[show abstract][hide abstract] ABSTRACT: With increasing calls for global health research there is growing concern regarding the ethical challenges encountered by researchers from high-income countries (HICs) working in low or middle-income countries (LMICs). There is a dearth of literature on how to address these challenges in practice. In this article, we conduct a critical analysis of three case studies of research conducted in LMICs. We apply emerging ethical guidelines and principles specific to global health research and offer practical strategies that researchers ought to consider. We present case studies in which Canadian health professional students conducted a health promotion project in a community in Honduras; a research capacity-building program in South Africa, in which Canadian students also worked alongside LMIC partners; and a community-university partnered research capacity-building program in which Ecuadorean graduate students, some working alongside Canadian students, conducted community-based health research projects in Ecuadorean communities. We examine each case, identifying ethical issues that emerged and how new ethical paradigms being promoted could be concretely applied. We conclude that research ethics boards should focus not only on protecting individual integrity and human dignity in health studies but also on beneficence and non-maleficence at the community level, explicitly considering social justice issues and local capacity-building imperatives. We conclude that researchers from HICs interested in global health research must work with LMIC partners to implement collaborative processes for assuring ethical research J Acad Ethics
[show abstract][hide abstract] ABSTRACT: Abstract The health service sector has a vital role to play in delivering human immunodeficiency virus (HIV) and tuberculosis (TB) prevention, treatment and care, yet evidence indicates that healthcare workers (HCWs) themselves lack adequate access to HIV and TB services. HCWs are also at increased risk from TB and other infectious diseases at work, and therefore accessing HIV services is particularly important. A systematic review was therefore conducted to inform the development of World Health Organization (WHO) guidelines to improve access to HIV and TB services, and specifically, to assess the evidence regarding providing such services through workplace-based programmes. We identified any study published since 1984 that addressed outcomes of interest as defined through multi-stakeholder consultations, and were related to workplace interventions in (1) the healthcare workplace and (2) any workplace that included HIV and/or TB diagnosis and/or treatment. Interventions focusing solely on primary prevention with no diagnostic or treatment services were excluded, as they were the subject of other guidelines. A minimum of two reviewers independently extracted data and assessed the articles against pre-set selection criteria; studies were also profiled and quality assessed by a minimum of two reviewers. Three studies met these criteria specifically for HCWs; all showed a preponderance of positive benefits, with minimal negative outcome. Seven studies met these criteria regarding workplace HIV and/or TB diagnosis and/or treatment from other sectors, public or private. Again, all showed positive results. The paucity of high-quality evidence in this field of research was itself an important finding, beckoning further research on workplace-based programmes for health workers. Nonetheless, while more well-designed intervention studies are definitely desirable, providing programmes for HCWs to obtain HIV and TB diagnosis and treatment at the workplace is supported by the literature and is consistent with the values of the stakeholders, justifying the WHO-International Labour Organization-UNAIDS guidelines that emerged.
[show abstract][hide abstract] ABSTRACT: BACKGROUND: Although information systems (IS) have been extensively applied in the health sector worldwide, few initiatives have addressed the health and safety of health workers, a group acknowledged to be at high risk of injury and illness, as well as in great shortage globally, particularly in low and middle-income countries. METHODS: Adapting a context-mechanism-outcome case study design, we analyze our team's own experience over two decades to address this gap: in two different Canadian provinces; and two distinct South African settings. Applying a realist analysis within an adapted structuration theory framing sensitive to power relations, we explore contextual (sociopolitical and technological) characteristics and mechanisms affecting outcomes at micro, meso and macro levels. RESULTS: Technological limitations hindered IS usefulness in the initial Canadian locale, while staffing inadequacies amid pronounced power imbalances affecting governance restricted IS usefulness in the subsequent Canadian application. Implementation in South Africa highlighted the special care needed to address power dynamics regarding both workeremployer relations (relevant to all occupational health settings) and North-south imbalances (common to all international interactions). Researchers, managers and front-line workers all view IS implementation differently; relationships amongst the workplace parties and between community and academic partners have been pivotal in determining outcome in all circumstances. Capacity building and applying creative commons and open source solutions are showing promise, as is international collaboration. CONCLUSIONS: There is worldwide consensus on the need for IS use to protect the health workforce. However, IS implementation is a resource-intensive undertaking; regardless of how carefully designed the software, contextual factors and the mechanisms adopted to address these are critical to mitigate threats and achieve outcomes of interest to all parties. Issues specific to IS development, including technological support and software licensing models, can also affect outcome and sustainability - especially in the North-south context. Careful attention must be given to power relations between the various stakeholders at macro, meso and micro levels when implementing IS. North-South-South collaborations should be encouraged. Governance as well as technological issues are crucial determinants of IS application, and ultimately whether the system is seen as a tool, weapon, or white elephant by the various involved parties. You may call me a fool, But was there a rule. The weapon should be turned into a tool? And what do we see? The first tool I step on turned into a weapon. -Robert Frost White (albino) elephants were regarded as holy in ancient times in Thailand and other Asian countries. Keeping a white elephant was a very expensive undertaking, since the owner had to provide the elephant with special food and provide access for people who wanted to worship it. If a Thai King became dissatisfied with a subordinate, he would give him a white elephant. The gift would, in most cases, ruin the recipient. - The Phrase Finder.
BMC Medical Informatics and Decision Making 08/2012; 12(1):84. · 1.60 Impact Factor
[show abstract][hide abstract] ABSTRACT: Chronic pesticide poisoning is difficult to detect. We sought to develop a low-cost test battery for settings such as Ecuador's floriculture industry. First we had to develop a case definition; as with all occupational diseases a case had to have both sufficient effective dose and associated health effects. For the former, using canonical discriminant analysis, we found that adding measures of protection and overall environmental stressors to occupational category and duration of exposure was useful. For the latter, factor analysis suggested three distinct manifestations of pesticide poisoning. We then determined sensitivity and specificity of various combinations of symptoms and simple neurotoxicity tests from the Pentox questionnaire, and found that doing so increased sensitivity and specificity compared to use of acethylcholinesterase alone--the current screening standard. While sensitivity and specificity varied with different case definitions, our results support the development of a low-cost test battery for screening in such settings.
International journal of occupational and environmental health 01/2012; 18(1):7-21. · 1.18 Impact Factor
[show abstract][hide abstract] ABSTRACT: To collect baseline data on infectious diseases and antibiotic use in two Andean indigenous communities in Ecuador in order to determine the feasibility and acceptability of applying an ecosystem approach to address associated problems.
In visits to 65 households with children under age 5 years, environmental risk factors for infectious diseases were evaluated through rapid assessment. Caregivers' knowledge, attitudes, and practices related to antibiotic use were determined through a knowledge, practices, and coverage survey; antibiotic use was gleaned from inspection of medicine chests; and overall health of the 91 children (including nutritional status) was assessed. A workshop was held to share results and to craft a multicomponent intervention using an ecohealth framework.
Numerous environmental risk factors were identified, especially related to water and sanitation. Knowledge, attitudes, and practices revealed use of traditional and Western medicines and serious knowledge gaps. Antibiotics were present in 60.9% of households in Correuco and 46.8% in La Posta; malnutrition rates were 22.2% in Correuco and 26.1% in La Posta; diarrheic episodes were experienced in the previous month by 26.7% of children in Correuco and 47.8% in La Posta, with antibiotics prescribed in 50.0% and 47.1% of cases, respectively; and acute respiratory infections were incurred by 28.9% of children in Correuco and 47.8% in La Posta, with antibiotics prescribed in 53.8% and 50.0% of cases, respectively.
Environmental, social, and cultural factors must be addressed to prevent antibiotic resistance in addition to training health personnel. An ecosystem approach is well-suited for this goal.
Revista Panamericana de Salud Pública 12/2011; 30(6):566-73. · 0.85 Impact Factor
[show abstract][hide abstract] ABSTRACT: Studies in the literature do not show clear evidence supporting the relationship between pain and depressive symptoms in individuals experiencing acute/subacute pain compared to those experiencing chronic pain. However, more information is needed about which variables act as mediators in the pain-depression relationship in people having acute/subacute pain, before pain becomes chronic. Our objectives were to test the suitability of the fear-avoidance model in a sample of 110 health care workers experiencing acute/subacute pain using path analyses, to improve the model as needed, and to examine a model involving both pain catastrophizing and pain self-efficacy with work status as a final outcome. Overall, the results indicated that adjustments to the fear-avoidance model were required for people experiencing acute/subacute pain, in which fear-avoidance beliefs and depressive symptoms were concurrent rather than sequential. The catastrophizing concept was most closely associated with depressive symptoms, while pain self-efficacy was directly associated with fear-avoidance beliefs and indirectly to work outcomes. Assessing and modifying pain self-efficacy in acute/subacute pain patients is important for interventions aiming to decrease fear-avoidance and improve work outcomes.
[show abstract][hide abstract] ABSTRACT: To consider how Cuba's acknowledged achievement of excellent health outcomes may relate to how health determinants are addressed intersectorally.
Our team of Canadian and Cuban researchers and health policy practitioners undertook a study to consider the organization and practices involved in addressing health determinants in 2 municipalities (1 urban and 1 rural). The study included a questionnaire of municipal Health Council members and others involved in health and non-health sectors, key informant interviews of policy makers, focus groups in each municipality and examination of three common case scenarios.
Regular engagement of different sectors and other agencies in addressing health determinants was quite systematic and comparable in both municipalities. Specific policies and organizational structures in support of intersectoral actions were frequently cited and illustrated in case scenarios that demonstrate how maintenance of regular linkages facilitates regular pursuit of intersectoral approaches.
The study demonstrates the feasibility of examining processes of intersectoral action for health processes and suggests that further examination in evaluating factors such as training, particular practices, etc., can be a fruitful direction to pursue comparatively and with analytical designs.
International Journal of Public Health 08/2011; 57(1):15-23. · 1.99 Impact Factor
[show abstract][hide abstract] ABSTRACT: Many agencies recommend that health care workers wear N95 filtering facepiece respirators (N95-FFR) to minimize occupational exposure to bioaerosols, such as tuberculosis and pandemic influenza. Published standards outline procedures for the proper selection of an N95-FFR model, including user seal checks and respirator fit-testing. Some health officials have argued that the respirator fit-test step should be eliminated altogether, given its additional time and cost factors, and that only a user seal check be utilized to ensure that an adequate face seal has been achieved. One of the aims of the current study is to examine whether a user seal check is an appropriate surrogate for respirator fit-testing. Subjects were assigned an N95-FFR and asked to perform a user seal check (as per manufacturer's instructions) after which they immediately underwent a respirator fit-test. Successfully passing a respirator fit-test was based on not detecting a leakage through the face seal (either qualitatively with a test agent or quantitatively with a particulate counter). The sample population consisted of 647 subjects who had never been previously fit-tested (naive), while the remaining 137 participants were experienced respirator users. Only four of the 647 naive subjects (0.62%) identified an inadequate seal during their user seal check. Of the 643 remaining naive subjects who indicated that they had an adequate face seal prior to fit-testing, 158 (25%) failed the subsequent quantitative fit-test and 92 (14%) failed the qualitative fit-test. All 137 experienced users indicated that they had an adequate seal after performing the user seal check; however, 41 (30%) failed the subsequent quantitative fit-test, and 30 (22%) failed the qualitative fit-test. These findings contradict the argument to eliminate fit-testing and rely strictly on a user seal check to evaluate face seal.
Journal of Occupational and Environmental Hygiene 05/2011; 8(5):267-70. · 1.28 Impact Factor
[show abstract][hide abstract] ABSTRACT: The Sustainably Managing Environmental Health Risk in Ecuador project was launched in 2004 as a partnership linking a large Canadian university with leading Cuban and Mexican institutes to strengthen the capacities of four Ecuadorian universities for leading community-based learning and research in areas as diverse as pesticide poisoning, dengue control, water and sanitation, and disaster preparedness.
In implementing curriculum and complementary innovations through application of an ecosystem approach to health, our interdisciplinary international team focused on the question: "Can strengthening of institutional capacities to support a community of practice of researchers, practitioners, policy-makers and communities produce positive health outcomes and improved capacities to sustainably translate knowledge?" To assess progress in achieving desired outcomes, we review results associated with the logic framework analysis used to guide the project, focusing on how a community of practice network has strengthened implementation, including follow-up tracking of program trainees and presentation of two specific case studies.
By 2009, train-the-trainer project initiation involved 27 participatory action research Master's theses in 15 communities where 1200 community learners participated in the implementation of associated interventions. This led to establishment of innovative Ecuadorian-led master's and doctoral programs, and a Population Health Observatory on Collective Health, Environment and Society for the Andean region based at the Universidad Andina Simon Bolivar. Building on this network, numerous initiatives were begun, such as an internationally funded research project to strengthen dengue control in the coastal community of Machala, and establishment of a local community eco-health centre focusing on determinants of health near Cuenca.
Strengthening capabilities for producing and applying knowledge through direct engagement with affected populations and decision-makers provides a fertile basis for consolidating capacities to act on a larger scale. This can facilitate the capturing of benefits from the "top down" (in consolidating institutional commitments) and the "bottom up" (to achieve local results).
Alliances of academic and non-academic partners from the South and North provide a promising orientation for learning together about ways of addressing negative trends of development. Assessing the impacts and sustainability of such processes, however, requires longer term monitoring of results and related challenges.
BMC International Health and Human Rights 01/2011; 11 Suppl 2:S5. · 1.44 Impact Factor
[show abstract][hide abstract] ABSTRACT: Globalization has been accompanied by the rapid spread of infectious diseases, and further strain on working conditions for health workers globally. Post-SARS, Canadian occupational health and infection control researchers got together to study how to better protect health workers, and found that training was indeed perceived as key to a positive safety culture. This led to developing information and communication technology (ICT) tools. The research conducted also showed the need for better workplace inspections, so a workplace audit tool was also developed to supplement worker questionnaires and the ICT. When invited to join Ecuadorean colleagues to promote occupational health and infection control, these tools were collectively adapted and improved, including face-to-face as well as on-line problem-based learning scenarios. The South African government then invited the team to work with local colleagues to improve occupational health and infection control, resulting in an improved web-based health information system to track incidents, exposures, and occupational injury and diseases. As the H1N1 pandemic struck, the online infection control course was adapted and translated into Spanish, as was a novel skill-building learning tool that permits health workers to practice selecting personal protective equipment. This tool was originally developed in collaboration with the countries from the Caribbean region and the Pan American Health Organization (PAHO). Research from these experiences led to strengthened focus on building capacity of health and safety committees, and new modules are thus being created, informed by that work.The products developed have been widely heralded as innovative and interactive, leading to their inclusion into "toolkits" used internationally. The tools used in Canada were substantially improved from the collaborative adaptation process for South and Central America and South Africa. This international collaboration between occupational health and infection control researchers led to the improvement of the research framework and development of tools, guidelines and information systems. Furthermore, the research and knowledge-transfer experience highlighted the value of partnership amongst Northern and Southern researchers in terms of sharing resources, experiences and knowledge.
BMC International Health and Human Rights 01/2011; 11 Suppl 2:S8. · 1.44 Impact Factor
[show abstract][hide abstract] ABSTRACT: To investigate the effectiveness of a risk assessment system in reducing the risk of violence in an acute care hospital in the Canadian province of British Columbia.
Hospital violence incident rates (number of incidents/100,000 work hours) were calculated and compared pre, during and post implementation of the Alert System, a violence risk assessment system, at one acute care hospital. Poisson regression models were used to examine the effect of the Alert System on hospital-level violent incident rates. Multivariable, conditional logistic regression was used to examine the effect of the Alert System on the individual-level risk of violent incidence using a case-control study.
The violent incident rate decreased during the Alert System implementation period only, but subsequently returned to pre-implementation levels. In the case-control analyses, the Alert flag was associated with an increased risk for a patient violent incident (odds ratio=7.74, 95% CI=4.81-12.47).
Although useful at identifying violent patients, the Alert System even though offered in conjunction with violence prevention training, does not appear to provide the resources or procedures needed by healthcare workers to prevent a patient from progressing to a violent incident once flagged. Violence in healthcare should be studied and prevented using a multifaceted approach.
International journal of nursing studies 12/2010; 48(5):534-9. · 1.91 Impact Factor
[show abstract][hide abstract] ABSTRACT: INTRODUCTION Workplace disability prevention is important, but stakeholders can differ in their appreciation of such interventions. We present a responsive evaluation of a workplace disability prevention intervention in a Canadian healthcare organization. Three groups of stakeholders were included: designers of the intervention, deliverers, and workers. The aim was to examine the appreciation of this intervention by analyzing the discrepancies with respect to what these various stakeholders see as the causes of work disability, what the intervention should aim at to address this problem, and to what extent the intervention works in practice. METHODS A qualitative research method was used, including data-triangulation: (a) documentary materials; (b) semi-structured interviews with the deliverers and workers (n = 14); (c) participatory observations of group meetings (n = 6); (d) member-checking meetings (n = 3); (e) focus-group meetings (n = 2). A grounded theory approach, including some ethnographic methodology, was used for the data-analysis. RESULTS Stakeholders' perceptions of causes for work disability differ, as do preferred strategies for prevention. Designers proposed work-directed measures to change the workplace and work organizations, and individual-directed measures to change workers' behaviour. Deliverers targeted individual-directed measures, however, workers were mostly seeking work-directed measures. To assess how the intervention was working, designers sought a wide range of outcome measures. Deliverers focused on measurable outcomes targeted at reducing work time-loss. Workers perceived that this intervention offered short-term benefits yet fell short in ensuring sustainable return-to-work. CONCLUSION This study provides understanding of where discrepancies between stakeholders' perceptions about interventions come from. Our findings have implications for workplace disability prevention intervention development, implementation and evaluation criteria.
Journal of Occupational Rehabilitation 10/2010; 21(2):179-89. · 2.80 Impact Factor
[show abstract][hide abstract] ABSTRACT: Intersectoral action on health determinants has long been recognized as an important factor in achieving better population health. Nevertheless, there is no process that provides empirical evidence to policy-makers on the extent of intersectoral collaboration. We aimed to fill this gap by conducting case studies in two municipalities in Cuba, a country well known for its intersectoral practice and good health outcomes. We surveyed an intentional sample of key members of Health Councils - virtual intersectoral spaces in Cuba - about links and related actions they had with other sectors on eleven health determinants. Using network analysis we were able to produce measures to evaluate and characterize the network of sectors. Findings show that the two municipalities were similar in reported importance of health determinants, extent of long-term engagement in intra-sectors actions and level of collaboration with other sectors for virtually all determinants. Municipalities also showed similar overall levels of collaboration for most determinants when considered as a network of different sectors (network density). However municipalities showed differences in the central role played by some sectors (centrality index). We further used the network analysis blockmodeling technique to typify the municipal Health Councils. We found that while one Health Council can be typified by a single well connected network structure, the other has two distinct structures with more sparse connections. We conclude that intersectoral collaboration can be assessed by the use of network analysis measurements. This approach is novel and provides evidence to decision-makers about their role and their effort towards collaboration in achieving better health outcomes.
Social Science [?] Medicine 07/2010; 71(2):394-9. · 2.73 Impact Factor
[show abstract][hide abstract] ABSTRACT: This PLoS Medicine Debate examines the different approaches that can be taken to tackle neglected tropical diseases (NTDs). Some commentators, like Jerry Spiegel and colleagues from the University of British Columbia, feel there has been too much focus on the biomedical mechanisms and drug development for NTDs, at the expense of attention to the social determinants of disease. Burton Singer argues that this represents another example of the inappropriate "overmedicalization" of contemporary tropical disease control. Peter Hotez and colleagues, in contrast, argue that the best return on investment will continue to be mass drug administration for NTDs.
PLoS Medicine 05/2010; 7(5):e1000255. · 15.25 Impact Factor
[show abstract][hide abstract] ABSTRACT: The Healthy Hospital Project, an international collaboration, aimed to strengthen Ecuador's capacity to promote healthier and safer hospitals by reducing occupational transmission of infectious diseases. Team members conducted a needs assessment to identify workplace hazards and health risks in three hospitals. A survey of health care workers' knowledge and practices of occupational health (OH) and infection control (IC) revealed positive practices such as a medical waste disposal program and widespread dissemination of health information. Challenges identified included a high frequency of recapping needles and limited resources for workers to apply consistent IC measures. The survey revealed underreporting of needlestick injuries and limited OH and safety (OHS) training. Therefore, project collaborators organized a training workshop for health care workers that aimed to overcome the identified obstacles by integrating interdisciplinary local, national, and international stakeholders to build capacity and institutionalize work-related infection prevention and control measures. The knowledge transferred and experience gained led to useful hospital-based projects and serves as a basis for implementation of other OHS projects nationwide. International interdisciplinary, interinstitutional collaboration in OHS and IC can build capacity to address OHS concerns in health care.
Revista Panamericana de Salud Pública 05/2010; 27(5):396-402. · 0.85 Impact Factor
[show abstract][hide abstract] ABSTRACT: As universities increasingly rely on external sources of research funding, researchers worldwide are realizing that if their work is financially supported by organizations with distinct political or financial interests, they risk their careers if their results deviate from the interests of their funding partners. This article presents a case that illustrates how ugly this situation can become. Reviewing the literature on the advantages and dangers of partnered research, the historical role of universities, funding trends, and university mission statements, the authors contend that universities must engage in service learning and participatory action research, but must ensure that faculty members engaging in academic activity with partners-whether industry, hospitals, governments, nongovernmental organizations, or communities-have their professional integrity protected. If doubt exists about whether the partner can or will honor these principles or the mission of universities for social good, universities should avoid granting joint or affiliate appointments or accepting funds or favors of any kind. Universities also need formal structures to ensure ethical application of innovation and principled partnership engagement. In becoming servants of government or corporatism, universities have become less vital to society and are failing in their mission to promote social justice and sustainability. Strong measures are needed to restore public trust.
International Journal of Health Services 01/2010; 40(3):485-505. · 1.24 Impact Factor
[show abstract][hide abstract] ABSTRACT: The intimate interdependence of human health and the ecosystems in which we are embedded is now a commonplace observation. For much of the history of public health, this was not so obvious. After over a century of focus on diseases, their biologic causes and the correction of exposures (clean water and air) and facilitation of responses (immunizations and nutrition), public health discourse shifted to embrace the concept of determinants of health as extending to social, economic and environmental realms. This moved the discourse and science of public health into an unprecedented level of complexity just as public concern about the environment heightened. To address multifactorial, dynamic impacts on health, a new paradigm was needed which would overcome the separation of humans and ecosystems. Ecosystem approaches to health arose in the 1990s from a rich background of intellectual ferment as Canada wrestled with diverse problems ranging from Great Lakes contamination to zoonotic diseases. Canada's International Development Research Centre (IDRC) played a lead role in supporting an international community of scientists and scholars who advanced ecosystem approaches to health. These collective efforts have enabled a shift to a research paradigm that embraces transdisciplinarity, social justice, gender equity, multi-stakeholder participation and sustainability.
Canadian journal of public health. Revue canadienne de santé publique 01/2010; 101(6):439-41. · 1.02 Impact Factor
[show abstract][hide abstract] ABSTRACT: The high rate of violence in the healthcare sector supports the need for greater surveillance efforts.
The purpose of this study was to use a province-wide workplace incident reporting system to calculate rates and identify risk factors for violence in the British Columbia healthcare industry by occupational groups, including nursing.
Data were extracted for a 1-year period (2004-2005) from the Workplace Health Indicator Tracking and Evaluation database for all employee reports of violence incidents for four of the six British Columbia health authorities. Risk factors for violence were identified through comparisons of incident rates (number of incidents/100,000 worked hours) by work characteristics, including nursing occupations and work units, and by regression models adjusted for demographic factors.
Across health authorities, three groups at particularly high risk for violence were identified: very small healthcare facilities [rate ratios (RR) = 6.58, 95% CI =3.49, 12.41], the care aide occupation (RR = 10.05, 95% CI = 6.72, 15.05), and paediatric departments in acute care hospitals (RR = 2.22, 95% CI = 1.05, 4.67).
The three high-risk groups warrant targeted prevention or intervention efforts be implemented. The identification of high-risk groups supports the importance of a province-wide surveillance system for public health planning.
Journal of Advanced Nursing 07/2009; 65(8):1655-63. · 1.53 Impact Factor