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...
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.
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...
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.
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.
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 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 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
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
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...
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 prevalence estimates for hypothyroidism. 3 Finally, The sample size for the individual level fluoride status was much smaller that the full sample and not reported fully within the paper; indeed, Statistics Canada prohibited the authors from carrying out some analyses due to ‘sample sizes requirements’. It is reasonable to estimate that no more than 15 people with hypothyroidism are likely to be included in the sample reported in table 3; this raises questions about the statistical power of this analysis.
Barberio et al suggest that the differences in findings could be – in part - due to iodine deficiency in England; however, they did not refer to the most recent data which showed that iodine intake was adequate in all age/sex groups.5 We suggest that the different classification of hypothyroidism prevalence and potential weaknesses in the statistical analysis account for the different findings of the two studies. We believe the following questions need to be answered:
1. How certain are they that participants understood they were being asked specifically about hypothyroidism when asked if they had a ‘thyroid condition’?
2. Why do they think age and sex, which are uncontentious predictors of hypothyroidism, do not provide any predictive value in the model of the biomarker TSH (presented in Table 2b)?
3. What was the statistical power for the comparisons presented in tables 3a and b?
Without further clarification of these issues, it is not possible to have confidence in the findings reported by Barberio et al, and we do not accept that their study refutes our findings. However, we do agree with Barberio et al and other commentators that more individual level analyses are required to explore the relationship between thyroid function and fluoride exposure.
References:
1. Barberio AM, Hosein FS, Quiñonez C, McLaren L. Fluoride exposure and indicators of thyroid functioning in the Canadian population: implications for community water fluoridation. J Epidemiol Community Health. 2017 Oct 1;71(10):1019-25.
2. Peckham S, Lowery D, Spencer S. Are fluoride levels in drinking water associated with hypothyroidism prevalence in England? A large observational study of GP practice data and fluoride levels in drinking water. J Epidemiol Community Health 2015;69:619–24.
3. Rotermann, M., Sanmartin, C., Hennessy, D., & Arthur, M. (2014). Prescription medication use by Canadians aged 6 to 79. Health reports, 25(6), 3.
4. Banks E, Beral V, Cameron R, Hogg A, Langley N, Barnes I, Bull D, Elliman J, Harris CL. Agreement between general practice prescription data and self-reported use of hormone replacement therapy and treatment for various illnesses. Journal of Epidemiology and Biostatistics. 2001 Jul 1;6(4):357-63.
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...
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 alcohol pricing and health warnings indicating alcohol is a carcinogen are pre-requisites. Alcohol is a human carcinogen (Class 1) with dose-related increases in prevalence of cancers beginning, at the 1-2 drinks/day (10-20g). Happily, Yukon, a small territory in Canada, implemented this November mandatory labels warning of an elevated risk of cancer on alcoholic beverages.(8)
Coincidentally, reducing nicotine content and banning menthol, the most effective measures for tobacco control are not implemented even in countries targeting the tobacco endgame. However, as a skeptic I do not believe in coincidence. Could the fox be the one in charge of the henhouse?
1 Madureira-Lima J, Galea S. Alcohol control policies and alcohol consumption: an international comparison of 167 countries. J Epidemiol Community Health. 2017. Online Oct 23. doi: 10.1136/jech-2017-209350.
2 Guérin S, Laplanche A, Dunant A, Hill C. Alcohol-attributable mortality in France. Eur J Public Health. 2013;23(4):588-93.
3 Braillon A, Dubois G. Alcohol control policy: evidence-based medicine versus evidence-based marketing. Addiction 2011;106(4):852-3.
4 Gallopel-Morvan K, Spilka S, Mutatayi C, Rigaud A, Lecas F, Beck F. France's Évin Law on the control of alcohol advertising: content, effectiveness and limitations. Addiction 2017;112 (Suppl 1):86-93.
5 Braillon A. Pinnochio awards: Public Health Responsibility Deal among the nominees! Health Policy. 2017;121(1):92-93.
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...
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 man in India, although the smaller segment of the society can afford it with health insurance and other health care schemes. WHO report shows around 38 million Indians suffer from stress and anxiety. There are only fewer research studies done in the area of stress and cancer in India. Ministry of Health and Family Welfare, Government of India and Indian Council of Medical Research (ICMR) should focus research studies on this road, which is still less travelled.
Biju Soman, Aswathi Raj Lathika.
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...
Show MoreIn 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
Show MoreWe 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...
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.
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 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 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 MoreThe 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 MoreBarberio 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...
Show MoreMadureira-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...
Show MoreStress 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].
Show MoreOfficial 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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