Archive for September, 2009

When H1N1 visits food banks and shelters, what then? We need a plan

Coughs and sneezes spread diseases. Trap the germs in your handkerchief.  ~  World War 2 health slogan

Charities and non-profits provide critical services to communities across Canada. What if they are not adequately prepared for an H1N1 outbreak? asks Marcel Lauzière, head of Imagine Canada, a national program to promote public and corporate giving, volunteering and support to the community.

In an opinion piece that appeared in a number of Canadian newspapers this week, including the Winnipeg Free Press, Lauzière attempts to bring to public attention the potential impact of the H1N1 pandemic on Canada’s charitable and non-profit organizations. From the blank looks and long pauses over the phone he says he has been experiencing when he starts talking about it, it is apparent that this issue is still languishing at lower levels in the nation’s health bureaucracies.

The focus of most official attention is on hospitals, schools, businesses, First Nations reserves, and vulnerable individuals like pregnant women. There is a lively and useful public debate about how prepared we are, and how prepared we should be, for a major outbreak. But charities and non-profits are too often not part of the discussion. Left out of the picture is the fact that charities and non-profit organizations deliver critical services to Canadians. If the H1N1 epidemic is severe, what will happen if charitable organizations lose up to a third of their staff and volunteers to illness?

What if food banks start closing? How will desperate families feed their kids? What if meals are no longer prepared and delivered to elderly people who can’t get out and who have no friends or relatives nearby to help them? What about Canadians needing dialysis or chemotherapy but who can’t get to the hospital because there are no volunteers to drive them? What about the thousands of children and their families who rely on local sports and recreation and arts and cultural organizations for their weekly activities? What if the homeless shelters shut their doors in the middle of winter?

As a third pillar of Canadian society alongside governments and business, charities and non-profit organizations are part of an intricate system of societal supports that significantly improve the quality of life in Canada. They are also a significant part of our economy. “The sector generates more than $87 billion annually, a contribution of almost seven per cent to Canada’s GDP. It employs more than 1.5 million Canadians (full-time equivalents)and mobilizes 12.5 million volunteers in Canada.”

Lauzière refers to the importance of “business continuity” during an outbreak and the plans that government and major corporations are putting in place. Everyone agrees that the economy must keep on working. That is precisely why we cannot forget charities and non-profits.

[They] are part of our economy too, as well as being major contributors to our quality of life… The demand many of them face is already greater given the impact of the recession and now they must prepare for the possibility of an H1N1 outbreak. What if they are not adequately prepared?

We will need them more than ever at a time of crisis. This is no time for blank looks. As a country, we need to figure out how we can help them be prepared for whatever this influenza season brings.

Lauzière’s argument is lucid and important, but he has put the focus largely on continuity of vital services to the disadvantaged. Yes, if H1N1 cripples charities the results could be, according to the Halifax Chronicle Herald’s melodramatic headline, “catastrophic.” But where are the plans to prevent H1N1 transmission among people these charities serve? This, it seems to me, is an issue that should be higher up the priority list of public health authorities. Toronto has a working document, the Toronto pandemic influenza plan: a planning guide for homeless and housing service providers [PDF]. Other Canadian agencies seem to be a little slow on the uptake.

Rather than focusing almost entirely on business continuity, it makes sense to intensify efforts to slow the spread of the virus among disadvantaged and equity seeking groups who make use of charitable services such as food banks and shelters. These are environments in which disease can spread quickly. Sleeping and eating in close quarters, the homeless are even more vulnerable to infection by H1N1, many of them already being immune compromised, poorly nourished, and suffering addiction and chronic illness.

While Marcel Lauzière’s plea for a plan to maintain services should not go unheard, it is also important that our public health authorities act now to slow the spread of H1N1 among the many vulnerable users of charitable services until the vaccine is ready. Or we may find down the road that we have adequately prepared service organizations with no one left to serve.

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Pharmaceutical flimflam: drug advertising in medical journals is a global issue

Advertising may be described as the science of arresting human intelligence long enough to get money from it.  ~  Stephen Leacock, Garden of Folly (1924) ‘The Perfect Salesman’

A recent systematic review in PLoS One demonstrates quite effectively something that shouldn’t surprise any intelligent high school student: pharmaceutical advertising in medical journals often provides “poor quality information.” This strikes me as the authors’ excessively polite way of saying that drug ads, even those that appear in authoritative periodicals widely read by physicians, are unregulated, manipulative, meretricious and mendacious. Selling the latest SSRI is not really different from shilling shampoo, with the difference, of course, that there is superior evidence of shampoo’s efficacy.

Othman N, Vitry A, Roughead EE. Quality of pharmaceutical advertisements in medical journals: a systematic review. PLoS One. 2009 Jul 22;4(7):e6350. PubMed PMID: 19623259; PubMed Central PMCID: PMC2709919.

The article, buffed to a high scholarly polish with any hint of libellous language or ethical disdain well suppressed, warrants close reading. Here are some highlights:

Advertising in medical journals is one of the techniques used by pharmaceutical companies to promote their products to medical doctors. During the first four years of a new medicine on the market, pharmaceutical companies may gain approximately US $2.43 for each dollar spent on medical journal advertisements for a medicine. The return on investment has been reported to increase to more than US $4 after that period.

We found that pharmaceutical advertisements in medical journals usually provided brand and generic name and indication. Other essential information required for rational prescribing including contraindications, interactions, side effects, warnings and precautions were less commonly provided. The majority of references cited to support pharmaceutical claims were journal articles. However, less than two-third [sic] of the claims were supported [emphasis mine] by a systematic review or a meta-analysis (110/1375, 8%) and randomised control trial (455/1500, 30%).

This review noted that references used to support pharmaceutical claims were often of low quality. The inappropriate use of references in journal advertising suggests that the availability of references does not always guarantee the quality of claims.

Information on medicines is essential to help doctors ensure the optimal use of medicines. However, studies show that doctors who use journal advertisements as a source of information may prescribe less appropriately. In addition, reliance on journal advertising for information is associated with increased costs of prescribing. Even doctors who think that they obtain their knowledge from the scientific literature can be influenced by promotional sources without being aware of it. As information provided in journal advertising has the potential to change doctors’ prescribing behaviour, our review indicates that ongoing efforts including complaints and recommendations by researchers, health professionals and policy makers to improve the quality of advertisements in medical journals are crucial.

Governments may need to take more proactive action such as engaging independent experts to help in designing regulation for journal advertising where self regulatory codes are limited. In addition to that, effective regulatory system may complement pharmaceutical litigation to ensure accuracy and reliability of information in journal advertising.

Our review found that the low quality of journal advertising was a global issue. Poor quality advertising has been observed in developing countries and post-Soviet Russia where controls might be weak and limited as well as in developed countries which have stricter regulations.

Globally, pharmaceutical advertising in medical journals often provides poor quality information. The impact of this problem on doctors’ prescribing behaviour might be even greater in developing countries and post-Soviet Russia where access to industry-free medicine information is limited. The results from our review suggest the need for a global pro-active and effective regulatory system to ensure that information provided in medical journal advertising is supporting the quality use of medicines.

It is the most extraordinary thing, but I never read a patent medicine advertisement without being impelled to the conclusion that I am suffering from the particular disease therein dealt with in its most virulent form.  ~  Jerome K. Jerome, Three Men in a Boat (1889)

Slow death by rubber duck: how the toxic chemistry of everyday life affects our health

“When I see a bird that walks like a duck and swims like a duck and quacks like a duck, I call that bird a duck.”  ~ James Whitcomb Riley

We consume hundreds of toxic chemicals from the things we use day to day to keep ourselves sheltered, fed, clothed and healthy. So say authors Rick Smith and Bruce Lourie in their recent book Slow death by rubber duck: how the toxic chemistry of everyday life affects our health (Knopf Canada, 323 pages, $32). But they are hopeful that things can change for the better, noting a recent European ban on noxious flame-retardant chemicals in television sets, Canadian legislative changes to end toxic baby bottles, and a new U.S. law to restrict hormone-mimicking ingredients in the plastic of children’s toys.

Almost everything we use, recline on, sleep in, eat off, wash with, or rub into our skin is a source of pollution. “For most people belching smokestacks, sewer outfalls, and car exhaust are the first images that come to mind when the word ‘pollution’ is mentioned,” the authors observe. Pollution is still seen as “an external concern, something floating around in the air or in the nearest lake. Something that can still be avoided.” But research makes it clear that pollution is so pervasive “it has become a marinade in which we bathe every day.”

Pollution is actually inside us all. It’s seeped into our bodies. And in many cases, once in, it is impossible to get out.

Toxic chemicals are now found at low levels in countless appliances, in everything from personal care products and cooking pots and pans to electronics, furniture clothing, building materials, and children’s toys. They make their way into our bodies through our food, air, and water.

From the moment we get up from a good night’s sleep under wrinkle-resistant sheets (which are treated with the known carcinogen formaldehyde), to the moment we go to bed at night after a snack of microwave popcorn (the interior of the bag being coated with an indestructible chemical that builds up in our bodies), pollution surrounds us … It has been estimated that, by the time the average woman grabs her coffee, she has applied 126 different chemicals in 12 different products to her body.

The authors advise readers on which products to choose in order to avoid the ones that are most dangerously polluting. But these are only short-term solutions. “For the long-term fix,” they warn, “only improved government regulation and oversight of toxic chemicals is the answer. It’s critical that we address this problem, not only as consumers, but also as engaged citizens demanding better of their governments.”

Rick Smith, one of Canada’s leading environmentalists, is director of Environmental Defence, a non-profit organization known for its innovative work on environmental issues.

Bruce Lourie started one of Canada’s largest environmental consultancies. He works closely with governments, businesses, foundations, and non-profit organizations. He is president of the Richard Ivey Foundation, which supports environmental and other beneficial projects.

This is a modified version of a review by Roy LaBerge which appeared in the September 2009 issue of The CCPA Monitor.

For academic librarians what’s hard to reach is time for research

research-definition
These be the stops that hinder study quite
And train our intellects to vain delight.

Love’s Labour’s Lost, 1.1

Who has the time for research? Very few of us, unless it is somehow part of our work day. Our teaching faculty colleagues do not teach from 9 to 5, Monday to Friday, nor are they always required to be in their offices when not in front of a class, especially between June and August. But academic librarians, it seems, can never have their cake and eat it too. We are expected to be on the job, at the workplace, every day, summer included, unless we are on vacation or on ventilation. And, with some variations, from the midst of this perpetual motion machine we are also expected to produce viable, publishable, imperishable research.

At the University of Manitoba we librarians take our research obligations seriously. We enjoy academic status and are members of the University of Manitoba Faculty Association (UMFA). We have senior management who by and large recognize the value of research and support our pursuit of it. We now also have new language in our Collective Agreement that guarantees us academic freedom and twelve paid days a year to devote entirely to scholarly pursuits. During our last protracted contract negotiations, obtaining recognition from the University that, as part of our academic status, librarians needed time to do the research required of them was a hard-fought battle.

Articles 17 and 20 of the UMFA Collective Agreement, not to mention our own promotion guidelines, more than adequately define both research and the purpose of the working time entitlement for librarians (in particular 17.A.2.5; and see also the Research, Scholarly and Other Creative Works section, 20.B.1.2.2, of the Promotion article). But lately there has been talk amongst my colleagues of establishing “guidelines” to determine the suitability or otherwise of someone’s research and whether a request for time away from other duties to pursue research should be granted.

My generous nature interprets this development as arising from good intentions, but I have to ask: why establish a set of guidelines separate from what has already been well defined in the contract, as well as in a detailed document on guidelines and criteria for the promotion of librarians through the ranks? As I see it, the subject of a librarian’s research is a matter of professional judgement in an atmosphere of academic freedom and collegiality. Our Collective Agreement wisely includes its own warning that librarians’ academic work must be undertaken responsibly: “Academic freedom carries with it the responsibility to use that freedom in a manner consistent with the scholarly obligation to base research, teaching and the collection, dissemination and structure of knowledge in a search for truth.” (17.A.1) Must we form yet another committee to encode and encapsulate what “responsibly” means?

Here is the controversial addition to our contract that seems to stick in some people’s craw. As I mentioned, Article 17 (Academic Librarians) was revised in 2007 to include language on so-called “research days”:

Academic librarians holding probationary and continuing appointments are entitled to twelve (12) working days on full salary in each academic year for research and scholarly activities relating to library science or an academic subject within their expertise, subject to notifying the department head of their proposed work and arranging a mutually agreeable schedule.  (17.A.2.5)

Article 20 on Promotion defines the nature of librarians’ research, scholarly work and other creative activities:

Factors that may be considered include:  the publication of books, monographs, and contributions to edited books; papers in both refereed and nonrefereed journals; papers delivered at professional meetings; participation in panels; both supported and nonsupported unpublished research including current work in progress; editorial and refereeing duties; creative works and performances; and scholarship as evidenced by the candidate’s advanced study and research in library and information science and/or a subject specialization, his/her depth and breadth of knowledge and general contributions to the research of the University. (20.B.1.2.2)

Here, in clear and unequivocal language, the UMFA Collective Agreement spells out what is considered research by librarians and carves out a bit of unencumbered space in which such research can be performed. Some have complained that the twelve days are no more than “automatic days off.” To argue so, I would reply, is misguided in the same way that it would be foolish to maintain that sick days should not be provided because they might, heaven forfend, actually be taken. Should the remote possibility that one of us might abuse a provision of the Collective Agreement be used as a pretext to reshape or subvert what is already appropriately defined in that document? Life is too short for us to start composing intricate commentaries on reasonably comprehensible contractual language. I think what Calvin Trillin once said is appropriate: if law school is so hard to get through, how come there are so many lawyers?

It might be argued that establishing more rigorous guidelines for librarians’ research activities would provide clarity and  improve equity across the library system. My response is that the existing contractual provisions for librarians’ research are entirely sufficient for this purpose. If all librarians read, understand and abide by it, the Collective Agreement itself is the best assurance of equity and should be the primary authority on this issue. It is only when the Collective Agreement specifically calls for the creation of guidelines that we are obligated to go beyond its provisions, as is the case with hiring and promotion at this university.

It is the responsibility of an academic library to foster librarians’ research and to organize the work of the academic staff in such a manner as to accommodate time away from other duties for that purpose. This is in the spirit of the Collective Agreement. If a manager disagrees with a librarian about his or her request for time to pursue research, that is an academic matter which should be resolved between the two of them. If no resolution is possible at that level, there are agreed-upon steps that individual can take. Under the terms of the UMFA Collective Agreement, extended postponement or denial of research time could lead to a grievance. Moreover, any attempt further to enumerate and codify what should or should not be the nature of a librarian’s research – beyond the very detailed provisions already cited above – could be interpreted as an infringement upon his or her academic freedom.

It is unfortunate that we have become accustomed to use the term “research days” – which, by the way, is not to be found in the Collective Agreement – as a convenient but demeaning moniker for what that document calls “twelve working days on full salary in each academic year for research and scholarly activities relating to library science or an academic subject within [a librarian’s] expertise.” (17.A.2.5) The entry of this term into common usage has contributed to a general perception that Article 17’s provision for time given over to research is somehow an add-on, accessory or perquisite, when in fact research is an essential component of our work. This is precisely the attitude that our hard-won provision for research time was meant to dispel.

As I see it – and I speak solely from my Canadian experience – some academic libraries have not yet developed or have not fully developed a culture of research. That goal can only be achieved by creating work environments and job expectations that are not so demanding as to discourage librarians from considering research and creative scholarly contributions, or from thinking that such pursuits could be an integral part of their “regular” working day. A strong faculty association and a Collective Agreement with guts are two other important factors in furthering librarians’ participation in academic research.

I have often heard from librarians at this and other universities that they are too busy just coping with their job even to contemplate doing research. That is why I think it vital to focus on fostering research rather than devising methods to contain or curtail it. It is part of moving away from what I call the “No” school of librarianship, the kind of passive-aggressive impasse where – I speak figuratively – it is illegal to make liquor privately or water publicly. If any more guidelines are to be written for us librarians, let them elaborate on how we can open up the taps of creativity, improve our working conditions, provide better service, and be more rounded scholars and professionals.

Hard-to-reach, hard to research

manhole-ladder
From a public health perspective, who are the hard-to-reach and how can we find research articles about them?

I was asked this question by a manager in the Winnipeg Regional Health Authority. He was looking for research specifically on immunization programs for the hard-to-reach as part of the WRHA’s ongoing preparation for the expected H1N1 epidemic. In order to assist my client, how was I to construct a search strategy in PubMed and other databases that would gather disparate materials together without a comprehensive catch-all subject heading?

Finding appropriate literature is just one of many challenges associated with conducting research on hard-to-reach populations. In the first place, how do we identify and sample certain groups of individuals for health research? Undoubtedly some populations are particularly vulnerable and difficult to contact. Other populations may be defined by characteristics such as ethnicity or sexual preference that are not recorded in routinely available data sources. Yet while the need for research on the hard-to-reach is pressing, a comprehensive definition of this population is lacking, and hence it is difficult to get one’s bearings.

Before creating my search strategy, I had to do some research of my own in order to get a handle on exactly the groups that I would be investigating.

Defining the hard-to-reach

What exactly is meant by ‘hard-to-reach’ is a matter of some debate. The term is inconsistently applied. It will sometimes be used to refer to minority groups, such as immigrants, LGBT people, or the homeless; it can be used to refer to ‘hidden populations’, groups of people who do not wish to be found or contacted, such as illegal drug users or gang members; at other times it may refer to broader segments of the population, such as the elderly, or young people, or people with disabilities. In the service context, hard-to-reach often refers to the underserved, certain minority groups, those slipping through the social safety net, and those who are deemed to be ‘service resistant’.

Yet another term used in this context is ‘hidden populations’, meaning those who are hidden from the point of view of research sampling. Hidden populations may also actively seek to conceal their group identity, as for example in the case of sniffers, injection drug users, LGBT people who are in the closet, sexually active teens, etc.

The hard-to-reach are also called the ‘seldom heard’. The use of this term indicates that these are people who do not have a collective voice and are often under-represented in consultation and involvement activities about developing services. ‘Hard-to-reach’ suggests that there is something that prevents their engagement with services. ‘Seldom heard’ emphasizes the responsibility of agencies to reach out to excluded people, ensuring that they have access to social care services and that their voices can be heard.

One of the chief difficulties in defining the hard-to-reach is the unintentional imputation of a homogeneity among distinct groups that does not necessarily exist. Or it may imply that the problem is one within the group itself and not within the approach. Attempts at categorization can have a stigmatizing effect. Hard-to-reach audiences have, with varying degrees of prejudice, been called obstinate, recalcitrant, chronically uninformed, disadvantaged, have-not, illiterate, dysfunctional, and information poor.

Associative and Nonassociative

In addition to these various ways to categorize the hard-to-reach, we can distinguish between ‘associative’ hard-to-reach populations, such as people at risk of AIDS, and ‘nonassociative’ hard-to-reach populations: those whose members do not normally have contact with other members.

Nonassociative populations share two primary characteristics. The first is demographic. There is no effective centralized information about them, and a large proportion of their members do not know each other. The second is that their members share characteristics or attributes that make it important for health and human services to have information about them to inform service planning, policy, and delivery. In addition to these features, they are often low-frequency populations, and they might be subject to stigma of various kinds.

There has been a large amount of research on associative hard-to-reach populations, those whose members are socially networked with each other and form a community (with literally thousands of studies being done on populations at risk of HIV and AIDS, such as injection drug users) – but there have been very few rigorous studies of nonassociative populations, particularly those that are less in the public eye, such as shut-ins.

The central focus of my search strategy was to gather together information precisely on these nonassociative populations. I was looking for groups defined by individual attributes (such as health or social status) where there is often no overriding reason for within-population socializing and where a substantial proportion of population members do not have strong social links with other members and, indeed, might even resist such contact. These hard-to-reach groups must be taken into account in immunization planning. No effective H1N1 prevention strategy can exclude them.

After much effort I decided to include the following in my search strategy:

  1. The homeless, the marginally housed, street people, and sex trade workers
  2. Shelter residents (including women and youth)
  3. Inmates in the correctional system (the incarcerated, parolees, the recently released, and those in half-way homes)
  4. Persons with serious and persistent mental health issues, including dementia or addiction
  5. Housebound persons (cystic fibrosis, arthritis), shut-ins, and the disabled
  6. The linguistically isolated (people with communication impairments, recent immigrants who are not fluent in English or French)
  7. Selected recipients of Family Services and Housing (employment income assistance, government housing, children in care)
  8. Miscellaneous nonassociative groups (transients, the uninsured, the socially isolated)

PubMed Search Strategy

Here, finally, is the strategy I employed for my PubMed search:

(“Immunization”[MAJR] OR vaccinat*[TI] OR immuniz*[TI] OR immunis*[TI] OR “Immunization Programs”[MAJR] OR “Immunization Schedule”[MAJR] OR “Influenza, Human/prevention and control”[MAJR] OR “unvaccinated population”)

AND

(hard-to-reach OR “seldom heard” OR “hidden population” OR “hidden populations” OR homeless OR homelessness OR  “Homeless Persons”[MAJR] OR “Transients and Migrants”[MAJR] OR “Housing”[MAJR] OR “Prostitution”[MAJR] OR “sex trade workers” OR migrant OR vagrants OR “street worker” OR “street workers” OR “street people” OR “street youth” OR “street kids” OR “street children” OR “street involved” OR “unstable housing” OR shelters OR “shelter residents” OR (marginally[TIAB] AND housed[TIAB]) OR under-housed OR “marginalized population” OR “marginalized populations”

OR “Emigrants and Immigrants”[MAJR] OR “Refugees”[MAJR] OR “recent immigrants” OR “recent immigrant” OR “undocumented immigrant” OR “undocumented immigrants” OR “illegal immigrant” OR “illegal immigrants” OR emigres

OR “Vulnerable Populations”[MAJR] OR “Poverty”[MAJR] OR “Poverty Areas”[MH] OR “Social Class”[MH] OR “Socioeconomic Factors”[MH] OR “Urban Population”[MH] OR welfare OR underserved OR “underserved areas” OR “high-risk inner-city” OR socially-at-risk OR “at-risk population” OR “at-risk populations” OR slum OR slums OR ghetto OR ghettos OR favela OR favelas OR “low-socio-economic” OR disadvantaged OR low-income OR impoverished OR uninsured OR underinsured

OR “Prisoners”[MAJR] OR “Prisons”[MAJR] OR incarcerated OR incarceration OR “corrections facility” OR “correctional facilities” OR  “correctional population” OR prisoners OR probation OR probationers OR probationary OR parole OR parolees OR inmates OR “half-way house” OR “half-way houses”

OR “Drug Users”[MAJR] OR “Substance Abuse, Intravenous/psychology”[MAJR] OR “drug users” OR addicts OR addicted OR “drug addicts” OR “substance abuser” OR “substance abusers”

OR deaf[TIAB] OR “Hearing Impaired Persons”[MAJR] OR “Social Isolation”[MAJR] OR “low literacy” OR “language isolated” OR (linguistically[TIAB] AND isolated[TIAB]) OR homebound OR shut-in OR shut-ins OR “disabled persons”[MH]

OR “Mentally Ill Persons”[MAJR] OR “mentally ill”)

References

1. Brackertz N. Who is hard to reach and why? ISR working paper 2007. SISRQ/EL 06.07Institute for Social Research (Australia) [online]. Available from: http://www.sisr.net/publications/0701brackertz.pdf

2. Southern DA, Lewis S, Maxwell CJ, Dunn JR, Noseworthy TW, Corbett G, Thomas K, Ghali WA. Sampling ‘hard-to-reach’ populations in health research: yield from a study targeting Americans living in Canada. BMC Med Res Methodol. 2008 Aug 18;8:57. PubMed PMID: 18710574

3. Stewart M, Makwarimba E, Barnfather A, Letourneau N, Neufeld A. Researching reducing health disparities: mixed-methods approaches. Soc Sci Med. 2008 Mar;66(6):1406-17. Epub 2008 Jan 14. PubMed PMID: 18248867.

4. Thompson S, Phillips D. Reaching and engaging hard-to-reach populations with a high proportion of nonassociative members. Qual Health Res. 2007 Nov;17(9):1292-303. PubMed PMID: 17968045.


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