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2.  Considerations for preparing a randomized population health intervention trial: lessons from a South African–Canadian partnership to improve the health of health workers 
Global Health Action  2014;7:10.3402/gha.v7.23594.
Community-based cluster-randomized controlled trials (RCTs) are increasingly being conducted to address pressing global health concerns. Preparations for clinical trials are well-described, as are the steps for multi-component health service trials. However, guidance is lacking for addressing the ethical and logistic challenges in (cluster) RCTs of population health interventions in low- and middle-income countries.
We aimed to identify the factors that population health researchers must explicitly consider when planning RCTs within North–South partnerships.
We reviewed our experiences and identified key ethical and logistic issues encountered during the pre-trial phase of a recently implemented RCT. This trial aimed to improve tuberculosis (TB) and Human Immunodeficiency Virus (HIV) prevention and care for health workers by enhancing workplace assessment capability, addressing concerns about confidentiality and stigma, and providing onsite counseling, testing, and treatment. An iterative framework was used to synthesize this analysis with lessons taken from other studies.
The checklist of critical factors was grouped into eight categories: 1) Building trust and shared ownership; 2) Conducting feasibility studies throughout the process; 3) Building capacity; 4) Creating an appropriate information system; 5) Conducting pilot studies; 6) Securing stakeholder support, with a view to scale-up; 7) Continuously refining methodological rigor; and 8) Explicitly addressing all ethical issues both at the start and continuously as they arise.
Researchers should allow for the significant investment of time and resources required for successful implementation of population health RCTs within North–South collaborations, recognize the iterative nature of the process, and be prepared to revise protocols as challenges emerge.
PMCID: PMC4009485  PMID: 24802561
cluster-randomized controlled trials; population health; pre-trial considerations; receptor capacity; feasibility studies; pilot testing; building relationships; ethical issues; iterative process
3.  Tool, weapon, or white elephant? A realist analysis of the five phases of a twenty-year programme of occupational health information system implementation in the health sector 
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.
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 (socio-political and technological) characteristics and mechanisms affecting outcomes at micro, meso and macro levels.
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 worker-employer 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.
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"
PMCID: PMC3532229  PMID: 22867054
4.  Establishing a community of practice of researchers, practitioners, policy-makers and communities to sustainably manage environmental health risks in Ecuador 
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.
PMCID: PMC3247836  PMID: 22165915
5.  Collaboration between infection control and occupational health in three continents: a success story with international impact 
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.
PMCID: PMC3247839  PMID: 22166059
6.  Intersectoral action for health at a municipal level in Cuba 
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.
PMCID: PMC3282006  PMID: 21845406
Intersectoral; Cuba; Population health; Determinants of health; Health system organization
7.  Evaluation of a Workplace Disability Prevention Intervention in Canada: Examining Differing Perceptions of Stakeholders 
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.
PMCID: PMC3098356  PMID: 20972703
Program evaluation; Workplace; Qualitative research; Disability prevention; Sickness absence; Canada
8.  Which New Approaches to Tackling Neglected Tropical Diseases Show Promise? 
PLoS Medicine  2010;7(5):e1000255.
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.
Background to the Debate
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.
PMCID: PMC2872649  PMID: 20502599
9.  The impact of requiring completion of an online infection control course on health professionals’ intentions to comply with infection control guidelines: A comparative study 
Ensuring good infection control practice in health care facilities is a constant concern, yet evidence shows that the compliance of health care professionals with proper procedures is lacking, despite the existence of guidelines and training programs. An online infection control module was developed to provide ready access to training. Controversy exists about whether successfully completing such a course should be mandatory or strongly encouraged for all health care professionals. The objective of the present study was to compare the perception of safety culture and intention to comply with infection control guidelines in professionals who were required by their supervisors to take the course, and those who did so voluntarily.
Survey responses on learning environment, safety climate and intention to comply with infection control guidelines in health care professionals who were required to take the course (supervisor-required group [n=143]) and those who took the same course voluntarily (voluntary group [n=105]) were compared. Because randomization was thought to be too difficult to implement in the policy context in which the study was conducted, significant differences between the two groups were taken into account in the analysis.
Those required to take the course had a significantly better perception of the institutional safety climate (P<0.001), and had a higher reported intention to comply with infection control guidelines (P=0.040) than those who took the course voluntarily.
Requiring that staff complete a 30 min interactive online infection control module increased their intention to comply with infection control guidelines compared with those who voluntarily accessed this material based on promotional material. Consideration should be given to making the successful completion of an online infection control module a requirement for all health care professionals.
PMCID: PMC2690520  PMID: 20190890
Compliance; Hand hygiene; Infection control; Online education; SARS; Training
11.  Lead and mercury exposures: interpretation and action 
Lead and mercury are naturally occurring elements in the earth's crust and are common environmental contaminants. Because people concerned about possible exposures to these elements often seek advice from their physicians, clinicians need to be aware of the signs and symptoms of lead and mercury poisoning, how to investigate a possible exposure and when intervention is necessary. We describe 3 cases of patients who presented to an occupational medicine specialist with concerns of heavy metal toxicity. We use these cases to illustrate some of the issues surrounding the investigation of possible lead and mercury exposures. We review the common sources of exposure, the signs and symptoms of lead and mercury poisoning and the appropriate use of chelation therapy. There is a need for a clear and consistent guide to help clinicians interpret laboratory investigations. We offer such a guide, with information about population norms, lead and mercury levels that suggest exposure beyond that seen in the general population and levels that warrant referral for advice about clinical management.
PMCID: PMC1764574  PMID: 17200393
12.  Community participation in a multisectoral intervention to address health determinants in an inner-city community in central Havana 
It is increasingly acknowledged that the process of community involvement is critical to the successful implementation of community-based health interventions. Between 1995 and 1999, a multisectoral intervention called Plan Cayo Hueso was launched in the inner-city community of Cayo Hueso in Havana, Cuba, to address a variety of health determinants. To provide a better understanding of the political structures and processes involved, the Cuban context is described briefly. The interventions included improvements in housing, municipal infrastructure, and social and cultural activities. A qualitative study, consisting of interviews of key informants as well as community members, was conducted to evaluate the community participatory process. Questions from an extensive household survey pre-and postintervention that had been conducted in Cayo Hueso and a comparison community to asses the effectiveness of the intervention also informed the analysis of community participation, as did three community workshops held to choose indicators for evaluating effectiveness and to discuss findings. It was found that formal leaders led the interventions, providing the institutional driving force behind the plan. However, extensive community involvement occurred as the project took advantage of the existing community-based organizations, which played an active role in mobilizing community members and enhanced linkage systems critical to the project's success. Women played fairly traditional, roles in interventions outside their households, but had equivalent roles to men in interventions within their household units. Most impressive about this project was the extent of mobilization to participate and the multidimensional ecosystem approach adopted. Indeed, Plan Cayo Hueso involved a massive mobilization of international, national, and community resources to address the needs of this community. This, as well as the involvement of community residents in the evaluation process, was seen as resulting in improved social interactions and community well-being and enhanced, capacity for future action. While Cuba is unique in many respects, the lessons, learned about enhancing community participation in urban health intervention projects, as well as in their evaluation, are applicable worldwide.
PMCID: PMC3456101  PMID: 12612097
14.  Return to work after occupational injury. Family physicians' perspectives on soft-tissue injuries. 
Canadian Family Physician  2002;48:1912-1919.
OBJECTIVE: To document physicians' views about facilitating factors for and barriers to their helping workers recover after occupational soft-tissue injuries and to ascertain physicians' knowledge and attitudinal barriers to their involvement in return to work. DESIGN: Faxed survey. SETTING: Manitoba family practices and emergency departments. PARTICIPANTS: General practitioners, family physicians, and emergency physicians regularly caring for injured workers. MAIN OUTCOME MEASURES: Physicians' ranking of facilitating factors and barriers, changes to help their involvement in return to work, and their attitudes and knowledge about return to work. RESULTS: Respondents and nonrespondents were demographically similar, 232 physicians (51.3%) responded. Respondents believed the main facilitating factors were physicians' ability to explain the nature and prognosis of injuries to workers (69%) and the willingness of workplaces to accommodate injured workers (26%). The main barriers were workers' misunderstandings and fears about their injuries (70.7%) and non-supportive supervisors and co-workers (20.8%). The most frequently requested change was better workplace job accommodation (48%). Most physicians agreed they had a role in planning return to work and were aware of the effect of job satisfaction, psychosocial elements, and work-related factors. Despite supporting evidence, only one third of physicians stated they would say "try to continue usual activities" to patients with occupational low back pain. CONCLUSION: Most physicians seemed aware of their role in return to work and the effect of occupational factors, but their advice on activity after injury differed from that in practice guidelines.
PMCID: PMC2213965  PMID: 12520791
15.  Determinants of tuberculin reactivity among health care workers: Interpretation of positivity following BCG vaccination 
To determine the extent to which a history of Bacille Calmette-Guerin (BCG) vaccination influences the likelihood of positive tuberculin skin test (TST) results.
Cross-sectional survey using a hospital-based tuberculosis surveillance program.
Health Sciences Centre, a tertiary care hospital in Winnipeg, Manitoba.
The 476 health care workers (HCWs) who had TST as part of the surveillance program between 1993 and 1997 constituted the study population. The two-step test was done in 91% of the participants who did not have a positive initial test, defined as 10 mm or greater of induration. Data were gathered through chart review supplemented by a short questionnaire administered to the HCWs.
One hundred and thirty-eight HCWs (29%) had a positive TST. In a stepwise, multiple logistic model controlling for age, sex, job title, work area, age of receiving BCG, time since BCG and duration of employment, only a history of BCG vaccination (odds ratio [OR] 22; 95% CI 12 to 41) and birth outside of Canada (OR 2.6; 95% CI 1.4 to 5.8) were significantly associated with a positive TST. When the definition of a positive TST was modified by increments of 1 mm, from 10 mm up to 20 mm of induration in BCG recipients, BCG was associated with positive reactions with indurations up to 19 mm but not 20 mm or greater. The OR declined with each increment. Of the 84 HCWs who were documented to have at least 20 years between BCG vaccination and testing, 41 (49%) had positive reactions.
BCG vaccination can produce lasting tuberculin reactivity, and indurations of 19 mm or less may be due to the effects of the vaccine.
PMCID: PMC3250716  PMID: 22346379
Bacille Calmette-Guerin vaccination; Epidemiology; Tuberculin skin test; Tuberculosis
16.  Throat colonization of neonatal nursery staff by Ureaplasma urealyticum: An infection control or occupational health consideration? 
Very low birth weight infants often have protracted respiratory tract colonization with Ureaplasma urealyticum. To determine whether prolonged contact with very low birth weight infants resulted in higher rates of upper respiratory tract colonization with this organism for caregivers, throat swabs for U urealyticum culture were obtained from medical, nursing and other support staff working in the neonatal intensive care and level II nurseries at the Health Sciences Centre and the St Boniface Hospital in Winnipeg, Manitoba. Throat colonization by U urealyticum was demonstrated in 7.3% (95% ci 0 to 15.6%) of 41 nurses working in the intensive care nurseries but in none of the 48 nurses working in other locations or the 66 other individuals tested (P=0.02). However, throat colonization was not significantly higher among the neonatal intensive care nurses than among the women delivering at one of the study institutions. Close contact with very low birth weight infants appears to constitute a minimal risk for increased throat colonization with U urealyticum among hospital staff members.
PMCID: PMC3250830  PMID: 22346506
Infection control; Occupational health; Throat colonization; Ureaplasma urealyticum
17.  Morbidity, cost and role of health care worker transmission in an influenza outbreak in a tertiary care hospital 
An influenza A outbreak involving 17 health care workers (HCWs) and 16 chronic geriatric patients on a ward in a tertiary care hospital was reviewed. Thirty-seven per cent of all HCWs and 47% of patients on the affected wards became ill with influenza. Three patients died during the outbreak. The majority of health care workers became ill prior to detecting the first patient case of influenza, suggesting that nosocomial spread from HCWs to patients may have occurred. Only 13.7% of the staff and 5.9% of the patients had been vaccinated prior to the outbreak. Lost time due to HCW absenteeism, outbreak-related medication costs and additional staff time involved in outbreak control resulted in considerable cost to the hospital. It is suggested that much of this cost, as well as morbidity and possibly mortality, could have been avoided by increased immunization of HCWs and patients.
PMCID: PMC3250813  PMID: 22346421
Cost; Health care worker; Influenza outbreak; Nosocomial transmission
18.  Effectiveness and cost-benefit of an influenza vaccination program for health care workers 
This study retrospectively reviewed the effectiveness of a vaccination program for hospital workers in a large tertiary care hospital, quantified influenza-induced absenteeism, and examined the factors determining the costs and benefits of this program. Absenteeism among high risk hospital workers was increased by 35% (P=0.001) during the virulent influenza epidemic of 1987–88. Benefits, measured as the value of sick time avoided, compared with costs, including materials, occupational nursing staff time, employee time during vaccination, and time lost due to adverse reactions, revealed a net benefit of $39.23 per vaccinated employee. Sensitivity analyses highlighted vaccine efficacy and absenteeism due to influenza and adverse reactions to vaccination as the most important factors; with time lost due to adverse reactions as much as 0.013 days per vaccinated employee and a vaccine efficacy of 70%, net positive benefits could be achieved if influenza-induced absenteeism is 0.5% or greater of paid employee time during the epidemic season. The results suggested that the net cost-benefit of a hospital employee vaccination program to decrease both employee morbidity and nosocomial influenza among patients, would be increased by active promotion of the vaccination program, especially for employees in high risk areas.
PMCID: PMC3328002  PMID: 22529718
Cost-benefit; Hospital workers; Influenza vaccine
19.  WHMIS—The Right to Know in Canada: Are Family Physicians Prepared? 
Canadian Family Physician  1989;35:2311-2313.
The family physician is in a unique position to provide information on health hazards and to answer questions about the causes of a person's illness, yet family physicians may not be prepared for the massive flow of new information being released to the public about workplace hazards. The Workplace Hazardous Material Information System (WHMIS) is designed to give Canadians information and training on workplace hazards. It requires that 1) all chemicals be labelled as to the nature of their hazards; 2) Material Safety Data Sheets be made available, which include health effects as well as control information; and 3) all workers be trained on the nature of the chemicals and their safe use. This report suggests sources of help for family physicians.
PMCID: PMC2280281  PMID: 21248926
family medicine; occupational medicine; work hazards
20.  Chronic Lead Poisoning From Industrial Exposure: A Review 
Canadian Family Physician  1980;26:1056-1062.
Lead poisoning from chronic industrial exposure is not uncommon. Early diagnosis is important in avoiding irreversible effects.
A good occupational history is key to alerting the unsuspecting physician to the correct diagnosis. Blood lead levels are useful but ridden with shortcomings. Specific tests to assess functional impairment, such as urinary aminolevulinic acid (ALA) and coproporphyrins should be included in the diagnostic work-up.
Lead poisoning is a preventable disease well worth the consideration of the family practitioner. (Can Fam Physician 1980; 26:1056-1062).
PMCID: PMC2383684  PMID: 21293668

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