Collaborative research partnerships with disadvantaged communities: challenges and potential solutions

Community/campus research collaborations face multiple challenges. An understanding of the community's background, history, habits and traditions, values and mode of operations is required. This article narrates a 3-year experience of undertaking collaborative public health research with five disadvantaged communities in various provinces of South Africa. Based on the experience, five main challenges exist: the value systems of those collaborating in the research; the stakeholders' costs and benefits of being involved; issues of empowerment and capacity transfer; the need for multidisciplinary research approaches; and the prerequisite of the clarity of relationships and roles between researcher and community. Categorized under the five main challenges are examples of 19 interlacing 'concepts' that detailed the South African research partnership from the perspective of the processes, dealings and daily difficulties. Examples of the challenges and concepts are highlighted from the author's research experiences with disadvantaged communities. These challenges increase exponentially with the inclusion of more research sites, more stakeholders or when undertaking cluster research. Possible preventative measures or solutions to the problems are suggested. Both the 'town' and 'gown' partners are required to attend to a multitude of factors when embarking on collaborative community-based research.     

Incorporating geographic settings into a social network analysis of injection drug use and bloodborne pathogen prevalence

Using social network analysis, we investigated how communal meeting places can link injection drug user (IDU) populations and create opportunities for the transmission of bloodborne pathogens. In our locale, specific hotels played a key role in the injection drug scene. Within this hotel network some IDU injected at only one hotel while others injected at multiple hotels; this latter group potentially acted as spatial bridges linking relatively distinct hotel networks. Pathogen prevalence showed a gradation with the highest prevalence occurring at the centre of the network. Consistent with pathogen prevalence, people most central to the network were more likely to engage in risky injection practices. Incorporating geographic place into analyses involving IDU can contribute to an understanding of pathogen transmission patterns in an area and assist public health efforts to develop targeted intervention programs.     

Modeling the cost effectiveness of injury interventions in lower and middle income countries: opportunities and challenges

Background

Hyponatremia is a disorder of fluid and electrolyte balance characterized by a relative excess of body water relative to body sodium content. It is the most common electrolyte disorder encountered in clinical medicine and is associated with negative outcomes in many chronic diseases. However, there is limited information in the literature about health care resource use and costs attributable to the effects of the condition. The purpose of this analysis was to estimate the annual cost of illness of hyponatremia in the United States.

Methods

The study utilized a prevalence-based cost of illness framework that incorporated data from publicly available databases, published literature and a consensus panel of expert physicians. Panel members provided information on: classification of hyponatremia patients, treatment settings for hyponatremia (i.e., hospital, emergency room, doctor's office), and health care resource use associated with the diagnosis and treatment of hyponatremia. Low and high prevalence scenarios were estimated and utilized in a spreadsheet-based cost of illness model. Costs were assigned to units of resources and summarized across treatment settings.

Results

The prevalence estimate for hyponatremia ranged from 3.2 million to 6.1 million persons in the U.S. on an annual basis. Approximately 1% of patients were classified as having acute and symptomatic hyponatremia, 4% acute and asymptomatic, 15%–20% chronic and symptomatic, and 75–80% chronic and asymptomatic. Of patients treated for hyponatremia, 55%–63% are initially treated as inpatients, 25% are initially treated in the emergency room, and 13%–20% are treated solely in the office setting. The direct costs of treating hyponatremia in the U.S. on an annual basis were estimated to range between $1.6 billion and $3.6 billion.

Conclusion

Treatment of hyponatremia represents a significant healthcare burden in the U.S. Newer therapies that may reduce the burden of hyponatremia in the inpatient setting could minimize the costs associated with this condition.     

Protecting against researcher bias in secondary data analysis: challenges and potential solutions

European Journal of Epidemiology - Analysis of secondary data sources (such as cohort studies, survey data, and administrative records) has the potential to provide answers to science and...     

走出困境开创电磁场卫生学研究新局面

自20世纪70年代流行病学调查发现工频磁场与儿童期白血病发生的相关性以来,电磁场的卫生学研究已开展了30多年.目前,该领域的研究还是阴性与阳性结果并存,无法正确判断日常环境强度的电磁场暴露是否会导致不良健康效应.     

Consumer exposure scenarios: development, challenges and possible solutions

Exposure scenarios (ES) under REACH (Registration, Evaluation, and Authorisation of Chemicals; new EU legislation) aim to describe safe conditions of product and substance use. Both operational conditions and risk management measures (RMMs) are part of the ES. For consumer use of chemicals, one of the challenges will be to identify all of the consumer uses of a given chemical and then quantify the exposure derived from each of them. Product use categories can be established to identify in a systematic fashion how products are used. These product categories comprise products that are used similarly (e.g. paints, adhesives). They deliver information about product use characteristics, and provide an easy-to-handle tool for exchanging standardised information. For practical reasons, broad ES will have to be developed, which cover a wide range of products and use. The challenge will be to define them broadly, but not in a way that they provide such an overestimation of exposure that a next iteration or a more complex model is always needed. Tiered and targeted approaches for estimation of exposure at the right level of detail may offer the best solution. RMMs relevant for consumers include those inherent to product design (controllable) and those that are communicated to consumers as directions for use (non-controllable). Quantification of the effect of non-controllable RMMs on consumer exposure can prove to be difficult. REACH requires aggregation of exposure from all relevant identified sources. Development of appropriate methodology for realistic aggregation of exposure will be no small challenge and will likely require probabilistic approaches and comprehensive databases on populations' habits, practices and behaviours. REACH regulation aims at controlling the use of chemicals so that exposure to every chemical can be demonstrated to be safe for consumers, workers, and the environment when considered separately, but also when considered in an integrated way. This integration will be another substantial challenge for the future.     

Environmental exposure scenarios: development, challenges and possible solutions

Under the new REACH system, companies importing, producing and marketing chemical substances will be obliged to register the single substances and to carry out a safety assessment for all identified uses during the life cycle of the substance. This duty will apply to about 10,000 existing substances in the EU market exceeding an annual production or import volume of 10 t per company. If the substance is already known to be dangerous or turns out to be dangerous(1) during the hazard assessment, the registrant is obliged to carry out an exposure assessment and a risk characterisation for all identified uses. The goal of the safety assessment is to define the conditions of use that allow for adequate control of risk with regard to health and safety at the work place, consumer safety and protection of the environment. Once the registrant has established and documented these conditions in the Chemicals Safety Report (CSR), that information is to be communicated down the supply chain by means of the Extended Safety Data Sheet (eSDS). The ultimate aim of the new legislation is to establish duties and mechanisms that systematically prevent or limit exposure to dangerous industrial chemicals. The current paper explains this concept with regard to environmental exposure and highlights the challenges and possible solutions.     

Bridging health technology assessment (HTA) with multicriteria decision analyses (MCDA): field testing of the EVIDEM framework for coverage decisions by a public payer in Canada

Background

In Japan, as the number of elderly covered by the Long-term Care Insurance (LTCI) system has increased, demand for long-term care services has increased substantially and consequently growing expenditures are threatening the sustainability of the system. Understanding the predictive factors associated with long-term care expenditures among the elderly would be useful in developing future strategies to ensure the sustainability of the system. We report a set of predictors of the highest long-term care expenditures in a cohort of elderly persons who received consecutive long-term care services during a year in a Japanese city.

Methods

Data were obtained from databases of the LTC insurer of City A in Japan. Binary logistic regression was used to examine the predictors of the highest long-term care expenditures. We used a simplified model that focused on the effects of disability status and type of services used, while controlling for several relevant factors. Goodness of fit, a multicollinearity test, and logistic regression diagnostics were carried out for the final model.

Results

The study cohort consisted of 862 current users of LTCI system in city A. After controlling for gender and income, age, increased utilization rate of benefits, decline in functional status, higher care needs level and institutional care were found to be associated with the highest LTCI expenditures. An increased utilization rate of benefits (OR = 24.2) was a strong main effect predictors of the high LTC expenditures. However, a significant interaction between institutional care and high care need level was found, providing evidence of the combined effect of the two covariates.

Conclusions

Beyond to confirm that disability status of elderly persons is the main factor driving the demand of LTC services and consequently the expenditures, we showed that changes in utilization rate of benefits -a specific insurance factor- and the use of institutional care conditional on the high care level, were strongest predictors of the highest LTC expenditures. These findings could become crucial for tracking policies aimed at ensuring financial sustainability of LTCI from a public insurer perspective in Japan.     

Three challenges described for identifying participants with missing data in trials reports,and potential solutions suggested to systematic reviewers

ObjectiveTo categorize the challenges in determining the extent of missing participant data in randomized trials and suggest potential solutions for systematic review authors.Study Design and SettingDuring the process of updating a series of Cochrane systematic reviews on the topic of anticoagulation in patients with cancer, we identified challenges and used an iterative approach to improve, and a consensus process to agree on the challenges identified, and to suggest potential ways of dealing with them. The five systematic reviews included 58 trials and 75 meta-analyses for patient-important dichotomous outcomes with 27,037 randomized participants.ResultsWe identified three categories of challenges: (1) Although systematic reviewers require information about missing data to be reported by outcome, trialists typically report the information by participant; (2) It is not always clear whether the trialists followed up participants in certain categories (e.g., noncompliers), that is, whether some categories of participants did or did not have missing data; (3) It is not always clear how the trialists dealt with missing data in their analysis (e.g., exclusion from the denominator vs. assumptions made for the numerator). We discuss potential solutions for each one of these challenges and suggest further research work.ConclusionCurrent reporting of missing data is often not explicit and transparent, and although our potential solutions to problems of suboptimal reporting may be helpful, reliable and valid characterization of the extent and nature of missing data remains elusive. Reporting of missing data in trials needs further improvement.     

Nutrition and physical activity interventions to reduce cardiovascular disease risk in health care settings: a quantitative review with a focus on women

The authors conducted a quantitative literature review of the impact of 32 diet and physical activity (PA) interventions delivered in health care settings on cardiovascular disease risk factors. Intervention effects were relatively modest but statistically significant for PA, body mass index or weight, dietary fat, blood pressure, and total and low-density lipoprotein serum cholesterol. Intervention effects were generally larger for samples with a mean age >50 years and for studies with <6 months follow-up. Type of comparison group, type of intervention, and use of a behavior theory did not have a consistent impact on intervention effects. Few studies focused on persons of color, although the results from these studies are promising.     

Guidelines for preventing the transmission of tuberculosis in health-care settings, with special focus on HIV-related issues

The transmission of tuberculosis is a recognized risk in health-care settings. Several recent outbreaks of tuberculosis in health-care settings, including outbreaks involving multidrug-resistant strains of Mycobacterium tuberculosis, have heightened concern about nosocomial transmission. In addition, increases in tuberculosis cases in many areas are related to the high risk of tuberculosis among persons infected with the human immunodeficiency virus (HIV). Transmission of tuberculosis to persons with HIV infection is of particular concern because they are at high risk of developing active tuberculosis if infected. Health-care workers should be particularly alert to the need for preventing tuberculosis transmission in settings in which persons with HIV infection receive care, especially settings in which cough-inducing procedures (e.g., sputum induction and aerosolized pentamidine [AP] treatments) are being performed. Transmission is most likely to occur from patients with unrecognized pulmonary or laryngeal tuberculosis who are not on effective antituberculosis therapy and have not been placed in tuberculosis (acid-fast bacilli [AFB]) isolation. Health-care facilities in which persons at high risk for tuberculosis work or receive care should periodically review their tuberculosis policies and procedures, and determine the actions necessary to minimize the risk of tuberculosis transmission in their particular settings. The prevention of tuberculosis transmission in health-care settings requires that all of the following basic approaches be used: a) prevention of the generation of infectious airborne particles (droplet nuclei) by early identification and treatment of persons with tuberculous infection and active tuberculosis, b) prevention of the spread of infectious droplet nuclei into the general air circulation by applying source-control methods, c) reduction of the number of infectious droplet nuclei in air contaminated with them, and d) surveillance of health-care-facility personnel for tuberculosis and tuberculous infection. Experience has shown that when inadequate attention is given to any of these approaches, the probability of tuberculosis transmission is increased. Specific actions to reduce the risk of tuberculosis transmission should include a) screening patients for active tuberculosis and tuberculous infection, b) providing rapid diagnostic services, c) prescribing appropriate curative and preventive therapy, d) maintaining physical measures to reduce microbial contamination of the air, e) providing isolation rooms for persons with, or suspected of having, infectious tuberculosis, f) screening health-care-facility personnel for tuberculous infection and tuberculosis, and g) promptly investigating and controlling outbreaks. Although completely eliminating the risk of tuberculosis transmission in all health-care settings may be impossible, adhering to these guidelines should minimize the risk to persons in these settings.     

Methodological issues in the collection, analysis, and reporting of granular data in Asian American populations: historical challenges and potential solutions

There are close to 15 million Asian Americans living in the United States, and they represent the fastest growing populations in the country. By the year 2050, there will be an estimated 33.4 million Asian Americans living in the country. However, their health needs remain poorly understood and there is a critical lack of data disaggregated by Asian American ethnic subgroups, primary language, and geography. This paper examines methodological issues, challenges, and potential solutions to addressing the collection, analysis, and reporting of disaggregated (or, granular) data on Asian Americans. The article explores emerging efforts to increase granular data through the use of innovative study design and analysis techniques. Concerted efforts to implement these techniques will be critical to the future development of sound research, health programs, and policy efforts targeting this and other minority populations.     

Transition of patients with COPD across different care settings: challenges and opportunities for hospitalists

Hospitalists play an important role in treating current and preventing future acute exacerbations of chronic obstructive pulmonary disease (AECOPD), which are associated with high rates of medical resource use and morbidity. Comprehensive admission screening and diagnostic tests are important in enabling hospitalists to reliably identify patients with AECOPD, the severity of the episode, and related issues that may prolong patients' hospital length of stay. Recurring exacerbations, especially those that require repeated acute care, can reduce physical activity and accelerate pulmonary decline and risk of death. Recommended pharmacotherapies for AECOPD should include short-acting bronchodilators, systemic corticosteroids, and appropriate antibiotics in cases of suspected bacterial infection. Patients with demonstrable hypoxemia or respiratory failure may benefit from oxygen and/or ventilatory support. Long-term disease management with the goal of preventing future exacerbations should include ongoing emphasis toward smoking cessation and up-to-date vaccination, in addition to prescribing maintenance pharmacotherapies in accordance with respiratory treatment guidelines. Additional benefits may be derived from nonpharmacologic therapies, such as pulmonary rehabilitation, weight-loss recommendations, and treatment of obstructive sleep dyspnea when present. Effective communication among members of the inpatient and outpatient health care teams, the patient, and his or her caregivers is an important aspect of care transitions. Hospital discharge summaries should be transmitted to the patient's primary care physician and be readily available at the first follow-up visit. Discharge coaches and other allied health care providers can aid hospitalists in reinforcing self-management skills and patient education, and in emphasizing the importance of follow-up visits. Recent findings suggest that health and cost benefits are associated with improved COPD management. This article focuses on the pivotal role of the hospitalist in promoting and facilitating the steps toward improving quality outcomes and transitions of care for patients with COPD.     

Filling America's fiber intake gap: summary of a roundtable to probe realistic solutions with a focus on grain-based foods

Current fiber intakes are alarmingly low, with long-term implications for public health related to risk of coronary heart disease, stroke, hypertension, certain gastrointestinal disorders, obesity, and the continuum of metabolic dysfunctions including prediabetes and type 2 diabetes. Eating patterns high in certain fibers are known to lower LDL cholesterol and blood pressure, lower blood glucose, and decrease insulin resistance in people with prediabetes and type 2 diabetes; help with both weight loss and maintenance; and improve bowel regularity and gastrointestinal health. With >90% of adults and children who fall short of meeting their daily fiber recommendations, the 2010 Dietary Guidelines for Americans once again classified fiber as a nutrient of concern. Despite efforts over the past decade to promote adequate fiber through fruit, vegetable, and whole-grain intakes, fiber consumption has remained flat at approximately half the daily recommended amount. The public health implications of inadequate fiber intake prompted the roundtable session "Filling America's Fiber Gap: Probing Realistic Solutions," which assembled nutrition researchers, educators, and communicators to identify challenges, opportunities, and realistic solutions to help fill the current fiber gap. The roundtable discussions highlighted the need for both consumer and professional education to improve acceptance for and inclusion of grain-based foods with added fiber as one strategy for increasing fiber intakes within daily energy goals.