We describe a conceptual framework that we have developed for evaluating primary care research networks. The framework includes objectives, process indicators, and outcome indicators. We propose the framework as a provisional model that we hope will promote further research and debate.
OBJECTIVE: To assess and compare the quality of nonstructured and structured abstracts of original research articles in three medical journals. DESIGN: Blind, criterion-based observational study. SAMPLE: Random sample of 300 abstracts (25 abstracts per journal each year) of articles published in the British Medical Journal (BMJ), the Canadian Medical Association Journal and the Journal of the American Medical Association (JAMA) in 1988 and 1989 (nonstructured abstracts) and in 1991 and 1992 (structured abstracts). MAIN OUTCOME MEASURES: The quality of abstracts was measured against 33 objective criteria, which were divided into eight categories (purpose, research design, setting, subjects, intervention, measurement of variables, results and conclusions). The quality score was determined by dividing the number of criteria present by the number applicable; the score varied from 0 to 1. RESULTS: The overall mean quality scores for nonstructured and structured abstracts were 0.57 and 0.74 respectively (p < 0.001). The frequency in meeting the specific criteria was generally higher for the structured abstracts than for the nonstructured ones. The mean quality score was higher for nonstructured abstracts in JAMA than for those in BMJ (0.60 v. 0.54...
By the end of 1987, almost 50,000 cases of acquired immunodeficiency syndrome (AIDS) will have been reported in the United States. Although the primary epidemiology of the disease has been described, much work remains to be done to complete our understanding of the dynamics of transmission and infection with the causative virus, human immunodeficiency virus (HIV). At the state and local level, the highest priorities for epidemiologic research are to understand better the precise populations at risk of prevalent and incident HIV infection, and to use this information to direct and monitor specific prevention programs that are likely to be effective for the populations at risk. These parallel efforts-sophisticated investigative epidemiologic research and applied epidemiologic and serosurveillance studies-must be expanded rapidly and continued for the forseeable future if we are to accomplish the goal of preventing further spread of HIV.
Epidemiologic studies involving HIV (human immunodeficiency virus) antibody testing create ethical dilemmas, particularly about notifying asymptomatic seropositive subjects. Four study designs address this problem: mandatory notification, optional notification, anonymous testing, and blind testing. No single design consistently optimizes the trade-off between valid and ethical research. Each strategy differs substantially from the others in its effect on response rates, bias, ability to perform longitudinal studies, numbers of subjects who learn their test results, and the number of subjects counseled about HIV risk reduction. Both local institutional review boards and potential subjects of study (and their sexual partners) should participate in decisions regarding the conduct of sensitive AIDS (acquired immunodeficiency syndrome) research.
The age of maturity of children to consent for medical research is under debate, as different authorities regard the capacity of young teenagers as either satisfactory or not to grant consent without parental participation in the process. The present paper contrasts the generally accepted guideline for ethics in paediatric research in Canada with what the same children are allowed and expected to be able to do as babysitters. This comparison reveals deep incongruences in the way the maturity of the same children is appreciated for two different tasks.
Each Local Research Ethics Committee (LREC) is expected to produce an annual report for its establishing authority. Reports from 145 LRECs were examined with regard to (a) whether the committees were working within the terms of the most recent guidelines from the Department of Health and (b) observations on the role of LRECs with particular reference to accountability. Most LRECs had produced a report, although their length varied greatly. Most reports showed how seriously the committee took its task. Most committees met many of the guidelines; for example, almost all had two or more lay-members. The guideline most frequently not met was that committees should have no more than 12 members. Many committees review very large numbers of projects (maximum 351). Approximately two-thirds provide details in the annual report of individual project titles, their author and the committee decision; all reports should contain this information. Although it may in fact happen more generally, only 23 per cent of the reports referred to any form of monitoring of the eventual outcome of the research. A significant issue to arise from the reports is the extent to which the framework for the operation of LRECs has been confused by the development of the purchaser-provider split. The paper concludes with suggestions for remedying the situation.
The objective of this paper is to stimulate academic debate on embryo and fetal research from the perspective of the drafting of a protocol to the European Convention on Biomedicine. The Steering Committee on Bioethics of the Council of Europe was mandated to draw up such a protocol and for this purpose organised an important symposium on reproductive technologies and embryo research, in Strasbourg from the 16th to the 18th of December 1996.
This paper reviews restraints on the provision of mental health services in primary health care under the broad categories of physician profile, patient behavior, the nature of psychiatric illness as presented in primary care, and service system characteristics. An extensive research agenda is proposed toward improving mental health care in primary care settings. Research recommendations focus on the following types of issues: seeking a better understanding of the clinical decision making process when confronted with psychological or emotional problems, designing more focused mental health training for primary care physicians and nurses, providing patient education to encourage communication of psychosocial problems to medical providers, clarifying the nature and course of psychiatric disorder in primary care, designing innovative clinical interventions applicable to primary care, and examining organizational models for better coordination of health and mental health services.
The past 2 decades have taught us that HIV prevention can work. We now have evidence from places as diverse as Senegal, Thailand, Uganda, and Australia that concerted HIV prevention efforts at the national level have resulted in the maintenance of low seroprevalence rates where they otherwise would have been expected to rise. We are beginning to observe declining rates of HIV prevalence and incidence in places and populations with historically high rates--for example, injection drug users in New York City. This trend points to the long-term impact of prevention efforts in those communities. The best of these efforts have been based on sound scientific research. As we move into the third decade of the AIDS epidemic, it is important to restate principles, acknowledge advances, and identify challenges and future directions in HIV prevention research.
Historically, quality assurance studies have received scant ethical attention. The advent of information systems capable of supporting research-grade continuous quality improvement projects demands that we clearly define how these projects differ from research and when they require external review. The ethical obligation for the performance of quality assurance projects, with its emphasis on identifiable immediate action for a served population, is a critical distinction. The obligation to perform continuous quality improvement is a deliverable of the social contract entered into implicitly by patients and health care providers and systems.
Advances in geographic information system (GIS) technology, developed by geographers, provide new opportunities for environmental epidemiologists to study associations between environmental exposures and the spatial distribution of disease. A GIS is a powerful computer mapping and analysis technology capable of integrating large quantities of geographic (spatial) data as well as linking geographic with nongeographic data (e.g., demographic information, environmental exposure levels). In this paper we provide an overview of some of the capabilities and limitations of GIS technology; we illustrate, through practical examples, the use of several functions of a GIS including automated address matching, distance functions, buffer analysis, spatial query, and polygon overlay; we discuss methods and limitations of address geocoding, often central to the use of a GIS in environmental epidemiologic research; and we suggest ways to facilitate its use in future studies. Collaborative efforts between epidemiologists, biostatisticians, environmental scientists, GIS specialists, and medical geographers are needed to realize the full potential of GIS technology in environmental health research and may lead to innovative solutions to complex questions.
The study of mouse genetics is a science in its own right. Currently, the mouse is the central platform for model building in biomedical research. Recombinant DNA technology and mouse transgenesis have provided an almost unlimited resource of new animals that is constantly expanding. Investigators, through their selection of the most appropriate type of mouse and by imaginative combinations of animals in breeding or culture experiments, have the opportunity for discovery of new information that will benefit the health of both humans and species of veterinary interest. Wider appreciation and use of the mouse as a discovery tool in veterinary research should be encouraged.
An empirical biobehavioral research approach to the conditions generally identified as alcohol abuse and alcoholism emphasizes the temporal ordering of participating biochemical, physiological, and behavioral events that provide an operational basis for characterizing the functional aspects of this complex disorder and identifying distinguishable features of the alcohol abuse and dependence process. The available evidence suggests that alcoholism is a condition determined by a host of continuous variables rather than an entity possessing static qualities that imply intractability. The challenge for biobehavioral research is to determine the details of how chronic and excessive alcohol drinking is generated as well as the conditions under which such overindulgence can be attenuated and prevented. Environmental context, for example, can dramatically alter the frequency and amount of alcohol intake. Such contextual malleability is suggested as an important key to at least some of the inconsistencies in the literature with regard to the conditions under which chronic and excessive alcohol intake occurs. Excessive and chronic alcohol ingestion would seem most parsimoniously viewed as a set of behaviors for which others might have been substituted...
Research on ulcerative colitis and Crohn disease, the two conditions grouped under the heading of inflammatory bowel disease (IBD), is improving our understanding of how the intestine functions at the cellular level in health and disease. Researchers in the McGill Inflammatory Bowel Disease Research Program are studying the factors that affect the transport of nutrients, salt and water across cell membranes in the intestinal epithelium and investigating the cellular mechanisms of diarrhea. Their main interest is in how the intestine adapts in response to inflammation. Their findings promise to yield new targets for the pharmacologic and dietary management of IBD.
Despite the widespread use of prenatal care, the evidence for its effectiveness remains equivocal and its primary purpose and effects continue to be a subject of debate. To provide some perspective on why the effectiveness and organization of prenatal care continue to be debated, the authors (a) briefly review the history of the development of prenatal care in the US; (b) attempt to conceptually define prenatal care in terms of its utilization, content, and quality; and, (c) highlight some of the research controversies and challenges facing investigators and advocates who seek to establish the value of prenatal care. In addition, the authors recommend directions for future research to address persistent questions regarding the function, structure, and significance of prenatal care in improving US perinatal outcomes.
OBJECTIVES: This study assessed whether skin color and ways of handling anger can serve as markers for experiences of racial discrimination and responses to unfair treatment in public health research. METHODS: Survey data on 1844 Black women and Black men (24 to 42 years old), collected in the year 5 (1990-1991) and year 7 (1992-1993) examinations of the Coronary Artery Risk Development in Young Adults (CARDIA) study, were examined. RESULTS: Skin color was not associated with self-reported experiences of racial discrimination in 5 of 7 specified situations (getting a job, at work, getting housing, getting medical care, in a public setting). Only moderate associations existed between darker skin color and being working class, having low income or low education, and being male (risk ratios under 2). Comparably moderate associations existed between internalizing anger and typically responding to unfair treatment as a fact of life or keeping such treatment to oneself. CONCLUSIONS: Self-reported experiences of racial discrimination and responses to unfair treatment should be measured directly in public health research; data on skin color and ways of handling anger are not sufficient.
Minority populations face a wide variety of economic, institutional, and cultural barriers to health care. These barriers and low levels of education and income pose significant challenges for health professionals in developing cancer research and prevention-control strategies. It is suggested that specific segments of Hispanic populations fit the model of an underdeveloped country in the intermediate stage of epidemiological transition. Since noncommunicable diseases have not yet fully emerged in some of these Hispanic population segments, the opportunity exists to apply primordial prevention strategies. Such campaigns would focus on dissuading members of these populations from adopting negative health behaviors while promoting positive lifestyle choices. Optimal programs would increase cancer screening participation and discourage risk behaviors through community-oriented, population-based interventions. Future directions in prevention and control efforts for minority populations should include expanded health insurance coverage, improved access to health care, greater emphasis on minority recruitment in health care fields, focused epidemiologic and clinical research, and identification and replication of effective components within existing prevention-control programs.
Research conducted during the last four decades has established that consumption of alcoholic beverages causes cancer. Etiologic research questions that remain relate to increases in risk at specific sites, the effects of various types of alcoholic beverages, the effect of various concentrations of alcohol, and the mechanism(s) of action, including possible interactions with other agents such as tobacco smoke. Prevention priorities for alcohol-related cancer depend on whether alcohol causes only the upper aerodigestive cancers or whether it also causes breast and possibly colon cancers. If alcohol causes aerodigestive cancers only, existing prevention programs to prevent alcohol abuse by heavy drinkers are sufficient. The possible small cancer risk faced by moderate drinkers may be more than offset by a decrease in the risk of cardiovascular death. On the other hand, if alcohol consumption increases the occurrence of breast cancer, a prevention program aimed at women who are at high risk for breast cancer is worth considering, but the risks must be weighed against the cardiovascular benefits for moderate drinkers.
There is no question that the risk of many cancers varies substantially by race, ethnic group, and gender. Although important clues to cancer etiology may come from investigating the differences in risk across subgroups of the population, epidemiologic research has often focused on white men. More descriptive and analytic studies are needed to identify and explain variations in risk among population subgroups. Especially important are studies to clarify the role of differential exposures, susceptibility, and diagnostic factors in cancer incidence, although differences in treatment may contribute to variations in cancer mortality. Improvements in classification of ethnicity, assessment of carcinogenic exposures in various subpopulations, and measures of host susceptibility states should augment future epidemiologic research designed to better understand mechanisms underlying the racial, ethnic, and gender differences in cancer risk.
There is increasing evidence that some environmental chemicals can interrupt neurodevelopmental processes during critical periods of development, resulting in effects on sensory, motor, and cognitive function. It is now generally accepted that developing organisms are differentially sensitive to chemical exposure because of toxicokinetic and/or toxicodynamic factors. Regulatory mechanisms have been implemented to protect humans from over- or inappropriate exposures to environmental chemicals. Current regulatory practices, however, may be insufficient because of the possibility that some environmental chemicals interfere with endocrine function at key periods of neurodevelopment. In addition, a recent National Research Council (NRC) report on pesticide contamination in the diets of infants and children concluded that current regulatory practices may not sufficiently protect infants and children from the risk of pesticide exposure. The NRC report indicates that regulatory agencies might underestimate the actual exposure of infants and children to pesticides and rely too heavily on data from adults in the risk assessment of pesticides. Consideration of endocrine-disrupting chemicals and the differential susceptibility of infants and children has led to identification of a number of information gaps and research needs that should be addressed in order to improve future risk assessments for these chemicals.