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• Concerns re: Kondo and Ishikawa - 2nd Editors' note
  James R Dunn, Martin Bobak
  Published on: 12 April 2018
• Authors' responses
  Naoki Kondo, Yoshiki Ishikawa
  Published on: 12 April 2018
• A typical example of unethical study and a wrong editorial decision
  Patrick Ip
  Published on: 12 April 2018
• Critique of Kondo and Ishikawa's article
  Edward Chan
  Published on: 12 April 2018
• Concern about interactions and true effect of heroic stimuli
  Hiraku Tsujimoto, Yasushi Tsujimoto and Yuki Kataoka
  Published on: 12 April 2018
• Criticism of Kondo and Ishikawa article
  Noriko Yamamoto-Mitani
  Published on: 12 April 2018
• Concerns re: Kondo and Ishikawa - Editors' note
  James R. Dunn, Martin Bobak
  Published on: 12 April 2018

• Published on: 12 April 2018

  Concerns re: Kondo and Ishikawa - 2nd Editors' note

  • James R Dunn, Co-Editor Journal of Epidemiology & Community Health
  • Other Contributors:
    • Martin Bobak, Co-Editor

  This is the second E-letter from the Editors of the Journal of Epidemiology & Community Health concerning a paper by Kondo and Ishikawa [http://jech.bmj.com/content/early/2018/01/12/jech-2017-209943]. The paper examined the impact of an intervention to encourage people of lower socio-economic status attending pachinko parlours in Japan to undergo health checkups. The intervention, which was not controlled by the authors, used gendered stereotypes of the nursing profession and suggestive uniforms that play on women’s sexuality to encourage people to engage in health checkups. The study conducted was granted ethical approval by an institutional research ethics board.

  JECH condemns the use of sexism, gender and professional stereotypes and other forms of discriminatory practice or language for any purpose, including health promotion programs. The intervention studied in the article contradicts our principles. Concerns about this paper have been sent to us and we have published these as E-letters that are attached to the article.

  We have conducted an audit of our review processes and determined that an improbable chain of accidental human processing errors in the online editorial system meant that we failed to give this paper the usual scrutiny and oversight our submissions receive. In our time as Editors, we have overseen more than 10,000 manuscript submissions prior to this withou...

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  This is the second E-letter from the Editors of the Journal of Epidemiology & Community Health concerning a paper by Kondo and Ishikawa [http://jech.bmj.com/content/early/2018/01/12/jech-2017-209943]. The paper examined the impact of an intervention to encourage people of lower socio-economic status attending pachinko parlours in Japan to undergo health checkups. The intervention, which was not controlled by the authors, used gendered stereotypes of the nursing profession and suggestive uniforms that play on women’s sexuality to encourage people to engage in health checkups. The study conducted was granted ethical approval by an institutional research ethics board.

  JECH condemns the use of sexism, gender and professional stereotypes and other forms of discriminatory practice or language for any purpose, including health promotion programs. The intervention studied in the article contradicts our principles. Concerns about this paper have been sent to us and we have published these as E-letters that are attached to the article.

  We have conducted an audit of our review processes and determined that an improbable chain of accidental human processing errors in the online editorial system meant that we failed to give this paper the usual scrutiny and oversight our submissions receive. In our time as Editors, we have overseen more than 10,000 manuscript submissions prior to this without incident, and we deeply regret this lapse. We have already identified how similar situations can be avoided in the future. Effective immediately, we will implement changes to our web-based submission system to add extra checks and sign-offs in the editorial process in order to avoid errors and ensure we uphold our editorial principles.

  Research published in articles in JECH will inevitably study social situations where sexism, racism and other forms of discrimination, injustice and exploitation are present, but we as Editors have a responsibility to ensure that our published content names such practices and condemns them as socially unacceptable. Reporting such practices uncritically or neutrally is not acceptable, and perpetuates societal perceptions that such practices are normal and/or unproblematic. In this particular case, we failed to meet this standard, and we sincerely apologize to all of our readers for this lapse in oversight.

  In addition, we are also taking this opportunity to make additional improvements to the journal. First, we will develop a statement of principles for submissions to ensure that discriminatory and/or exploitative practices are examined in a critical fashion and our articles avoid discriminatory language. Second, the Editors will write to the Institutional Research Ethics Board that gave approval for this study and make that body aware of our concerns, the concerns published in E-letters, and other concerns we have received.

  We are mindful of the fact that the journal’s reputation is important to an entire community of scholars and readers, and we take that very seriously. We will use this incident as an opportunity to address not only the direct challenges of consistently attaining the highest standards for editorial handling of manuscripts, but also solidifying the values that underpin the journal and the scholarship it publishes. It has not escaped our attention that many of the voices who rightly critiqued our error also provided informed and thoughtful insights, and it is our commitment that the journal be a trusted platform for such rigorous, critical scholarship that challenges health and social inequities both locally and globally.

  James R. Dunn and Martin Bobak
  Co-Editors, JECH

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  Conflict of Interest:
  None declared.

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• Published on: 12 April 2018

  Authors' responses

  • Naoki Kondo, Associate Professor The University of Tokyo
  • Other Contributors:
    • Yoshiki Ishikawa, Visiting Researcher

  In this paper we sought to explore the idea that the delivery of health promoting interventions could be tailored in ways that might increase uptake among hard-to-reach populations, potentially helping to reduce health inequalities. In hindsight, we realise that the specific intervention used in this study was extremely inappropriate. We acknowledge that the intervention involved drew on stereotypes for female nurses, reinforced the objectification of both women and nurses, thus reinforcing gender inequalities. We also acknowledge criticism that some of the terms we used in translating our paper into English caused offense to some readers.

  We are deeply sorry for our poor judgement and for the negative impacts of this paper. As health inequalities researchers, we are very concerned about the macrosocial determinants of health inequality and recognize that gender inequalities are one such determinant. While it has been very difficult for us to receive such a negative response to our paper, we are grateful to those who have helped us understand its limitations and how we can avoid these in future.

  Response to Tsujimoto and Kataoka
  We thank the Tsujimoto and Kataoka for their comments. While we agree that it would be helpful to formally test for gender differences in the effect of the study intervention, we are unable to conduct such an analysis since permission to use the data, as approved by the ethics board, has now expired. As we discuss in the paper...

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  In this paper we sought to explore the idea that the delivery of health promoting interventions could be tailored in ways that might increase uptake among hard-to-reach populations, potentially helping to reduce health inequalities. In hindsight, we realise that the specific intervention used in this study was extremely inappropriate. We acknowledge that the intervention involved drew on stereotypes for female nurses, reinforced the objectification of both women and nurses, thus reinforcing gender inequalities. We also acknowledge criticism that some of the terms we used in translating our paper into English caused offense to some readers.

  We are deeply sorry for our poor judgement and for the negative impacts of this paper. As health inequalities researchers, we are very concerned about the macrosocial determinants of health inequality and recognize that gender inequalities are one such determinant. While it has been very difficult for us to receive such a negative response to our paper, we are grateful to those who have helped us understand its limitations and how we can avoid these in future.

  Response to Tsujimoto and Kataoka
  We thank the Tsujimoto and Kataoka for their comments. While we agree that it would be helpful to formally test for gender differences in the effect of the study intervention, we are unable to conduct such an analysis since permission to use the data, as approved by the ethics board, has now expired. As we discuss in the paper, however, the proportion of study participants in the intervention group (rather than the control group) was similar for women and men; and the association between intervention uptake and low-SES was of similar magnitude for women and men (Table 2). Thus it is possible that the higher levels of health check uptake in the intervention group are due to factors other than sexual attraction (as noted in our discussion of possible mechanisms to explain the observed association). We agree that this question warrants further investigation.

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  Conflict of Interest:
  None declared.

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• Published on: 12 April 2018

  A typical example of unethical study and a wrong editorial decision

  • Patrick Ip, Consultant in Paediatrics and Adolescent Medicine; Clinical Associate Professor Queen Mary Hospital, LKS Faculty of Medicine, The University of Hong Kong

  We read the article published online in Journal of Epidemiology and Community Health by Dr.Kondo and Dr.Ishikawa with great sorrow and have major concern on the authors' unethical design by regarding young women wearing sexy nurse costumes as a form of acceptable behavioural intervention. As an experienced clinician who can fully appreciate the difficulty in motivating clients for health check-up, the proposed incentive/strategy is totally unethical which insults all ladies and is a strong humiliation to our professional nurses and even to the respectable Japanese culture. We can hardly believe why this kind of study with major methodology flaw can obtain an ethical approval and even being accepted and published by an esteemed journal like Journal of Epidemiology and Community Health. We are terribly sorry to say that this kind of practice is totally unacceptable in clinical medicine and academic world, hence I am writing to ask for a more serious explanation from the Editor on the Journal's and his standpoint on this classical "black" and "white" issue. The authors should be adviced to withdraw this paper as soon as possible, otherwise the integrity of future studies published in the Journal may be unnecessarily affected.

  Conflict of Interest:
  None declared.

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• Published on: 12 April 2018

  Critique of Kondo and Ishikawa's article

  • Edward Chan, Professor Department of Applied Social Sciences, The Hong Kong Polytechnic University

  I am writing to express my strong concern on the article "Affective stimuli in behavioural interventions soliciting for health check-up services and the service users' socioeconomic statuses: A study at Japanese pachinko parlours," authored by N. Kondo and Y. Ishikawa (2018). Seeing an article which encourages the objectification of women being published in this peer-reviewed journal is both shocking and disappointing. In that article, the authors suggest that an intervention involving "young female staff" wearing "sexually attractive nurse costumes"/ "erotic nurse costumes" could be effective in "soliciting" men to engage in health check-ups. I am extremely disappointed by the use of such methods, as well as such terms, in Kondo and Ishikawa's study, and strongly in doubt that they are objectifying and inappropriately sexualising women and the nursing staff in Japan.

  It is clear that ethics and code of morality are always the first and the top priority in research. Involving ethically incorrect practices (i.e., asking young women to wear erotic nurse costumes to engage men in healthcare service in this case) and even providing supportive evidence for their effectiveness to the public via an open-access journal are by no means acceptable. Despite my disappointment in the authors and the relevant private healthcare company using those gender-stereotyped practices, I am also provoked by the indifference of th...

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  I am writing to express my strong concern on the article "Affective stimuli in behavioural interventions soliciting for health check-up services and the service users' socioeconomic statuses: A study at Japanese pachinko parlours," authored by N. Kondo and Y. Ishikawa (2018). Seeing an article which encourages the objectification of women being published in this peer-reviewed journal is both shocking and disappointing. In that article, the authors suggest that an intervention involving "young female staff" wearing "sexually attractive nurse costumes"/ "erotic nurse costumes" could be effective in "soliciting" men to engage in health check-ups. I am extremely disappointed by the use of such methods, as well as such terms, in Kondo and Ishikawa's study, and strongly in doubt that they are objectifying and inappropriately sexualising women and the nursing staff in Japan.

  It is clear that ethics and code of morality are always the first and the top priority in research. Involving ethically incorrect practices (i.e., asking young women to wear erotic nurse costumes to engage men in healthcare service in this case) and even providing supportive evidence for their effectiveness to the public via an open-access journal are by no means acceptable. Despite my disappointment in the authors and the relevant private healthcare company using those gender-stereotyped practices, I am also provoked by the indifference of the ethics committee board, the reviewers of that article, and the Editor of this journal when they took no actions when seeing such social unjust. Problems undoubtedly appear if the society has become so used to some inappropriate marketing gimmicks involving gender stereotypes that they do not feel anything wrong about them. I am very much concerned about the possibility that the use of those sexually arousal practices to gratify one's sexual desire in healthcare services would be linked to the promotion of sexism and stereotypes on nursing staff.

  I do have faith in the journal editors that they would make every effort to assert the journal principle and disapprove all means of gender and professional stereotypes and discriminations. Here I hope that the editors would consider taking stronger actions regarding that article in the coming future.

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  Conflict of Interest:
  None declared.

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• Published on: 12 April 2018

  Concern about interactions and true effect of heroic stimuli

  • Hiraku Tsujimoto, Research associate Hospital Care Research Unit, Hyogo Prefectural Amagasaki General Medical Center
  • Other Contributors:
    • Yasushi Tsujimoto, Physician
    • Yuki Kataoka, Physician

  We read an article recently published online in Journal of Epidemiology and Community Health by Dr.Kondo and Dr.Ishikawa with great interest and appreciate the authors' efforts to seek effective interventions for socioeconomically vulnerable people to have a health check-up. They suggested "hedonic stimuli" promote socially vulnerable people to have health check-up services. The "heroic effect" in this research directed to one gender only (mostly). We consider they should have performed the analysis which compares the difference of the intervention effect between on male (sensitive to this heroic stimuli) and on female (insensitive to the stimuli) in order to consider interactions (e.g. simply wearing healthcare staff's costumes). We believe that the difference in effect size between genders is the true intervention effect arisen from the "hedonic stimuli". We suggest it should be investigated using the original data of Table 2.

  Conflict of Interest:
  None declared.

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• Published on: 12 April 2018

  Criticism of Kondo and Ishikawa article

  • Noriko Yamamoto-Mitani, Professor University of Tokyo

  I felt deeply offended after reading ‘Affective stimuli in behavioural interventions soliciting for health check-up services and the service users’ socioeconomic statuses: a study at Japanese pachinko parlours’ by Kondo and Ishikawa (Kondo N, Ishikawa Y. J Epidemiol Community Health 2018; 0:1–6. doi:10.1136/jech-2017-209943). As a Japanese woman and a registered nurse, I found phrases such as ‘young women wearing mildly erotic nurse costumes’ or ‘solicitation by young women wearing sexy nurse costumes’ to be derogatory and disrespectful. If the authors needed to clarify the point of their hypothesis on the possible relationship between sexual stimuli and health behaviours, which is already disturbing enough as a research topic, it would be enough to mention ‘a person wearing mildly erotic clothes’ or ‘invitation by persons wearing sexy costumes.’ When the authors add (and the editors retain) such words as ‘young women’ or ‘nurses’ to describe the distinctive features of the intervention, they tacitly accept and capitalize on stereotypes and prejudices against young women and nurses, and assume that readers will share such insulting views as well. I was very disappointed that the paper was developed by the authors, reviewed by peer reviewers, and accepted in its current form by the editor-in-chief of the Journal of Epidemiology and Community Health. I sincerely hope that the authors, reviewers, and editor-in-chief give some more thought to how social disparity could persist...

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  I felt deeply offended after reading ‘Affective stimuli in behavioural interventions soliciting for health check-up services and the service users’ socioeconomic statuses: a study at Japanese pachinko parlours’ by Kondo and Ishikawa (Kondo N, Ishikawa Y. J Epidemiol Community Health 2018; 0:1–6. doi:10.1136/jech-2017-209943). As a Japanese woman and a registered nurse, I found phrases such as ‘young women wearing mildly erotic nurse costumes’ or ‘solicitation by young women wearing sexy nurse costumes’ to be derogatory and disrespectful. If the authors needed to clarify the point of their hypothesis on the possible relationship between sexual stimuli and health behaviours, which is already disturbing enough as a research topic, it would be enough to mention ‘a person wearing mildly erotic clothes’ or ‘invitation by persons wearing sexy costumes.’ When the authors add (and the editors retain) such words as ‘young women’ or ‘nurses’ to describe the distinctive features of the intervention, they tacitly accept and capitalize on stereotypes and prejudices against young women and nurses, and assume that readers will share such insulting views as well. I was very disappointed that the paper was developed by the authors, reviewed by peer reviewers, and accepted in its current form by the editor-in-chief of the Journal of Epidemiology and Community Health. I sincerely hope that the authors, reviewers, and editor-in-chief give some more thought to how social disparity could persist by promoting stereotyped, derogatory views on a certain group of people.

  Noriko Yamamoto-Mitani, PhD, RN
  The University of Tokyo

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  Conflict of Interest:
  None declared.

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• Published on: 12 April 2018

  Concerns re: Kondo and Ishikawa - Editors' note

  • James R. Dunn, Co-Editor Journal of Epidemiology & Community Health
  • Other Contributors:
    • Martin Bobak, Co-Editor

  The paper by Kondo and Ishikawa uncritically investigates a public health program that contradicts the journal’s values. We are aware of the concerns raised and have already begun to address them, with more action to come. We are conducting an audit of our editorial processes to determine where errors were made and will be publishing e-letters that articulate the concerns about the paper. The Editors have attached the statement below to the paper as an ‘Editorial Note’. This represents an interim measure to assert our principles. In the coming days, we publish additional E-letters to provide more detail on the actions we will take to ensure that we are consistently upholding these principles going forward.

  The Editorial Note reads:

  “The study reported in this article examines a health intervention which uses gendered stereotypes of the nursing profession and suggestive uniforms that play on women’s sexuality to encourage people to engage in health checkups. The intervention was not under the control of the authors and the study was approved by an institutional research ethics board.”

  “The Journal of Epidemiology & Community Health condemns the use of sexism, gender and professional stereotypes and other forms of discriminatory or exploitive behaviour for any purpose, including health promotion programs. In light of concerns raised about this paper, we are conducting an audit of our review process and will put in place measures to ensure that the m...

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  The paper by Kondo and Ishikawa uncritically investigates a public health program that contradicts the journal’s values. We are aware of the concerns raised and have already begun to address them, with more action to come. We are conducting an audit of our editorial processes to determine where errors were made and will be publishing e-letters that articulate the concerns about the paper. The Editors have attached the statement below to the paper as an ‘Editorial Note’. This represents an interim measure to assert our principles. In the coming days, we publish additional E-letters to provide more detail on the actions we will take to ensure that we are consistently upholding these principles going forward.

  The Editorial Note reads:

  “The study reported in this article examines a health intervention which uses gendered stereotypes of the nursing profession and suggestive uniforms that play on women’s sexuality to encourage people to engage in health checkups. The intervention was not under the control of the authors and the study was approved by an institutional research ethics board.”

  “The Journal of Epidemiology & Community Health condemns the use of sexism, gender and professional stereotypes and other forms of discriminatory or exploitive behaviour for any purpose, including health promotion programs. In light of concerns raised about this paper, we are conducting an audit of our review process and will put in place measures to ensure that the material we publish condemns sexism, racism and other forms of discrimination and embodies principles of inclusion and non-discrimination.”

  J. Dunn & M. Bobak
  Co-Editors, Journal of Epidemiology & Community Health

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  Conflict of Interest:
  None declared.

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