perspectiva de género para responder a los numerosos retos biopsicosociales a los que se enfrentan las personas afectadas.

Task-shifting for point-of-care cervical cancer prevention in low- and middle-income countries: a case study from Uganda.

Cervical cancer remains the leading cause of female cancer deaths in sub-Saharan Africa. This is despite cervical cancer being both preventable and curable if detected early and treated adequately. This paper reports on a series of action-research 'cycles' designed to progressively integrate a comprehensive, task-shifted, point-of-care, prevention program in a community-based public health facility in Uganda. The work has been undertaken through a UK-Ugandan Health Partnership coordinated by Knowledge for Change, a UK-registered Charity. The intervention demonstrates the effectiveness of task-shifting responsibility to Community Health Workers combined with the use of Geographic Information Systems to strategically guide health awareness-raising and the deployment of medical devices supporting respectful and sustainable point-of-care screen-and-treat services. The integration of this with public human immunodeficiency virus services demonstrates the ability to engage hard-to-reach 'key populations' at greatest risk of cervical cancer. The findings also demonstrate the impact of external influences including the Results Based Financing approach, adopted by many foreign Non-Governmental Organizations. The model presents opportunities for policy transfer to other areas of health promotion and prevention with important lessons for international Health partnership engagement. The paper concludes by outlining plans for a subsequent action-research cycle embracing and evaluating the potential of Artificial Intelligence to enhance service efficacy.

Measuring alcohol use among adolescents in Africa: A systematic scoping review of consumption, screening and assessment tools.

ISSUES: Globally, adolescent drinking is a major public health concern. Alcohol measurements are influenced by local consumption practices, patterns and perceptions of alcohol-related harm. This is the first review to examine what tools are used to measure alcohol consumption, or screen for or assess harmful use in African adolescents, and how these tools take into account the local context. APPROACH: A systematic scoping review was conducted in line with the Arksey and O'Malley framework. A search in MEDLINE, CINAHL, Global Health and the Cochrane Database covered the period of 2000-2020. KEY FINDINGS: The search identified 121 papers across 25 African countries. A range of single- and multi-item tools were identified. Very few adaptations of existing questions were specified, and this search identified no tools developed by local researchers that were fundamentally different from established tools often designed in the USA or Europe. Inconsistencies were found in the use of cut-off scores; many studies used adult cut-off scores. IMPLICATIONS AND CONCLUSION: The possible impact of African drinking practices and culture on the accuracy of alcohol screening tools is currently unknown, but is also not taken into account by most research. This, in combination with a limited geographical distribution of alcohol-related research across the continent and inconsistent use of age- and gender-specific cut-off scores, points towards probable inaccuracies in current data on adolescent alcohol use in Africa.

Promotive, preventive, and treatment interventions for adolescent mental health in sub-Saharan Africa: A protocol for two scoping reviews including systematic analyses of intervention effectiveness.

INTRODUCTION: The increasing prevalence of mental health difficulties amongst adolescents is a worldwide concern. Poor mental health in adolescence is associated with a range of mental, physical and social problems in later life. In sub-Saharan Africa, limited data suggests that mental disorders amongst adolescents are common. It is important that interventions to address this are rooted in an understanding of the unique local context and culture. Yet, the current use, development, and effectiveness of adolescent mental health interventions in sub-Saharan Africa is unclear. In response, this paper presents a protocol for two scoping reviews that together will examine the available evidence on promotive, preventive, and treatment interventions for adolescent mental health in sub-Saharan Africa. METHODS AND ANALYSIS: The scoping reviews will follow the five-step methodological framework proposed by Arksey and O'Malley, with further recommendations from the Joanna Briggs Institute. They will review scientific and grey literature published between 2000 and 2021, without restrictions in language or study type. A wide range of sources, including MEDLINE, CINAHL, Global Health, PsychINFO, Cochrane and Google Scholar will be searched. Eligibility screening and data extraction will be done by two independent reviewers, and disagreements resolved by a third reviewer. Data will be summarised in two phases. A narrative synthesis will provide a descriptive profile of all studies included and will explore key concepts related to intervention types, target populations and adaptations to local context. A systematic review element will collate evidence of intervention effectiveness from (cluster) Randomised Controlled Trials. DISCUSSION AND DISSEMINATION: To the best of our knowledge, these scoping reviews are the first to synthesise a wide range of available evidence on promotive, preventive and treatment interventions for adolescent mental health in sub-Saharan Africa. The results will be published in peer-reviewed publications and will be presented as an evidence base for future intervention development and implementation.

Exploring the role of the UK renal social worker: The nexus between health and social care for renal patients.

INTRODUCTION: Patients living with progressive chronic kidney disease may face a variety of ongoing physical, emotional, financial and/or social challenges along the disease pathway. In most UK renal units, psychosocial support has traditionally been provided by a renal social worker. However, in recent years, the numbers of renal social workers have been declining. The specialised role is poorly understood and there is no UK research about the profession. To inform future research and guide workforce planning, this study presents the first-ever exploration of the UK renal social worker role. It aimed to map the profession's activities and reasons for involvement in patient care, as well as providing an initial evaluation of that involvement on patient wellbeing. METHODS AND ANALYSIS: This mixed-method study recruited adult renal social workers (n = 14), who completed diaries over a 4-month period, participated in a focus group, and provided secondary data (caseload data and audit files where available) to give insight into their role. The evaluation of social work involvement on patient wellbeing used a pre-post intervention design. It measured distress, anxiety and depression levels as captured by the Distress Thermometer and Emotional Thermometers. A total of 161 patients completed the pre-involvement questionnaire, and 87 (55%) returned the post-involvement questionnaire. RESULTS AND CONCLUSION: The renal social worker role is creative, broad and fluid, with variations in roles linked to differences in employment and funding arrangements, configurations of the wider multidisciplinary renal team, level of standardisation of psychosocial care, availability of community services, and staff-to-patient ratios. Renal social work is different from statutory social work, and renal social workers are generally able to offer continuous rather than episodic care and support patients that would not meet strict local authority eligibility criteria. The findings showed that this support leads to significantly reduced distress and anxiety.

Adolescent mental health research in Tanzania: a study protocol for a priority setting exercise and the development of an interinstitutional capacity strengthening programme.

INTRODUCTION: Poor adolescent mental health is a barrier to achieving several sustainable development goals in Tanzania, where adolescent mental health infrastructure is weak. This is compounded by a lack of community and policy maker awareness or understanding of its burden, causes and solutions. Research addressing these knowledge gaps is urgently needed. However, capacity for adolescent mental health research in Tanzania remains limited. The existence of a National Institute for Medical Research (NIMR), with a nationwide mandate for research conduct and oversight, presents an opportunity to catalyse activity in this neglected area. Rigorous research priority setting, which includes key stakeholders, can promote efficient use of limited resources and improve both quality and uptake of research by ensuring that it meets the needs of target populations and policy makers. We present a protocol for such a research priority setting study and how it informs the design of an interinstitutional adolescent mental health research capacity strengthening strategy in Tanzania. METHODS AND ANALYSIS: From May 2021, this 6 month mixed-methods study will adapt and merge the James Lind Alliance approach and validated capacity strengthening methodologies to identify priorities for research and research capacity strengthening in adolescent mental health in Tanzania. Specifically, it will use online questionnaires, face-to-face interviews, focus groups, scoping reviews and a consensus meeting to consult expert and adolescent stakeholders. Key evidence-informed priorities will be collaboratively ranked and documented and an integrated strategy to address capacity gaps will be designed to align with the nationwide infrastructure and overall strategy of NIMR. ETHICS AND DISSEMINATION: National and institutional review board approvals were sought and granted from the National Health Research Ethics Committee of the NIMR Medical Research Coordinating Committee (Tanzania) and the Liverpool School of Tropical Medicine (United Kingdom). Results will be disseminated through a national workshop involving all stakeholders, through ongoing collaborations and published commentaries, reviews, policy briefs, webinars and social media.

Examining patient distress and unmet need for support across UK renal units with varying models of psychosocial care delivery: a cross-sectional survey study.

OBJECTIVE: To examine in-centre haemodialysis patients' emotional distress and need for support across UK renal units with varying models of psychosocial service provision. DESIGN: The study used a cross-sectional survey design. Logistic regression analysis was used to examine patient distress, as captured by the Distress Thermometer, and need for support, across different renal units. SETTING: Seven renal units across England, Wales and Scotland. The units were purposively selected so that varying workforce models of renal psychosocial services were represented. PARTICIPANTS: In total, 752 patients were on dialysis in the participating centres on the days of data collection. All adult patients, who could understand English, and with capacity (as determined by the nurse in charge), were eligible to participate in the study. The questionnaire was completed by 509 patients, resulting in an overall response rate of 67.7%. OUTCOME MEASURES: The prevalence of distress and patient-reported need for support. RESULTS: The results showed that 48.9% (95% CI 44.5 to 53.4) of respondents experienced distress. A significant association between distress and models of renal psychosocial service provision was found (χ2(6)=15.05, p=0.019). Multivariable logistic regression showed that patients in units with higher total psychosocial staffing ratios (OR 0.65 (95% CI 0.47 to 0.89); p=0.008) and specifically higher social work ratios (OR 0.49 (95% CI 0.33 to 0.74); p=0.001) were less likely to experience distress, even after controlling for demographic variables. In addition, a higher patient-reported unmet need for support was found in units where psychosocial staffing numbers are low or non-existent (χ2(6)=37.80, p<0.001). CONCLUSIONS: The novel findings emphasise a need for increased incorporation of dedicated renal psychosocial staff into the renal care pathway. Importantly, these members of staff should be able to offer support for psychological as well as practical and social care-related issues.

Opportunities and Challenges for Improving Anti-Microbial Stewardship in Low- and Middle-Income Countries; Lessons Learnt from the Maternal Sepsis Intervention in Western Uganda.

This paper presents findings from an action-research intervention designed to identify ways of improving antimicrobial stewardship in a Ugandan Regional Referral Hospital. Building on an existing health partnership and extensive action-research on maternal health, it focused on maternal sepsis. Sepsis is one of the main causes of maternal mortality in Uganda and surgical site infection, a major contributing factor. Post-natal wards also consume the largest volume of antibiotics. The findings from the Maternal Sepsis Intervention demonstrate the potential for remarkable changes in health worker behaviour through multi-disciplinary engagement. Nurses and midwives create the connective tissue linking pharmacy, laboratory scientists and junior doctors to support an evidence-based response to prescribing. These multi-disciplinary 'huddles' form a necessary, but insufficient, grounding for active clinical pharmacy. The impact on antimicrobial stewardship and maternal mortality and morbidity is ultimately limited by very poor and inconsistent access to antibiotics and supplies. Insufficient and predictable stock-outs undermine behaviour change frustrating health workers' ability to exercise their knowledge and skill for the benefit of their patients. This escalates healthcare costs and contributes to anti-microbial resistance.

Mapping the UK renal psychosocial workforce: the first comprehensive workforce survey.

BACKGROUND: Emerging evidence of psychosocial problems in CKD patients has led to an acceptance that a focus on the emotional wellbeing of the patient should be included in the provision of comprehensive CKD care. It is unclear if an increased attention for psychosocial needs in guidelines and policy documents has led to a rise in psychosocial staffing levels or change in composition of staff since the last workforce mapping in 2002. This paper offers a critical analysis and in-depth discussion of findings and their implications, in addition to providing an international perspective and exposing gaps in current knowledge. METHODS: Data on psychosocial staffing levels was taken from a survey based on the Scottish Renal Association's (SRA) staffing survey that was sent to all units in England, Wales and Northern-Ireland in 2016. In addition, data from a psychosocial staffing survey designed by and distributed via psychosocial professional groups was used. This data was then completed with Freedom of Information (FOI) requests and collated to describe the current renal psychosocial workforce in all 84 UK renal units. This was compared to results from the last renal workforce mapping in 2002. RESULTS: The results from this mapping show great variability in models of service provision, significant exceeding of benchmarks for staffing levels, and a change in staffing patterns over the past 15 years. Adult psychology services have increased in number, but provision remains low due to increased patient numbers, whereas adult social work and paediatric services have decreased. CONCLUSION: A lack in the provision of renal psychosocial services has been identified, together with the absence of a general service provision model. These findings provide a valuable benchmark for units, a context from which to review and monitor provision alongside patient need. Along with recommendations, this paper forms a foundation for future research and workforce planning. Research into best practice models of service provision and the psychosocial needs of CKD patients lies at the heart of the answers to many identified questions.

Route learning in Korsakoff's syndrome: Residual acquisition of spatial memory despite profound amnesia.

Korsakoff's syndrome (KS) is characterized by explicit amnesia, but relatively spared implicit memory. The aim of this study was to assess to what extent KS patients can acquire spatial information while performing a spatial navigation task. Furthermore, we examined whether residual spatial acquisition in KS was based on automatic or effortful coding processes. Therefore, 20 KS patients and 20 matched healthy controls performed six tasks on spatial navigation after they navigated through a residential area. Ten participants per group were instructed to pay close attention (intentional condition), while 10 received mock instructions (incidental condition). KS patients showed hampered performance on a majority of tasks, yet their performance was superior to chance level on a route time and distance estimation tasks, a map drawing task and a route walking task. Performance was relatively spared on the route distance estimation task, but there were large variations between participants. Acquisition in KS was automatic rather than effortful, since no significant differences were obtained between the intentional and incidental condition on any task, whereas for the healthy controls, the intention to learn was beneficial for the map drawing task and the route walking task. The results of this study suggest that KS patients are still able to acquire spatial information during navigation on multiple domains despite the presence of the explicit amnesia. Residual acquisition is most likely based on automatic coding processes.