Provider perspectives on liberty and harm in the treatment of persons with tuberculosis and mental illness.

To examine how frontline health care workers (HCWs) and decision-makers working in tuberculosis (TB) care and mental health care conceptualise liberty, harm and the harm principle-which are often invoked in health care legislation to justify liberty restrictions-in the treatment and care of persons with TB and severe and persistent mental illness (SPMI). Qualitative study of 20 semi-structured interviews with HCWs and decision-makers working in public or mental health from three public health units and two psychiatric hospitals in the Greater Toronto Area in Ontario, Canada. Interviews were evaluated using thematic analysis. Three themes were identified: 1) the contextual nature of liberty restrictions; 2) the concept of liberty as a matter of degree; and 3) the challenges of balancing the treatment and care goals of TB and mental health for persons with both TB and SPMI. Harm is understood by HCWs caring for persons with TB and/or SPMI in a context-dependent manner. This is compounded in the case of persons with both TB and SPMI. Liberty restrictions to advance public health goals entail reciprocal obligations from society, including social protections and additional resources, to ease the effects and range of liberty restrictions. Attention is required to ensure that treatment and care for SPMI does not impede that of TB and vice versa. .

Canadian survey on pandemic flu preparations.

BACKGROUND: The management of pandemic influenza creates public health challenges.An ethical framework, 'Stand on Guard for Thee: ethical considerations in pandemic influenza preparedness' that served as a template for the World Health Organization's global consultation on pandemic planning, was transformed into a survey administered to a random sample of 500 Canadians to obtain opinions on key ethical issues in pandemic preparedness planning. METHODS: All framework authors and additional investigators created items that were pilot-tested with volunteers of both sexes and all socioeconomic strata. Surveys were telephone administered with random sampling achieved via random digit dialing (RDD). Eligible participants were adults, 18 years or older, with per province stratification equaling provincial percent of national population. Descriptive results were tabulated and logistic regression analyses were used to assess whether demographic factors were significantly associated with outcomes. RESULTS: 5464 calls identified 559 eligible participants of whom 88.5% completed surveys. Over 90% of subjects agreed the most important goal of pandemic influenza preparations was saving lives, with 41% endorsing saving lives solely in Canada and 50% endorsing saving lives globally as the highest priority. Older age (OR = 8.51, p < 0.05) and current employment (OR = 9.48, p < 0.05) were associated with an endorsement of saving lives globally as highest priority. About 90% of respondents supported the obligation of health care workers to report to work and face influenza pandemic risks excepting those with a serious health condition that increased risks. Over 84% supported the government's provision of disability insurance and death benefits for health care workers facing elevated risk. Strong majorities favored stocking adequate protective antiviral dosages for all Canadians (92%) and, if effective, influenza vaccinations (95%). Over 70% agreed Canada should provide international assistance to poorer countries for pandemic preparation, even if resources for Canadians were reduced. While 92% of this group, believed provision should be 7 to 10% of all resources generated, 43% believed the provision should be greater than 10%. CONCLUSIONS: Results suggest trust in public health officials to make difficult decisions, providing emphasis on reciprocity and respect for individual rights.

An exploratory spatial analysis of pneumonia and influenza hospitalizations in Ontario by age and gender.

Pneumonia and influenza represent a significant public health burden in Canada and abroad. Knowledge of how this burden varies geographically provides clues to understanding the determinants of these illnesses, and insight into the effective management of health-care resources. We conducted a retrospective, population-based, ecological-level study to assess age- and gender-specific spatial patterns of pneumonia and influenza hospitalizations in the province of Ontario, Canada from 1992 to 2001. Results revealed marked variability in hospitalization rates by age, as well as clear and statistically significant patterns of high rates in northern rural counties and low rates in southern urban counties. A moderate yet significant level of positive spatial autocorrelation (Moran's I=0.21, P<0.05) was found in the global data, with significant, age-specific clusters of high values or 'hot spots' identified in several northern counties. Findings illustrate the need for geographically focused prevention strategies, and resource and service allocation policies informed by regional and population-specific demands.

Interactions of viral pathogens on hospital admissions for pneumonia, croup and chronic obstructive pulmonary diseases: results of a multivariate time-series analysis.

Co-circulation of respiratory syncytial virus (RSV) and influenza has made the partitioning of morbidity and mortality from each virus difficult. Given the interaction between chronic obstructive lung disease (COPD) and pneumonia, often one can be mistaken for the other. Multivariate time-series methodology was applied to examine the impact of RSV and influenza on hospital admissions for bronchiolitis, pneumonia, and COPD. The Granger Causality Test, used to determine the causal relationship among series, showed that COPD and pneumonia are not influenced by RSV (P=0.2999 and 0.7725), but RSV does influence bronchiolitis (P=0.0001). Influenza was found to influence COPD, pneumonia, and bronchiolitis (P<0.0001). The use of multivariate time series and Granger causality applied to epidemiological data clearly illustrates the significant contribution of influenza and RSV to morbidity in the population.

Project examining effectiveness in clinical ethics (PEECE): phase 1-- descriptive analysis of nine clinical ethics services.

OBJECTIVE: The field of clinical ethics is relatively new and expanding. Best practices in clinical ethics against which one can benchmark performance have not been clearly articulated. The first step in developing benchmarks of clinical ethics services is to identify and understand current practices. DESIGN AND SETTING: Using a retrospective case study approach, the structure, activities, and resources of nine clinical ethics services in a large metropolitan centre are described, compared, and contrasted. RESULTS: The data yielded a unique and detailed account of the nature and scope of clinical ethics services across a spectrum of facilities. General themes emerged in four areas-variability, visibility, accountability, and complexity. There was a high degree of variability in the structures, activities, and resources across the clinical ethics services. Increasing visibility was identified as a significant challenge within organisations and externally. Although each service had a formal system for maintaining accountability and measuring performance, differences in the type, frequency, and content of reporting impacted service delivery. One of the most salient findings was the complexity inherent in the provision of clinical ethics services, which requires of clinical ethicists a broad and varied skill set and knowledge base. Benchmarks including the average number of consults/ethicist per year and the hospital beds/ethicist ratio are presented. CONCLUSION: The findings will be of interest to clinical ethicists locally, nationally, and internationally as they provide a preliminary framework from which further benchmarking measures and best practices in clinical ethics can be identified, developed, and evaluated.

Craniomaxillofacial injury in sport: a review of prevention research.

Current decision making in prevention of sport related craniomaxillofacial injury is based on available data derived from surveillance and attitude based studies. The literature on this type of injury prevention lacks the high quality scientific design and evidence on which mandatory interventions can be based. Currently available prevention methodology can provide a better understanding of injury mechanisms and produce valid interventions.

Evidence-based health policy: context and utilisation.

Evidence-based decision-making is centred on the justification of decisions. In the shift from an individual-clinical to a population-policy level, the decision-making context becomes more uncertain, variable and complex. To address this we have developed a conceptual framework for evidence-based decision-making, focusing on how context impacts on what constitutes evidence and how that evidence is utilised. We present two distinct orientations towards what constitutes evidence, representing different relationships between evidence and context. We also categorise the decision-making context based on the ways in which context impacts on evidence-based decision-making. Furthermore, we invoke the concept of axes of evidence-based decision-making to describe the relationship between evidence and context as we move from evidence-based medicine to evidence-based health policy. From this, we suggest that it may be more important how evidence is utilised than how it is defined. Based on the research and knowledge utilisation literature, we present a process model of evidence utilisation, which forms the basis for the conceptual framework for context-based evidence-based decision-making. The conceptual framework attempts to capture the role that context plays in the introduction, interpretation and application of evidence. We illustrate this framework with examples from policy development for colorectal cancer screening.

Argumentation and evidence.

This essay explores the role of informal logic and its application in the context of current debates regarding evidence-based medicine. This aim is achieved through a discussion of the goals and objectives of evidence-based medicine and a review of the criticisms raised against evidence-based medicine. The contributions to informal logic by Stephen Toulmin and Douglas Walton are explicated and their relevance for evidence-based medicine is discussed in relation to a common clinical scenario: hypertension management. This essay concludes with a discussion on the relationship between clinical reasoning, rationality, and evidence. It is argued that informal logic has the virtue of bringing explicitness to the role of evidence in clinical reasoning, and brings sensitivity to understanding the role of dialogical context in the need for evidence in clinical decision making.

Ethical issues in international environmental health research.

Environmental health problems are among the world's most significant health concerns. Although environmental risks are experienced disproportionately by people in developing countries, environmental health research (EHR) is conducted primarily in developed countries. Human subjects participate in five main types of EHR: (1) documentation and quantification of exposure to potentially hazardous substances; (2) elucidation of biological responses to these materials; (3) characterization and measurement of susceptibility to harmful effects of hazardous materials; (4) trials involving environmental interventions to reduce risk; and (5) documentation and measurement of various manifestations of disease putatively linked to environmental exposures. Although existing frameworks for the ethics of international clinical research are generally relevant to EHR, they currently lack the specificity necessary to confront three inherent problems in EHR, namely under-determination in EHR findings, the unavoidable nature of some environmental hazards, and environmental justice implications. We examine these issues as they relate to community partnership, risk assessment, and the assessment and management of economic and political interests in EHR. We believe that there are 3 general features of ethical EHR, it has health promoting value, the populations studied are not restricted in their ability to avoid environmental hazards by economic or political repression, and the justification for conducting EHR on populations with known exposure to environmental hazards gets stronger as the limits on populations to reduce the hazards or remove themselves from them becomes greater, as long as the first and second conditions are also met.

Attitudes toward tuberculosis of final year medical students from Canada, India, and Uganda.

BACKGROUND: Tuberculosis, although both preventable and treatable, continues to be the world's leading cause of death from an infectious agent. PURPOSE: To extend the results of our previous study of knowledge and practices of final year medical students regarding tuberculosis at three medical schools from endemic and nonendemic areas and to describe their attitudes. METHODS: Eight statements assessing attitudes, as part of a larger survey, were administered to final year medical students at McMaster University in Canada, Christian Medical College in India, and Makerere University in Uganda. RESULTS: One hundred sixty surveys were returned with 155 completed attitude responses. The response rate was 68.4% (65 of 95) for McMaster University, 39.7% (23 of 58) for the Christian Medical College, and 78.3% (72 of 92) for Makerere University. Analysis showed that six of eight attitude items were slightly statistically different among the schools with minimal effect of curriculum time and patient exposure. CONCLUSIONS: Despite quite varied exposure to tuberculosis, students from endemic and nonendemic areas responded similarly on statements addressing attitudes toward tuberculosis.

Principles for the justification of public health intervention.

OBJECTIVES: The objective of this paper is to discuss principles relevant to ethical deliberation in public health. METHODS: Conceptual analysis and literature review. RESULTS: Four principles are identified: The Harm Principle, The Principle of Least Restrictive Means, The Reciprocity Principle, and The Transparency Principle. Two examples of how the principles are applied in practice are provided. INTERPRETATION: The paper illustrates how clinical ethics is not an appropriate model for public health ethics and argues that the type of reasoning involved in public health ethics may be at potential variance from that of empirical science. Further research and debate on the appropriate ethics for public health are required.

The virtues of evidence.

Evidence-based medicine has been defined as the conscientious and judicious use of current best evidence in making clinical decisions. This paper will attempt to explicate the terms "conscientious" and "judicious" within the evidence-based medicine definition. It will be argued that "conscientious" and "judicious" represent virtue terms derived from virtue ethics and virtue epistemology. The identification of explicit virtue components in the definition and therefore conception of evidence-based medicine presents an important starting point in the connection between virtue theories and medicine itself. In addition, a unification of virtue theories and evidence-based medicine will illustrate the need for future research in order to combine the fields of virtue-based approaches and clinical practice.

A population based time series analysis of asthma hospitalisations in Ontario, Canada: 1988 to 2000.

BACKGROUND: Asthma is a common yet incompletely understood health problem associated with a high morbidity burden. A wide variety of seasonally variable environmental stimuli such as viruses and air pollution are believed to influence asthma morbidity. This study set out to examine the seasonal patterns of asthma hospitalisations in relation to age and gender for the province of Ontario over a period of 12 years. METHODS: A retrospective, population-based study design was used to assess temporal patterns in hospitalisations for asthma from April 1, 1988 to March 31, 2000. Approximately 14 million residents of Ontario eligible for universal healthcare coverage during this time were included for analysis. Time series analyses were conducted on monthly aggregations of hospitalisations. RESULTS: There is strong evidence of an autumn peak and summer trough seasonal pattern occurring every year over the 12-year period (Fisher-Kappa (FK) = 23.93, p > 0.01; Bartlett Kolmogorov Smirnov (BKS) = 0.459, p < 0.01). This pattern was observed in both sexes. However, young males (0-4 years) were hospitalised at two to three times the rate of females of the same age. Rates were much lower in the older age groups. A downward trend in asthma hospitalisations was observed in the total population over the twelve-year period (beta = -0.980, p < 0.01). CONCLUSIONS: A clear and consistent seasonal pattern was observed in this study for asthma hospitalisations. These findings have important implications for the development of effective management and prevention strategies.

Meaning and measurement: an inclusive model of evidence in health care.

Evidence-based approaches are assuming prominence in many health-care fields. The core ideas of evidence-based health care derive from clinical epidemiology and general internal medicine. The concept of evidence has yet to be analysed systematically; what counts as evidence may vary across disciplines. Furthermore, the contribution of the social sciences, particularly qualitative methodology, has received scant attention. This paper outlines a model of evidence that describes four distinct but related types of evidence: qualitative-personal; qualitative-general; quantitative-general and quantitative-personal. The rationale for these distinctions and the implications of these for a theory of evidence are discussed.

Acting on an environmental health disaster: the case of the Aral Sea.

The Aral Sea area in Central Asia has been encountering one of the world's greatest environmental disasters for more than 15 years. During that time, despite many assessments and millions of dollars spent by large, multinational organizations, little has changed. The 5 million people living in this neglected and virtually unknown part of the world are suffering not only from an environmental catastrophe that has no easy solutions but also from a litany of health problems. The region is often dismissed as a chronic problem where nothing positive can be achieved. Within this complicated context, Medecins Sans Frontieres, winner of the Nobel Peace Prize in 1999, is actively trying to assess the impact of the environmental disaster on human health to help the people who live in the Aral Sea area cope with their environment. Medecins Sans Frontieres has combined a direct medical program to improve the health of the population while conducting operational research to gain a better understanding of the relationship between the environmental disaster and human health outcomes. In this paper we explore the health situation of the region and the broader policy context in which it is situated, and present some ideas that could potentially be applied to many other places in the world that are caught up in environmental and human health disasters.

Knowledge and practices regarding tuberculosis: a survey of final-year medical students from Canada, India and Uganda.

CONTEXT: Tuberculosis is one of the most common infectious diseases worldwide and is responsible for the largest number of deaths from a single infectious cause. OBJECTIVE: The objective of this study was to compare the knowledge of and practices regarding tuberculosis in final-year medical students at schools from endemic and non-endemic areas. SUBJECTS: Final-year medical students at McMaster University in Canada, the Christian Medical College in India, and Makerere University in Uganda. METHODS: A questionnaire consisting of 20 multiple-choice questions assessing knowledge, practices, and exposure. A total knowledge score (maximum=13) and a total practice score (maximum=5) were created for each study site. RESULTS: 160 questionnaires were returned; the response rate was 68.4% (65/95) for McMaster University, 39.7% (23/58) for the Christian Medical College and 78.3% (72/92) for Makerere University. Students from Makerere University had the highest knowledge scores but differences were non-significant after adjustment for patient exposure and curriculum time (F(2,153)= 1.80, P=0.16). Differences in practice scores, however, remained significant after adjusting for curriculum time and patient exposure (F(2,153)=5.14, P=0.006). Knowledge score (F(1,156)=5.05, P=0.02), patient exposure (F(1,153)=9.11, P=0.003), and curriculum time and patient exposure (F(2,153)=5.14, P=0.006) were statistically significant positive predictors of the total practice score. CONCLUSIONS: This study demonstrated significant differences in undergraduate exposure to tuberculosis, total knowledge, and practice competency at three medical schools in Canada, India, and Uganda. In general, the knowledge base and practice competency of all three graduating classes was adequate.

The health care information directive.

BACKGROUND: Developments in information technology promise to revolutionise the delivery of health care by providing access to data in a timely and efficient way. Information technology also raises several important concerns about the confidentiality and privacy of health data. New and existing legislation in Europe and North America may make access to patient level data difficult with consequent impact on research and health surveillance. Although research is being conducted on technical solutions to protect the privacy of personal health information, there is very little research on ways to improve individuals power over their health information. This paper proposes a health care information directive, analogous to an advance directive, to facilitate choices regarding health information disclosure. RESULTS AND DISCUSSION: A health care information directive is described which creates a decision matrix that combines the ethical appropriateness of the use of personal health information with the sensitivity of the data. It creates a range of possibilities with in which individuals can choose to contribute health information with or without consent, or not to contribute information at all. CONCLUSION: The health care information directive may increase individuals understanding of the uses of health information and increase their willingness to contribute certain kinds of health information. Further refinement and evaluation of the directive is required.

The ethics of alpha: reflections on statistics, evidence and values in medicine.

As health care embraces the tenets of evidence-based medicine it is important to ask questions about how evidence is produced and interpreted. This essay explores normative dimensions of evidence production, particularly around issues of setting the tolerable level of uncertainty of results. Four specific aspects are explored: what health care providers know about statistics, why alpha levels have been set at 0.05, the role of randomization in the generation of sufficient grounds of belief, and the role of observational studies. The essay concludes with recommendations to acknowledge the value permeation of outcome measures and suggests that attention to reasoning and argument analysis can augment traditional evidence-based approaches in providing a robust critical approach to medical knowledge.