We thank Professors Bartick and Tomori for their comments on our paper. [1] We entirely agree that unexplained death in infancy (UDI) in the (mainly White British) general population of England and Wales is strongly associated with deprivation, as shown by many previous studies. Clearly, any factor that is associated with deprivation among the White British group will be a risk factor for UDI in the general population.
However, our paper is about ethnic, not socio-economic, variation. [2] The finding of a nearly five-fold disparity in risk across ethnic groups in England and Wales is both striking and novel. Moreover, we demonstrate that this disparity is not explained by deprivation. Formal adjustment for deprivation (IMD quintiles) does not even slightly reduce the ethnic variation (see Table 2). A simple scatter plot of ethnic groups illustrates the lack of a relationship between deprivation and risk, with a virtually horizontal overall trend line (see Figure at https://doi.org/10.5287/bodleian:XmE4XBaoZ). For example, Black Caribbean babies have nearly triple the UDI risk of Black African babies, but similar levels of deprivation. The Indian, Pakistani and Bangladeshi ethnic groups each have around half the UDI risk of White British babies; the White British and Indian groups have similar (relatively low) levels of deprivation, and the Pakistani and Bangladeshi groups are the most deprived in England and...
We thank Professors Bartick and Tomori for their comments on our paper. [1] We entirely agree that unexplained death in infancy (UDI) in the (mainly White British) general population of England and Wales is strongly associated with deprivation, as shown by many previous studies. Clearly, any factor that is associated with deprivation among the White British group will be a risk factor for UDI in the general population.
However, our paper is about ethnic, not socio-economic, variation. [2] The finding of a nearly five-fold disparity in risk across ethnic groups in England and Wales is both striking and novel. Moreover, we demonstrate that this disparity is not explained by deprivation. Formal adjustment for deprivation (IMD quintiles) does not even slightly reduce the ethnic variation (see Table 2). A simple scatter plot of ethnic groups illustrates the lack of a relationship between deprivation and risk, with a virtually horizontal overall trend line (see Figure at https://doi.org/10.5287/bodleian:XmE4XBaoZ). For example, Black Caribbean babies have nearly triple the UDI risk of Black African babies, but similar levels of deprivation. The Indian, Pakistani and Bangladeshi ethnic groups each have around half the UDI risk of White British babies; the White British and Indian groups have similar (relatively low) levels of deprivation, and the Pakistani and Bangladeshi groups are the most deprived in England and Wales.
In the paper we discuss various potential mediators of the ethnic differences, including sleep practices [3] breastfeeding [4,5] and tobacco use [6], based on the ethnic-specific prevalence of these factors in prior survey data. We suggest that careful comparison of ethnic patterns of exposure and outcome might lead to a better understanding of the aetiology of these very distressing deaths.
1. Bartick M, Tomori C. Deprivation is the most striking finding of this study; other known risk factors must be explored to explain ethnic variation. 2018. https://jech.bmj.com/content/early/2018/07/04/jech-2018-210453.responses....
2. Kroll ME, Quigley MA, Kurinczuk JJ, et al. Ethnic variation in unexplained deaths in infancy, including sudden infant death syndrome (SIDS), England and Wales 2006-2012: national birth cohort study using routine data. J Epidemiol Community Health 2018;72(10):911-18. doi: 10.1136/jech-2018-210453
3. Farooqi S, Perry IJ, Beevers DG. Ethnic differences in infant-rearing practices and their possible relationship to the incidence of sudden infant death syndrome (SIDS). Paediatr Perinat Epidemiol 1993;7(3):245-52.
4. Griffiths LJ, Tate AR, Dezateux C. The contribution of parental and community ethnicity to breastfeeding practices: evidence from the Millennium Cohort Study. Int J Epidemiol 2005;34(6):1378-86. doi: 10.1093/ije/dyi162
5. Griffiths LJ, Tate AR, Dezateux C, et al. Do early infant feeding practices vary by maternal ethnic group? Public Health Nutr 2007;10(9):957-64. doi: 10.1017/S1368980007665513
6. Wardle H. Use of tobacco products. Health Survey for England 2004: the health of minority ethnic groups: The Information Centre 2006:93-129.
We congratulate the authors on this timely and interesting study: ‘Political views of doctors in the UK: a cross-sectional study’ [1]. We address Question 12, asking whether doctors agree that ‘Patients should be charged for non-urgent care if they are not eligible for free NHS treatment’.
The authors correctly state that agreement does not mean support for current NHS charging regulations, not least because the most recent amendments in England were introduced after this questionnaire (October 2017 [2]), however we remain concerned about potential misinterpretation, and suggest aspects of charging regulations where doctors’ opinions could be further explored.
Firstly, the question, which understandably echoes government policy language on charging, is similar to asking ‘Should people have to pay for things that are not free?’ without addressing complexity of eligibility, and the fact that some people living in the UK have lost their eligibility with recent regulations. An assessment of opinions would require measuring knowledge of charging and its relationship with immigration enforcement, as well as evaluating acceptance of the immigration system itself, as this now determines eligibility. Windrush patients being denied NHS treatment highlighted the complexity of this issue [3].
Secondly, doctors’ opinions on measures which penalise and threaten patients if they seek care, such as linking unpaid NHS debt to immigration enforcement [4], and NHS data shar...
We congratulate the authors on this timely and interesting study: ‘Political views of doctors in the UK: a cross-sectional study’ [1]. We address Question 12, asking whether doctors agree that ‘Patients should be charged for non-urgent care if they are not eligible for free NHS treatment’.
The authors correctly state that agreement does not mean support for current NHS charging regulations, not least because the most recent amendments in England were introduced after this questionnaire (October 2017 [2]), however we remain concerned about potential misinterpretation, and suggest aspects of charging regulations where doctors’ opinions could be further explored.
Firstly, the question, which understandably echoes government policy language on charging, is similar to asking ‘Should people have to pay for things that are not free?’ without addressing complexity of eligibility, and the fact that some people living in the UK have lost their eligibility with recent regulations. An assessment of opinions would require measuring knowledge of charging and its relationship with immigration enforcement, as well as evaluating acceptance of the immigration system itself, as this now determines eligibility. Windrush patients being denied NHS treatment highlighted the complexity of this issue [3].
Secondly, doctors’ opinions on measures which penalise and threaten patients if they seek care, such as linking unpaid NHS debt to immigration enforcement [4], and NHS data sharing with the Home office in general, should also be explored.
Thirdly, assessing acceptability of charging for non-urgent treatment should address pricing, and whether treatment should be denied without payment. The current system enforces denial of non-urgent treatment unless 150% is paid upfront in secondary care and some community services, and urgent care is chargeable retrospectively. Furthermore, ‘urgency’ should be defined, given that life-saving chemotherapy has been denied in the current system.
Lastly, an assessment should explore attitudes to charging vulnerable groups including children, pregnant women, refused asylum seekers and undocumented migrants. Discussions often focus on ‘health tourism’, overlooking the population of undocumented migrants living in the UK, including an estimated 120,000 children [5]. By denying care to these groups the UK’s approach is inconsistent with many comparable countries, and breeches international human rights law [6].
The authors showed that public health specialists had greater disagreement with the statement, perhaps due to greater awareness of current regulations. We suggest that greater awareness raising amongst heath-workers is crucial, and would change opinions. As more patients are denied or deterred from care with new changes, doctors will be instrumental in collecting evidence of harm, and as advocates for our patients.
Word count: 406
Dr Robert Verrecchia, Public Health Registrar, Imperial College Healthcare NHS Trust
Dr Neal Russell, Clinical Research Fellow and Paediatric Registrar, St George’s University, London
Dr Jessica Potter, Clinical Research Fellow and Respiratory Registrar, Queen Mary University, London
1. Mandeville KL, Satherley R-M, Hall JA, et al (2018) Political views of doctors in the UK: a cross-sectional study. Journal of Epidemiology and Community Health Published Online First: 30 July 2018. doi: 10.1136/jech-2018-210801
2. GOV.UK. (2018) Guidance on implementing the overseas visitor charging regulations. UK Government: Department of Health and Social Care. Available at: https://assets.publishing.service.gov.uk/government/uploads/system/uploa... Accessed on 12.08.2018
3. Gentleman A. (2018) Londoner denied NHS care: 'It's like I'm being left to die' The Guardian Available at: https://wwwtheguardiancom/uk-news/2018/mar/10/denied-free-nhs-cancer-car.... Accessed on 12.08.2018
4. Corbett J. (2018) Response to the Independent Chief Inspector of Borders and Immigration's call for evidence: Home Office partnership working with other govenment departments https://www.doctorsoftheworld.org.uk/Handlers/Download.ashx?IDMF=0ab1fbf..., Accessed on 12.08.2018
5. Sigona N, Hughes, V. . (2012) No Way Out, No Way In. Irregular Migrant Children and Families in the UK https://www.compas.ox.ac.uk/wp-content/uploads/PR-2012-Undocumented_Migr... ESRC Centre on Migration, Policy and Society Accessed on 12.08.2018
6. CESCR. (2000)Committee on Economic, Social and Cultural Rights: The Right to the Highest Attainable Standard of Health (Article 12) http://www.refworld.org/pdfid/4538838d0.pdf: Office of the High Commissioner for Human Rights, Accessed on 12.08.2018
We read with interest the article by Kroll et al., “Ethnic variation in unexplained death in infancy, including sudden infant death syndrome (SIDS), England and Wales 2006-12: national birth cohort study using routine data”[1]. While the five-fold disparity in death rates across ethnic groups is notable, the most striking finding was marked association of infant death with deprivation seen in Table 1, with an OR of 3.45 (95% CI 2.82-4.23) between the most deprived group and the least deprived group. Indeed, 69% of deaths were found in the two most deprived quintiles. The analytical attention on ethnic variation in the paper overshadows the central finding that the majority of risk is driven by poverty.
Furthermore, unmarried status is a potent indicator of socioeconomic status that may cluster with poverty, lack of social support and experiences of racial discrimination. The remaining variation that the paper attributes to possible cultural variation must be broken down into specific known risk factors, such as tobacco exposure, sleep position, preterm birth, alcohol and substance abuse, lack of prenatal care, formula feeding, sofa sharing, and the combination of bedsharing with these other risk factors[2].These known risk factors are also largely clustered around poverty. Even sleep position is indirectly associated with poverty via formula feeding, as videographic data show that bedsharing formula feeding infants are more likely to assume hazardous sleep position...
We read with interest the article by Kroll et al., “Ethnic variation in unexplained death in infancy, including sudden infant death syndrome (SIDS), England and Wales 2006-12: national birth cohort study using routine data”[1]. While the five-fold disparity in death rates across ethnic groups is notable, the most striking finding was marked association of infant death with deprivation seen in Table 1, with an OR of 3.45 (95% CI 2.82-4.23) between the most deprived group and the least deprived group. Indeed, 69% of deaths were found in the two most deprived quintiles. The analytical attention on ethnic variation in the paper overshadows the central finding that the majority of risk is driven by poverty.
Furthermore, unmarried status is a potent indicator of socioeconomic status that may cluster with poverty, lack of social support and experiences of racial discrimination. The remaining variation that the paper attributes to possible cultural variation must be broken down into specific known risk factors, such as tobacco exposure, sleep position, preterm birth, alcohol and substance abuse, lack of prenatal care, formula feeding, sofa sharing, and the combination of bedsharing with these other risk factors[2].These known risk factors are also largely clustered around poverty. Even sleep position is indirectly associated with poverty via formula feeding, as videographic data show that bedsharing formula feeding infants are more likely to assume hazardous sleep positions than breastfeeding infants[3], and prone sleep is generally not seen in breastfeeding infants sleeping with their mothers[4].
While some of the ethnic variation may be driven by genuine cultural traditions, without data on other major known risk factors of SUID associated with poverty, this analysis could lead to a mistaken overemphasis on ethnicity.
1 Kroll ME, Quigley MA, Kurinczuk JJ, et al. Ethnic variation in unexplained deaths in infancy, including sudden infant death syndrome (SIDS), England and Wales 2006-2012: national birth cohort study using routine data. J Epidemiol Community Health 2018.
2 Bartick M, Tomori C. Sudden infant death and social justice: A syndemics approach. Matern Child Nutr 2018 Aug 23:e12652.{Epub ahead of print].
3 Ball HL. Parent-infant bed-sharing behavior : Effects of feeding type and presence of father. Hum Nat 2006;17:301-18.
4 Richard C, Mosko S, McKenna J, et al. Sleeping position, orientation, and proximity in bedsharing infants and mothers. Sleep 1996;19:685-90.
It is bittersweet to see one’s predictions of a fall in life expectancy coming into being.
I work on statistics, but also talk to patients regularly about their diets, lifestyles and
environments. The medical service struggles to deal with the results of poor diet and
pollution. Perhaps it is time for a health service to deal with the causes of illness.
Ancel Keys crusaded against fats. He cherry picked data from only 6 of the available
22 countries. Sugar was then used to make low fat food palatable. Fructose and
galactose, in sugar, milk, corn syrup and fruit, are implicated in cancer, heart disease,
dementia and diabetes.
Are the NHS and social care the priorities? Perhaps money to buy good food is more
important, and maybe we have too much medicine, not too little. I have seen patients
taking up to 29 different drugs. No pharmacologist can work out how they interact.
One patient took 5 drugs for his asthma. People complain of drug side effects and are
just given more drugs to deal with these symptoms.
The Depression was forgotten, and it was assumed we could keep becoming richer,
until 2008. Similarly we cannot just extrapolate the increasing life expectancy figures.
Public health improved after building reservoirs, chlorinating water, installing sewage
systems, reducing overcrowding and setting up smokeless zones.
However, chemical production has increased greatly...
It is bittersweet to see one’s predictions of a fall in life expectancy coming into being.
I work on statistics, but also talk to patients regularly about their diets, lifestyles and
environments. The medical service struggles to deal with the results of poor diet and
pollution. Perhaps it is time for a health service to deal with the causes of illness.
Ancel Keys crusaded against fats. He cherry picked data from only 6 of the available
22 countries. Sugar was then used to make low fat food palatable. Fructose and
galactose, in sugar, milk, corn syrup and fruit, are implicated in cancer, heart disease,
dementia and diabetes.
Are the NHS and social care the priorities? Perhaps money to buy good food is more
important, and maybe we have too much medicine, not too little. I have seen patients
taking up to 29 different drugs. No pharmacologist can work out how they interact.
One patient took 5 drugs for his asthma. People complain of drug side effects and are
just given more drugs to deal with these symptoms.
The Depression was forgotten, and it was assumed we could keep becoming richer,
until 2008. Similarly we cannot just extrapolate the increasing life expectancy figures.
Public health improved after building reservoirs, chlorinating water, installing sewage
systems, reducing overcrowding and setting up smokeless zones.
However, chemical production has increased greatly since 1945, polluting air and
water. Many chemicals are in household products. Animal feed is often from poorly
tested GM crops. One food can contain a variety of pesticides, herbicides and food
additives. Heavy traffic pollutes the towns. Cars and machines have made exercise
optional. Antibiotics have been abused in agriculture and medicine, damaging gut
bacteria and producing drug resistant infections. Amalgam fillings, fluorescent lights
and some vaccines contain mercury. Vaccines and some water supplies contain
aluminium. People are exposed to cordless phones, microwaves, phone masts and
wifi. Over the counter, prescription, alcohol and illegal drugs interact. Many drugs
cause nutritional deficiencies, for example statin drugs cause coenzyme Q10
deficiency. Food banks cannot provide fresh food. People have had to move away
from their families to find work, and are no longer nearby to help relatives. These
factors interact.
The increases in, autism, asthma, dementia, diabetes and cancer should warn us to
make life healthier for the population, rather than dealing with damage already done.
We should maximise healthy life expectancy, not mere existence.
References:
1. Moss M, Freed D. The Cow and the Coronary: Epidemiology,
Biochemistry and Immunology. Int J Cardiol 2003; 87: 203-216.
2. Moss M. Drugs as Anti-nutrients. J Nutr Env Med 2007; 16(2):149-
166. DOI: 10.1080/13590840701352740.
In “Years of life lost due to encounters with law enforcement in the USA, 2015–2016,” Bui et al. estimate the public health impact of police use of force by a simple computation of the years of life lost by the people killed by police.[1] Unnecessary use of force by police is a problem demanding serious attention, and leadership in policing has responded with interventions and training in recent years to improve de-escalation techniques and reduce the incidence of unnecessary or unlawful use of force. Bui et al.’s analysis, however, fails to consider three key factors in these analyses: first, the distinction between necessary and unnecessary/unlawful uses of force; second, the potential impacts on years of life lost had the police not have intervened in these specific scenarios; and third, the broader impacts of police intervention on public health.
Police may use lethal force when they have sufficient reason to believe that a person poses a risk of serious physical injury or death to another person. A reporter for The Washington Post concludes that “the vast majority of individuals shot and killed by police officers… were armed with guns and killed after attacking police officers or civilians or making other direct threats.”[2] Unnecessary or unjustified use of force by police are thought to account for about five percent of the total number of incidents of use of force,[2] with great skeptics acknowledging they are certainly fewer than 50%.[3] Including sensitivit...
In “Years of life lost due to encounters with law enforcement in the USA, 2015–2016,” Bui et al. estimate the public health impact of police use of force by a simple computation of the years of life lost by the people killed by police.[1] Unnecessary use of force by police is a problem demanding serious attention, and leadership in policing has responded with interventions and training in recent years to improve de-escalation techniques and reduce the incidence of unnecessary or unlawful use of force. Bui et al.’s analysis, however, fails to consider three key factors in these analyses: first, the distinction between necessary and unnecessary/unlawful uses of force; second, the potential impacts on years of life lost had the police not have intervened in these specific scenarios; and third, the broader impacts of police intervention on public health.
Police may use lethal force when they have sufficient reason to believe that a person poses a risk of serious physical injury or death to another person. A reporter for The Washington Post concludes that “the vast majority of individuals shot and killed by police officers… were armed with guns and killed after attacking police officers or civilians or making other direct threats.”[2] Unnecessary or unjustified use of force by police are thought to account for about five percent of the total number of incidents of use of force,[2] with great skeptics acknowledging they are certainly fewer than 50%.[3] Including sensitivity analyses to account for necessary versus unnecessary/unlawful use of force, including the range of reasonable estimates of the proportion of incidents in which use of force was unjustified, would allow for more meaningful insights from Bui et al.’s estimates.
Additionally, as noted above, police use of lethal force often occurs in the context of imminent threats to the safety of others. So one of the counterfactuals of police use of force is the years of life that would have been lost were it not for police intervention. These are not merely co-occurring outcomes; one specifically seeks to bring about the other. In the language of public health, police use of force is intended to reduce imminent risks of morbidity and mortality. Estimates for years of potential life lost by other potential victims, had the police not intervened, are entirely missing from Bui et al.’s model.
Finally, there are broader impacts of policing at the individual and population levels that are not captured in these analyses. The substantial reduction in homicide in America over the past two and a half decades has been characterized as a “public health triumph,” and police work—including the use of force in the face of imminent morbidity and mortality risks—has played a non-negligible part in it. It has added hundreds of thousands of years of life to the population, since, for example, “the impact of the decline in homicide on the life expectancy of black men is roughly equivalent to the impact of eliminating obesity altogether.”[4]
To compare the deaths caused by policing to those caused meningitis or bicycle crashes is facile because unlike diseases or accidents, policing is an intervention. When police interventions are done well, they also stand to reduce their own incidence: for example, as the violent crime rate in New York City decreased precipitously, so did the need for its police to make forceful interventions.[5] As a result, shootings by police in New York City have fallen to record lows along with violent crime.[6]
In that same way public health officials seek to reduce the iatrogenic effects of interventions (think of the prescribing of opioid analgesics), police seek ways to reduce the use of unnecessary and unlawful force, and to make force less necessary to begin with. Practitioners have made strides in this regard. The police killing of unarmed people has shown significant declines in the US in the last three years,[7] and innovative use of force curricula are being introduced across the nation.[8]
The victims whose lives were saved by police interventions may have counterfactual stories to tell, but they are not just anecdotal. The interventionist nature of policing should shape the structure of research questions. Future models estimating the impact of use of police force on public health outcomes should explicitly account for justified versus unjustified use of force, the counterfactual of lack of police intervention, and the broader context of policing efforts on the outcomes of interest to more precisely estimate the magnitude of the impact of unlawful police intervention on public health. In a model with these additional inputs, the 57,754 years of life lost due to use of force by police in 2016 would likely decline to a level well below the threshold of a public health emergency from a population-level perspective.
REFERENCES
[1] Bui AL, Coates MM, Matthay EC. Years of life lost due to encounters with law enforcement in the USA, 2015-2016. J Epidemiol Community Health 2018;72:715-8
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...
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
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...
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
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.
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...
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.
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.
We thank Professors Bartick and Tomori for their comments on our paper. [1] We entirely agree that unexplained death in infancy (UDI) in the (mainly White British) general population of England and Wales is strongly associated with deprivation, as shown by many previous studies. Clearly, any factor that is associated with deprivation among the White British group will be a risk factor for UDI in the general population.
However, our paper is about ethnic, not socio-economic, variation. [2] The finding of a nearly five-fold disparity in risk across ethnic groups in England and Wales is both striking and novel. Moreover, we demonstrate that this disparity is not explained by deprivation. Formal adjustment for deprivation (IMD quintiles) does not even slightly reduce the ethnic variation (see Table 2). A simple scatter plot of ethnic groups illustrates the lack of a relationship between deprivation and risk, with a virtually horizontal overall trend line (see Figure at https://doi.org/10.5287/bodleian:XmE4XBaoZ). For example, Black Caribbean babies have nearly triple the UDI risk of Black African babies, but similar levels of deprivation. The Indian, Pakistani and Bangladeshi ethnic groups each have around half the UDI risk of White British babies; the White British and Indian groups have similar (relatively low) levels of deprivation, and the Pakistani and Bangladeshi groups are the most deprived in England and...
Show MoreWe congratulate the authors on this timely and interesting study: ‘Political views of doctors in the UK: a cross-sectional study’ [1]. We address Question 12, asking whether doctors agree that ‘Patients should be charged for non-urgent care if they are not eligible for free NHS treatment’.
Show MoreThe authors correctly state that agreement does not mean support for current NHS charging regulations, not least because the most recent amendments in England were introduced after this questionnaire (October 2017 [2]), however we remain concerned about potential misinterpretation, and suggest aspects of charging regulations where doctors’ opinions could be further explored.
Firstly, the question, which understandably echoes government policy language on charging, is similar to asking ‘Should people have to pay for things that are not free?’ without addressing complexity of eligibility, and the fact that some people living in the UK have lost their eligibility with recent regulations. An assessment of opinions would require measuring knowledge of charging and its relationship with immigration enforcement, as well as evaluating acceptance of the immigration system itself, as this now determines eligibility. Windrush patients being denied NHS treatment highlighted the complexity of this issue [3].
Secondly, doctors’ opinions on measures which penalise and threaten patients if they seek care, such as linking unpaid NHS debt to immigration enforcement [4], and NHS data shar...
We read with interest the article by Kroll et al., “Ethnic variation in unexplained death in infancy, including sudden infant death syndrome (SIDS), England and Wales 2006-12: national birth cohort study using routine data”[1]. While the five-fold disparity in death rates across ethnic groups is notable, the most striking finding was marked association of infant death with deprivation seen in Table 1, with an OR of 3.45 (95% CI 2.82-4.23) between the most deprived group and the least deprived group. Indeed, 69% of deaths were found in the two most deprived quintiles. The analytical attention on ethnic variation in the paper overshadows the central finding that the majority of risk is driven by poverty.
Furthermore, unmarried status is a potent indicator of socioeconomic status that may cluster with poverty, lack of social support and experiences of racial discrimination. The remaining variation that the paper attributes to possible cultural variation must be broken down into specific known risk factors, such as tobacco exposure, sleep position, preterm birth, alcohol and substance abuse, lack of prenatal care, formula feeding, sofa sharing, and the combination of bedsharing with these other risk factors[2].These known risk factors are also largely clustered around poverty. Even sleep position is indirectly associated with poverty via formula feeding, as videographic data show that bedsharing formula feeding infants are more likely to assume hazardous sleep position...
Show MoreIt is bittersweet to see one’s predictions of a fall in life expectancy coming into being.
I work on statistics, but also talk to patients regularly about their diets, lifestyles and
environments. The medical service struggles to deal with the results of poor diet and
pollution. Perhaps it is time for a health service to deal with the causes of illness.
Ancel Keys crusaded against fats. He cherry picked data from only 6 of the available
22 countries. Sugar was then used to make low fat food palatable. Fructose and
galactose, in sugar, milk, corn syrup and fruit, are implicated in cancer, heart disease,
dementia and diabetes.
Are the NHS and social care the priorities? Perhaps money to buy good food is more
important, and maybe we have too much medicine, not too little. I have seen patients
taking up to 29 different drugs. No pharmacologist can work out how they interact.
One patient took 5 drugs for his asthma. People complain of drug side effects and are
just given more drugs to deal with these symptoms.
The Depression was forgotten, and it was assumed we could keep becoming richer,
until 2008. Similarly we cannot just extrapolate the increasing life expectancy figures.
Public health improved after building reservoirs, chlorinating water, installing sewage
systems, reducing overcrowding and setting up smokeless zones.
However, chemical production has increased greatly...
Show MoreIn “Years of life lost due to encounters with law enforcement in the USA, 2015–2016,” Bui et al. estimate the public health impact of police use of force by a simple computation of the years of life lost by the people killed by police.[1] Unnecessary use of force by police is a problem demanding serious attention, and leadership in policing has responded with interventions and training in recent years to improve de-escalation techniques and reduce the incidence of unnecessary or unlawful use of force. Bui et al.’s analysis, however, fails to consider three key factors in these analyses: first, the distinction between necessary and unnecessary/unlawful uses of force; second, the potential impacts on years of life lost had the police not have intervened in these specific scenarios; and third, the broader impacts of police intervention on public health.
Show MorePolice may use lethal force when they have sufficient reason to believe that a person poses a risk of serious physical injury or death to another person. A reporter for The Washington Post concludes that “the vast majority of individuals shot and killed by police officers… were armed with guns and killed after attacking police officers or civilians or making other direct threats.”[2] Unnecessary or unjustified use of force by police are thought to account for about five percent of the total number of incidents of use of force,[2] with great skeptics acknowledging they are certainly fewer than 50%.[3] Including sensitivit...
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...
Show MoreI 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...
Show MoreWe 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.
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...
Show MoreWe 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.
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