32 e-Letters

published between 2015 and 2018

  • A typical example of unethical study and a wrong editorial decision

    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.

  • Critique of Kondo and Ishikawa's article

    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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  • Concern about interactions and true effect of heroic stimuli

    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.

  • Criticism of Kondo and Ishikawa article

    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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  • Concerns re: Kondo and Ishikawa - Editors' note

    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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  • Response to Barberio et al's claim that there is no link between fluoridation and hypothyroidism

    Barberio et al1 report a study which – in contrast to our own study2 - shows no relationship between fluoride intake and hypothyroidism. However, Barberio et al study is limited by the methods used for identifying hypothyroidism prevalence, fluoridation status and sample sizes.

    Barberio et al utilised three methods to determine hypothyroidism prevalence: self-report and two biomarkers: thyroid-stimulating hormone (TSH), and free T4 blood results. This is problematic as self-report is unlikely to provide accurate prevalence data when compared to clinical diagnosis data, as used in our study4; and there are a number of studies demonstrating that self-reported estimates of thyroid functioning are unreliable. Further, the self-report question does not appear to differentiate between under and over active thyroid functioning. The biomarker data only included individuals with un-medicated hypothyroidism; consequently, the sample is unrepresentative of the population. The analysis of this data provides correlations between the biomarkers TSH, T4 readings and fluoride exposure in a sub-sample of respondents, assuming that all respondents received uniform levels of fluoride. From our data, we observed wide variability within fluoridated areas. This may explain why in table 2b, none of the variables, including age and sex, were predictive of TSH levels. This contradicts Barberio et al’s own data on what is predictive of hypothyroidism and the Canadian Health Measures Survey...

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  • Could alcohol control policies be a smokescreen?

    Madureira-Lima and Galea developped an Alcohol Control Policy Index (ACPI) and claimed higher scores with their index were associated with lower consumption.(1) This deserved comment.

    First, why looking for a complex and time consuming surrogate when the relevant endpoint, consumption, is so easy to assess? Moreover, if reliable data about consumption were not accessible, this would be the best indicator for lack of alcohol control policy.

    Second, how France can rank in the top, 6th among 48 developed countries, for alcohol control? Indeed: a) France is among the barrels, the male population drank an average of 43g/day (female 13g) and, male regular drinkers drank 64g (women 45g).(2) b) serial laws in 2009 and 2016 were used to almost nullify the 1991 Évin law protecting people from alcohol advertising.(3,4) c) for the devastating flawed Responsibility Lansley only copied/pasted a 2006 decree (#159) issued by Bussereau, a French minister for agriculture;(5) d) France even lobbied against the Act about minimum alcohol pricing in Scotland, claiming it “would be disastrous on the balance of European trade”(6) e) the new president hired the CEO of the wine professional organization as his special advisor for agriculture (7) because alcohol is France's second biggest export sector after the aerospace industry.

    Last, in my opinion no country has implemented alcohol control yet as alcohol control must be comprehensive with robust measures. Minimum alc...

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  • Stress and Cancer: India being the vulnerable Asian country

    Stress resilience and cancer risk: a nationwide cohort study (Journal of Epidemiology and Community Health, Volume 71 Issue 10) was a real eye opener to throw light on a new arena of cancer studies. This could be a serious issue in a developing country like India, where the number of patients diagnosed with cancer is shooting up quite alarmingly[1]. The data of National Institute of Cancer Prevention and Research ( September 2017) highlights that, people living with cancer in India is estimated to be around 2.5 million, more than 7 lakh people are newly diagnosed with cancer every year and 5,56,400 people died in 2016 alone, due to this deadly disease[2]. The burden of Thyroid cancer in India has signalled the health authority as the people suffering from thyroid cancer is more than 10 million in the population of 1.324 billion[3].
    Official statistics reveal that there are only about 2000 oncologists in India to treat 10 million cancer patients and the ratio of oncologists to cancer patients is about 1:5,000, whereas, the US has a ratio of about 1:100. There are only 27 Regional Cancer Centres (RCC) in India, which are funded by Central and State Governments and 300 general hospitals. These institutions with inadequate staff, amalgamated with other constraints like financial burden and supply chain challenges make the treatment of cancer even worse[4].
    The escalating cost of cancer treatment in corporate hospitals have made the treatment a night mare for common...

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  • A chicken and egg conundrum

    This paper is a welcome addition to attempts to explain the effects of the increased deaths in 2015 and beyond. Based on a 25-year career in NHS analysis and demand forecasting may I point out that these recurring periods of higher deaths and medical admissions are always accompanied by higher delayed discharges. Observations such as the association between delayed discharges and deaths/medical admissions have, unfortunately, never been published, however, the curious association between increased deaths and medical admissions has been published. Rather than cite over 100 studies the reader is advised to go to a list of publications at http://www.hcaf.biz/2010/Publications_Full.pdf where multiple aspects of cause and effect and possible causes have been explored.

    Time lags are evident, with unexplained increased deaths always lagging unexplained increased emergency admissions, and lags between males and females evident in very small area geographies. Admissions for particular diagnoses rise while others fall during these curious events. Casemix severity may well be affected.

    While it is clear that austerity has only exacerbated the impact of the current event on delayed discharges, as noted by the authors, I would be reluctant to say which trends are cause and effect, and which trends arise from association rather than causation.

    The clear message is that far more research is required by both...

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  • Do cardiometabolic, behavioural and socioeconomic factors explain the ‘healthy migrant effect’ in the UK? Linked mortality follow-up of South Asians compared with white Europeans in the Newcastle Heart Project

    We thank Timaeus and Scott for drawing readers' attention to our interpretation(1) of their data which differs from their own(2) (rapid response 28/7/2017). We are glad to explain our thinking especially as the issues go beyond their data and to the concepts and the UK quantitative evidence. We agree that in their paper after adjustment for three socio-economic and an area of residence variables the mortality rate ratios are lower in South Asian groups than in the White group.(2) The explanation for our different interpretation is that we placed emphasis on their model adjusting mortality for age, sex and period while they emphasised the results of models further adjusting for socio-economic status and residence.(2)

    Generally the ‘healthy migrant effect’ is considered as unexpected and hence a paradox because immigrant populations sometimes have better health, most usually mortality, despite their socio-economic and other disadvantages.(3, 4) It is not generally understood as an effect that arises after adjustments for socio-economic and other related factors. In Timaeus and Scott’s model 1 the rate ratios for Indian, Pakistani and Bangladeshi populations born abroad and participating in the Longitudinal Study in England and Wales are shown in their table 5 and were 0.91, 0.95 and 1.01 with the 95% confidence intervals all including the reference value of 1. In model 1, the point estimates of the rate ratios for the same ethnic groups born in the UK were simil...

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