Protecting healthcare workers during a pandemic: what can a WHO collaborating centre research partnership contribute?

Objectives

To ascertain whether and how working as a partnership of two World Health Organization collaborating centres (WHOCCs), based respectively in the Global North and Global South, can add insights on "what works to protect healthcare workers (HCWs) during a pandemic, in what contexts, using what mechanism, to achieve what outcome".

Methods

A realist synthesis of seven projects in this research program was carried out to characterize context (C) (including researcher positionality), mechanism (M) (including service relationships) and outcome (O) in each project. An assessment was then conducted of the role of the WHOCC partnership in each study and overall.

Results

The research found that lower-resourced countries with higher economic disparity, including South Africa, incurred greater occupational health risk and had less acceptable measures to protect HCWs at the onset of the COVID-19 pandemic than higher-income more-equal counterpart countries. It showed that rigorously adopting occupational health measures can indeed protect the healthcare workforce; training and preventive initiatives can reduce workplace stress; information systems are valued; and HCWs most at-risk (including care aides in the Canadian setting) can be readily identified to trigger adoption of protective actions. The C-M-O analysis showed that various ways of working through a WHOCC partnership not only enabled knowledge sharing, but allowed for triangulating results and, ultimately, initiatives for worker protection.

Conclusions

The value of an international partnership on a North-South axis especially lies in providing contextualized global evidence regarding protecting HCWs as a pandemic emerges, particularly with bi-directional cross-jurisdiction participation by researchers working with practitioners.

Impacts of economic inequality on healthcare worker safety at the onset of the COVID-19 pandemic: cross-sectional analysis of a global survey

OBJECTIVES

To assess the extent to which protection of healthcare workers (HCWs) as COVID-19 emerged was associated with economic inequality among and within countries.

DESIGN

Cross-sectional analysis of associations of perceptions of workplace risk acceptability and mitigation measure adequacy with indicators of respondents' respective country's economic income level (World Bank assessment) and degree of within-country inequality (Gini index).

SETTING

A global self-administered online survey.

PARTICIPANTS

4977 HCWs and healthcare delivery stakeholders from 161 countries responded to health and safety risk questions and a subset of 4076 (81.2%) answered mitigation measure questions. The majority (65%) of study participants were female.

RESULTS

While the levels of risk being experienced at the pandemic's onset were consistently deemed as unacceptable across all groupings, participants from countries with less income inequality were somewhat less likely to report unacceptable levels of risk to HCWs regarding both workplace environment (OR=0.92, p=0.012) and workplace organisational factors (OR=0.93, p=0.017) compared with counterparts in more unequal national settings. In contrast, considerable variation existed in the degree to which mitigation measures were considered adequate. Adjusting for other influences through a logistic regression analysis, respondents from lower middle-income and low-income countries were comparatively much more likely to assess both occupational health and safety (OR=10.91, p≤0.001) and infection prevention and control (IPC) (OR=6.61, p=0.001) protection measures as inadequate, despite much higher COVID-19 rates in wealthier countries at the time of the survey. Greater within-country income inequality was also associated with perceptions of less adequate IPC measures (OR=0.94, p=0.025). These associations remained significant when accounting for country-level differences in occupational and gender composition of respondents, including specifically when only female care providers, our study's largest and most at-risk subpopulation, were examined.

CONCLUSIONS

Economic inequality threatens resilience of health systems that rely on health workers working safely to provide needed care during emerging pandemics.

Psychological Distress in South African Healthcare Workers Early in the COVID-19 Pandemic: An Analysis of Associations and Mitigating Factors

While the global COVID-19 pandemic has been widely acknowledged to affect the mental health of health care workers (HCWs), attention to measures that protect those on the front lines of health outbreak response has been limited. In this cross-sectional study, we examine workplace contextual factors associated with how psychological distress was experienced in a South African setting where a severe first wave was being experienced with the objective of identifying factors that can protect against HCWs experiencing negative impacts. Consistent with mounting literature on mental health effects, we found a high degree of psychological distress (57.4% above the General Health Questionnaire cut-off value) and a strong association between perceived risks associated with the presence of COVID-19 in the healthcare workplace and psychological distress (adjusted OR = 2.35, p < 0.01). Our research indicates that both training (adjusted OR 0.41, 95% CI 0.21−0.81) and the reported presence of supportive workplace relationships (adjusted OR 0.52, 95% CI 0.27−0.97) were associated with positive outcomes. This evidence that workplace resilience can be reinforced to better prepare for the onset of similar outbreaks in the future suggests that pursuit of further research into specific interventions to improve resilience is well merited.

Industrialization and food safety for the Tsleil-Waututh Nation: An analysis of chemical levels in shellfish in Burrard Inlet

While Indigenous food systems remain critical for community well-being, traditionally harvested foods are a potential source of toxic exposures. The Tsleil-Waututh Nation (TWN) is seeking to restore shellfish harvesting in Burrard Inlet (British Columbia [BC], Canada), where the cumulative effects of industrial activity have nearly eliminated safe harvesting. The Trans Mountain Expansion project would triple the capacity to transport oil through the inlet, threatening TWN's progress to restore shellfish harvesting. To inform ongoing efforts we assessed contamination by heavy metals (arsenic, cadmium, lead, and mercury) and 48 polycyclic aromatic hydrocarbons (PAHs) congeners in different shellfish species (Softshell clams, Varnish clams, and Dungeness crab) in three areas. We compared our results against local screening values (SVs) established by the TWN and BC Ministry of Environment and Climate Change Strategy, as well as provincial and national benchmarks. In total, we analyzed 18 composite samples of Softshell clams and Varnish clams (5 individuals per sample), as well as 17 individual crabs. We found chemical contamination in all species at all sites. PAHs were most frequently detected in Softshell clams, highest in the site closest to the pipeline terminus. Clams presented higher levels of contamination than crabs for PAHs, but not for heavy metals. For Softshell and Varnish clams, all heavy metals across study sites exceeded at least one of the population-specific SVs. Of the 14 PAHs detected, benzo(a)pyrene presented a median concentration in Softshell clams of 3.25 μ/kg, exceeding local SV for subsistence fisher. Our results call for further assessment of human health impacts related to food harvesting within Burrard Inlet and establishing a long-term coordinated program co-led by the TWN to monitor contamination and inform future harvesting programs. The study draws attention to the need to consider locally-relevant toxicity benchmarks, and include potential health impacts of food contamination in appraising development project proposals.

Using Artificial Intelligence for High-Volume Identification of Silicosis and Tuberculosis: A Bio-Ethics Approach

Although Artificial Intelligence (AI) is being increasingly applied, considerable distrust about introducing "disruptive" technologies persists. Intrinsic and contextual factors influencing where and how such innovations are introduced therefore require careful scrutiny to ensure that health equity is promoted. To illustrate one such critical approach, we describe and appraise an AI application - the development of computer assisted diagnosis (CAD) to support more efficient adjudication of compensation claims from former gold miners with occupational lung disease in Southern Africa. In doing so, we apply a bio-ethical lens that considers the principles of beneficence, non-maleficence, autonomy and justice and add explicability as a core principle. We draw on the AI literature, our research on CAD validation and process efficiency, as well as apprehensions of users and stakeholders. Issues of concern included AI accuracy, biased training of AI systems, data privacy, impact on human skill development, transparency and accountability in AI use, as well as intellectual property ownership. We discuss ways in which each of these potential obstacles to successful use of CAD could be mitigated. We conclude that efforts to overcoming technical challenges in applying AI must be accompanied from the onset by attention to ensuring its ethical use.

Mining, Colonial Legacies, and Neoliberalism: A Political Ecology of Health Knowledge : Minerıa, legados coloniales y neoliberalismo: una ecologıa polıtica del conocimiento en salud

Scholarship on the health impacts of resource extraction displays prominent gaps and apparent corporate and neocolonial footprints that raise questions about how science is produced. We analyze production of knowledge, on the health impacts of mining, carried out in relation to the Canadian International Resources and Development Institute (CIRDI), a university-based organization with substantial extractive industry involvement and links to Canada’s mining-dominated foreign policy. We use a “political ecology of knowledge” framework to situate CIRDI in the context of neoliberal capitalism, neocolonial sustainable development discourses, and mining industry corporate social responsibility techniques. We then document the interactions of specific health disciplinary conventions and knowledges within CIRDI-related research and advocacy efforts involving a major Canadian global health organization. This analysis illustrates both accommodation and resistance to large-scale political economic structures and the need to directly confront the global North governments and sectors pushing extractive-led neoliberal development globally.

Resumen

La investigación sobre los impactos en la salud de la extracción de recursos naturales delata brechas importantes y huellas corporativas y neocoloniales, que plantean dudas acerca de cómo se produce la ciencia. Analizamos la producción de conocimiento sobre los impactos en la salud de la minería en relación con el Instituto Canadiense de Desarrollo y Recursos Internacionales (CIRDI, siglas en inglés), una organización universitaria que cuenta con participación sustancial de la industria extractiva y tiene vínculos con la política exterior de Canadá, la cual es dominada por intereses mineros. Utilizamos un marco de "ecología política del conocimiento" para situar a CIRDI en el contexto del capitalismo neoliberal, los discursos neocoloniales de desarrollo sostenible y las técnicas de responsabilidad social corporativa de la industria minera. Luego, documentamos las interacciones entre los conocimientos y convenciones disciplinarias de salud dentro de los esfuerzos de investigación y promoción relacionados con CIRDI que involucran a una importante organización canadiense de salud global. Este análisis muestra tanto la complacencia como la resistencia a las estructuras políticas económicas a gran escala, y la necesidad de confrontar directamente a los gobiernos y sectores del Norte global que manejan el desarrollo neoliberal impulsado por la extracción a nivel mundial.

Towards TB elimination: how are macro-level factors perceived and addressed in policy initiatives in a high burden country?

BACKGROUND

Notwithstanding extensive general discussion of the effects of upstream forces on health, there has been limited empirical examination, let alone systematic evidence documenting policy responses to such pathways in the area of tuberculosis (TB) management and control. Our study aimed to gain insight into how macro level drivers of TB are perceived by key stakeholders involved in TB management and control in a high-endemic country, and to assess how such concerns are being addressed in policy initiatives in this setting. South Africa was chosen for this case study due to our team's long-standing collaborations there, its very high burden of TB, and its introduction of a strategic plan to combat this disease.

METHOD

Semi-structured interviews were conducted with 20 key informants who were purposively selected for their knowledge and expertise of TB in South Africa. South Africa's National Strategic Plan for HIV, TB and STIs 2017-2022 was then reviewed to examine how identified themes from the interviews were reflected in this policy document.

RESULTS

A history of colonization, the migrant labour system, economic inequality, poor shelter, health system challenges including TB governance, the HIV epidemic, and pertinent socio-cultural factors were all perceived to be major drivers of the epidemic. Although South Africa's current National Strategic Plan makes a firm discursive commitment to addressing the structural or macro-level drivers of TB, our analysis revealed that this commitment was not clearly reflected in projected budgetary allocations.

CONCLUSION

As in many other high burden settings, macro-level drivers of TB are widely recognized. Nonetheless, while micro-level (biomedical and clinical) measures, such as improving diagnostic procedures and investment in more efficacious drugs, are being (and well should be) implemented, our findings showed that macro-level drivers of TB are underrepresented in budgeting allocations for initiatives to combat this disease. Although it could be argued that structural drivers that undermine health-promoting actions are beyond the purview of the health sector itself, we argue that strategic plans to combat TB in high burden settings need more attention to directly considering such drivers to prompt the necessary changes and reduce the burden of this and other such diseases.

Preventing Occupational Tuberculosis in Health Workers: An Analysis of State Responsibilities and Worker Rights in Mozambique

Given the very high incidence of tuberculosis (TB) among health workers in Mozambique, a low-income country in Southern Africa, implementation of measures to protect health workers from occupational TB remains a major challenge. This study explores how Mozambique's legal framework and health system governance facilitate-or hinder-implementation of protective measures in its public (state-provided) healthcare sector. Using a mixed-methods approach, we examined international, constitutional, regulatory, and policy frameworks. We also recorded and analysed the content of a workshop and policy discussion group on the topic to elicit the perspectives of health workers and of officials responsible for implementing workplace TB policies. We found that despite a well-developed legal framework and national infection prevention and control policy, a number of implementation barrier persisted: lack of legal codification of TB as an occupational disease; absence of regulations assigning specific responsibilities to employers; failure to deal with privacy and stigma fears among health workers; and limited awareness among health workers of their legal rights, including that of collective action. While all these elements require attention to protect health workers from occupational TB, a stronger emphasis on their human and labour rights is needed alongside their perceived responsibilities as caregivers.

Current Guidelines for Protecting Health Workers from Occupational Tuberculosis Are Necessary, but Not Sufficient: Towards a Comprehensive Occupational Health Approach

Health workers globally are at elevated occupational risk of tuberculosis infection and disease. While a raft of guidelines have been published over the past 25 years on infection prevention and control (IPC) in healthcare, studies in different settings continue to show inadequate implementation and persistence of risk. The aim of this commentary is to argue, based on the literature and our own research, that a comprehensive occupational health approach is an essential complement to IPC guidelines. Such an approach includes a health system framework focusing on upstream or mediating components, such as a statutory regulation, leadership, an information system, and staff trained in protective disciplines. Within the classical prevention framework, primary prevention needs to be complemented by occupational health services (secondary prevention) and worker's compensation (tertiary prevention). A worker-centric approach recognises the ethical implications of screening health workers, as well as the stigma perceived by those diagnosed with tuberculosis. It also provides for the voiced experience of health workers and their participation in decision-making. We argue that such a comprehensive approach will contribute to both the prevention of occupational tuberculosis and to the ability of a health system to withstand other crises of infectious hazards to its workforce.

Workplace-Based Organizational Interventions Promoting Mental Health and Happiness among Healthcare Workers: A Realist Review

Mental illness, deemed globally to account for 32% of years lived with a disability, generates significant impacts on workplaces. In particular, healthcare workers experience high rates of mental ill health such as burnout, stress, and depression due to workplace conditions including excessive workloads, workplace violence and bullying, which also produces negative effects on patients as well as on the happiness and wellbeing of those who remain at work. This review was undertaken to synthesize the evidence on workplace-based interventions at the organizational level promoting mental health and wellbeing among healthcare workers, to identify what has been receiving attention in this area and why, especially considering how such positive effects are produced. A search of three premier health-related databases identified 1290 articles that discussed healthcare workers, workplace interventions, and mental health. Following further examination, 46 articles were ultimately selected as meeting the criteria specifying interventions at the organizational level and combined with similar studies included in a relevant Cochrane review. The 60 chosen articles were then analyzed following a realist framework analyzing context, mechanism, and outcome. Most of the studies included in the realist review were conducted in high-income countries, and the types of organizational-level interventions studied included skills and knowledge development, leadership development, communication and team building, stress management as well as workload and time management. Common themes from the realist review highlight the importance of employee engagement in the intervention development and implementation process. The literature review also supports the recognized need for more research on mental health and happiness in low- and middle-income countries, and for studies evaluating the longer-term effects of workplace mental health promotion.

Results Communication in Breast Milk Biomonitoring Studies: A Scoping Review and Stakeholder Consultation

Researchers investigating breast milk contamination face substantive ethical dilemmas regarding how biomonitoring results should be conveyed, with limited guidance available to help them. To identify effective processes for undertaking such research, we sought to critically assess practices being followed in reporting results. To consider how researchers have reported on this and related ethical issues, we searched three English-language databases for articles published between 2010-2016 on measuring presence of pesticides in breast milk. Data on report-back processes and discussed ethical issues were charted from retained articles (n=102). To deepen our understanding of issues, we further consulted authors (n=20) of retained articles through an online survey. Quantitative data from surveys were tabulated and qualitative data were analyzed thematically. Of 102 articles, only two mentioned sharing results with subjects, while 10 out of 20 survey participants confirmed that they had indeed conducted report-back in their studies. Articles discussing ethical considerations were few (n=5), although researchers demonstrated awareness of common ethical debates to inform report-back decisions. Our review suggests that greater explicit attention should be given to practices of engaging study subjects and their communities in contamination studies so that an evidence base on best ethical practices can be more readily available.

Tackling injustices of occupational lung disease acquired in South African mines: recent developments and ongoing challenges

BACKGROUND

South Africa's mineral resources have produced, and continue to produce, enormous economic wealth; yet decades of colonialism, apartheid, capital flight, and challenges in the neoliberal post-apartheid era have resulted in high rates of occupational lung disease and low rates of compensation for ex-miners and their families. Given growing advocacy and activism of current and former mine workers, initiatives were launched by the South African government in 2012 to begin to address the legacy of injustice. This study aimed to assess developments over the last 5 years in providing compensation, quantify shortfalls and explore underlying challenges.

METHODS

Using the database with compensable disease claims from over 200,000 miners, the medical assessment database of 400,000 health records and the employment database with 1.6 million miners, we calculated rates of claims, unpaid claims and shortfall in claim filing for each of the southern African countries with at least 25,000 miners who worked in South African mines, by disease type and gender. We also conducted interviews in Johannesburg, Eastern Cape, Lesotho and a local service unit near a mine site, supplemented by document review and auto-reflection, adopting the lens of a critical rights-based approach.

RESULTS

By the end of 2017, 111,166 miners had received compensation (of which 55,864 were for permanent lung impairment, and another 52,473 for tuberculosis), however 107,714 compensable claims remained unpaid. Many (28.4%) compensable claims are from Mozambique, Lesotho, Swaziland, Botswana and elsewhere in southern Africa, a large proportion of which have been longstanding. A myriad of diverse systemic barriers persist, especially for workers and their families outside South Africa. Calculating predicted burden of occupational lung disease compared to compensable claims paid suggests a major shortfall in filing claims in addition to the large burden of still unpaid claims.

CONCLUSION

Despite progress made, our analysis reveals ongoing complex barriers and illustrates that the considerable underfunding of the systems required for sustained prevention and social protection (including compensation) needs urgent attention. With class action suits in the process of settlement, the globalized mining sector is now beginning to be held accountable. A critical rights-based approach underlines the importance of ongoing concerted action by all.

Political Ecologies of Global Health: Pesticide Exposure in Southwestern Ecuador's Banana Industry

Pesticide exposure in Ecuador's banana industry reflects political economic and ecological processes that interact across scales to affect human health. We use this case study to illustrate opportunities for applying political ecology of health scholarship in the burgeoning field of global health. Drawing on an historical literature review and ethnographic data collected in Ecuador's El Oro province, we present three main areas where a political ecological approach can enrich global health scholarship: perceptive characterization of multi-scalar and ecologically entangled pathways to health outcomes; critical analysis of discursive dynamics such as competing scalar narratives; and appreciation of the environment-linked subjectivities and emotions of people experiencing globalized health impacts. Rapprochement between these fields may also provide political ecologists with access to valuable empirical data on health outcomes, venues for engaged scholarship, and opportunities to synthesize numerous insightful case studies and discern broader patterns.

Occupational tuberculosis in South Africa: are health care workers adequately protected?

Setting: A provincial tertiary hospital in Gauteng province, South Africa, with a high burden of tuberculosis (TB) patients and high risk of TB exposure among health care workers (HCWs). Objective: To determine HCWs' adherence to recommended TB infection prevention and control practices, TB training and access to health services and HCW TB rates. Design: Interviews with 285 HCWs using a structured questionnaire as part of a large, international mixed-methods study. Results: Despite 10 HCWs (including seven support HCWs) acquiring clinical TB during their period of employment, 62.8% of interviewees were unaware of the hospital's TB management protocol. Receipt of training was low (34.5% of all HCWs and <5% of support HCWs trained on TB transmission; 27.5% of nurses trained on respirator use), as was use of respiratory protection (44.5% of HCWs trained on managing TB patients). Support HCWs were over 36 times more likely to use respiratory protection if trained; nurses who were trained were approximately 40 times more likely to use respirators if they were readily available. Conclusion: Improved coordination and uptake of TB infection prevention training is urgently needed, especially for non-clinical HCWs in settings of regular exposure to TB patients. Adequate supplies of appropriate respiratory protection must be made available.

Protecting health workers from infectious disease transmission: an exploration of a Canadian-South African partnership of partnerships

BACKGROUND

Health workers are at high risk of acquiring infectious diseases at work, especially in low and middle-income countries (LMIC) with critical health human resource deficiencies and limited implementation of occupational health and infection control measures. Amidst increasing interest in international partnerships to address such issues, how best to develop such collaborations is being actively debated. In 2006, a partnership developed between occupational health and infection control experts in Canada and institutions in South Africa (including an institute with a national mandate to conduct research and provide guidance to protect health workers from infectious diseases and promote improved working conditions). This article describes the collaboration, analyzes the determinants of success and shares lessons learned.

METHODS

Synthesizing participant-observer experience from over 9 years of collaboration and 10 studies already published from this work, we applied a realist review analysis to describe the various achievements at global, national, provincial and hospital levels. Expectations of the various parties on developing new insights, providing training, and addressing service needs were examined through a micro-meso-macro lens, focusing on how each main partner organization contributed to and benefitted from working together.

RESULTS

A state-of-the-art occupational health and safety surveillance program was established in South Africa following successful technology transfer from a similar undertaking in Canada and training was conducted that synergistically benefitted Northern as well as Southern trainees. Integrated policies combining infection control and occupational health to prevent and control infectious disease transmission among health workers were also launched. Having a national (South-South) network reinforced by the international (North-south) partnership was pivotal in mitigating the challenges that emerged.

CONCLUSIONS

High-income country partnerships with experience in health system strengthening - particularly in much needed areas such as occupational health and infection control - can effectively work through strong collaborators in the Global South to build capacity. Partnerships are particularly well positioned to sustainably reinforce efforts at national and sub-national LMIC levels when they adopt a "communities of practice" model, characterized by multi-directional learning. The principles of effective collaboration learned in this "partnership of partnerships" to improve working conditions for health workers can be applied to other areas where health system strengthening is needed.

Food sovereignty, food security and health equity: a meta-narrative mapping exercise

There has been growing policy interest in social justice issues related to both health and food. We sought to understand the state of knowledge on relationships between health equity--i.e. health inequalities that are socially produced--and food systems, where the concepts of 'food security' and 'food sovereignty' are prominent. We undertook exploratory scoping and mapping stages of a 'meta-narrative synthesis' on pathways from global food systems to health equity outcomes. The review was oriented by a conceptual framework delineating eight pathways to health (in)equity through the food system: 1--Multi-Scalar Environmental, Social Context; 2--Occupational Exposures; 3--Environmental Change; 4--Traditional Livelihoods, Cultural Continuity; 5--Intake of Contaminants; 6--Nutrition; 7--Social Determinants of Health and 8--Political, Economic and Regulatory context. The terms 'food security' and 'food sovereignty' were, respectively, paired with a series of health equity-related terms. Combinations of health equity and food security (1414 citations) greatly outnumbered pairings with food sovereignty (18 citations). Prominent crosscutting themes that were observed included climate change, biotechnology, gender, racialization, indigeneity, poverty, citizenship and HIV as well as institutional barriers to reducing health inequities in the food system. The literature indicates that food sovereignty-based approaches to health in specific contexts, such as advancing healthy school food systems, promoting soil fertility, gender equity and nutrition, and addressing structural racism, can complement the longer-term socio-political restructuring processes that health equity requires. Our conceptual model offers a useful starting point for identifying interventions with strong potential to promote health equity. A research agenda to explore project-based interventions in the food system along these pathways can support the identification of ways to strengthen both food sovereignty and health equity.

Healthcare Worker Preferences for Active Tuberculosis Case Finding Programs in South Africa: A Best-Worst Scaling Choice Experiment

Objective

Healthcare workers (HCWs) in South Africa are at a high risk of developing active tuberculosis (TB) due to their occupational exposures. This study aimed to systematically quantify and compare the preferred attributes of an active TB case finding program for HCWs in South Africa.

Methods

A Best–Worst Scaling choice experiment estimated HCW’s preferences using a random-effects conditional logit model. Latent class analysis (LCA) was used to explore heterogeneity in preferences.

Results

“No cost”, “the assurance of confidentiality”, “no wait” and testing at the occupational health unit at one’s hospital were the most preferred attributes. LCA identified a four class model with consistent differences in preference strength. Sex, occupation, and the time since a previous TB test were statistically significant predictors of class membership.

Conclusions

The findings support the strengthening of occupational health units in South Africa to offer free and confidential active TB case finding programs for HCWs with minimal wait times. There is considerable variation in active TB case finding preferences amongst HCWs of different gender, occupation, and testing history. Attention to heterogeneity in preferences should optimize screening utilization of target HCW populations.

Why language matters: insights and challenges in applying a social determination of health approach in a North-South collaborative research program

Background

Focus on “social determinants of health” provides a welcome alternative to the bio-medical illness paradigm. However, the tendency to concentrate on the influence of “risk factors” related to living and working conditions of individuals, rather than to more broadly examine dynamics of the social processes that affect population health, has triggered critical reaction not only from the Global North but especially from voices the Global South where there is a long history of addressing questions of health equity. In this article, we elaborate on how focusing instead on the language of “social determination of health” has prompted us to attempt to apply a more equity-sensitive approaches to research and related policy and praxis.

Discussion

In this debate, we briefly explore the epistemological and historical roots of epidemiological approaches to health and health equity that have emerged in Latin America to consider its relevance to global discourse. In this region marked by pronounced inequity, context-sensitive concepts such as “collective health” and “critical epidemiology” have been prominent, albeit with limited acknowledgement by the Global North. We illustrate our attempts to apply a social determination approach (and the “4 S” elements of bio-Security, Sovereignty, Solidarity and Sustainability) in five projects within our research collaboration linking researchers and knowledge users in Ecuador and Canada, in diverse settings (health of healthcare workers; food systems; antibiotic resistance; vector borne disease [dengue]; and social circus with street youth).

Conclusions

We argue that the language of social determinants lends itself to research that is more reductionist and beckons the development of different skills than would be applied when adopting the language of social determination. We conclude that this language leads to more direct analysis of the systemic factors that drive, promote and reinforce disparities, while at the same time directly considering the emancipatory forces capable of countering negative health impacts. It follows that “reverse innovation” must not only recognize practical solutions being developed in low and middle income countries, but must also build on the strengths of the theoretical-methodological reasoning that has emerged in the South.

Labor Markets and Employment Insecurity: Impacts of Globalization on Service and Healthcare-sector Workforces

Global changes in the economies of most developed nations have impacted the way healthcare is organized, even within largely public systems, and the working conditions of healthcare workers. Since the acceleration of globalization in the 1970s, service-sector workers in developed nations have faced high unemployment, increased skill requirements for most jobs, and a rise in non-traditional work arrangements. These secular shifts in service-sector labor markets have occurred against the background of an erosion of the welfare state and growing income inequality. As well, many healthcare systems, including Canada's, were severely downsized and restructured in the 1990s, exacerbating the underlying negative secular trends in the service sector, and worsening the working conditions for many healthcare workers. Globalization has altered the labor market and shifted working conditions in ways that have been unfavorable to many healthcare workers.

Effectiveness of joint health and safety committees: a realist review

BACKGROUND

Joint health and safety committees (JHSCs) are widely acknowledged as important to a healthy and safe work environment. However, it is also generally believed that having a JHSC is necessary but not sufficient; the JHSC must be effective.

METHODS

A systematic review was undertaken to find empirical studies regarding the effectiveness of JHSCs; realist review methodology was applied to determine context-mechanism-outcome patterns. Experts from across Canada and from various sectors and perspectives including government, employers, and unions, were brought together to inform the synthesis.

RESULTS

Thirty-one studies met inclusion criteria. Mechanisms identified as important determinants of JHSC effectiveness across various jurisdictions include adequate information, education and training; appropriate committee composition; senior management commitment to JHSCs; and especially a clear mandate with a broad scope and corresponding empowerment (through legislation and/or union presence).

CONCLUSIONS

Consistent empowerment mechanisms emerge as determinants of successful JHSCs across contexts despite few evidence-based details for best practice implementation. Intervention research is warranted.

Workplace programmes for HIV and tuberculosis: a systematic review to support development of international guidelines for the health workforce

The health service sector has a vital role to play in delivering human immunodeficiency virus (HIV) and tuberculosis (TB) prevention, treatment and care, yet evidence indicates that healthcare workers (HCWs) themselves lack adequate access to HIV and TB services. HCWs are also at increased risk from TB and other infectious diseases at work, and therefore accessing HIV services is particularly important. A systematic review was therefore conducted to inform the development of World Health Organization (WHO) guidelines to improve access to HIV and TB services, and specifically, to assess the evidence regarding providing such services through workplace-based programmes. We identified any study published since 1984 that addressed outcomes of interest as defined through multi-stakeholder consultations, and were related to workplace interventions in (1) the healthcare workplace and (2) any workplace that included HIV and/or TB diagnosis and/or treatment. Interventions focusing solely on primary prevention with no diagnostic or treatment services were excluded, as they were the subject of other guidelines. A minimum of two reviewers independently extracted data and assessed the articles against pre-set selection criteria; studies were also profiled and quality assessed by a minimum of two reviewers. Three studies met these criteria specifically for HCWs; all showed a preponderance of positive benefits, with minimal negative outcome. Seven studies met these criteria regarding workplace HIV and/or TB diagnosis and/or treatment from other sectors, public or private. Again, all showed positive results. The paucity of high-quality evidence in this field of research was itself an important finding, beckoning further research on workplace-based programmes for health workers. Nonetheless, while more well-designed intervention studies are definitely desirable, providing programmes for HCWs to obtain HIV and TB diagnosis and treatment at the workplace is supported by the literature and is consistent with the values of the stakeholders, justifying the WHO-International Labour Organization-UNAIDS guidelines that emerged.

Tool, weapon, or white elephant? A realist analysis of the five phases of a twenty-year programme of occupational health information system implementation in the health sector

Background

Although information systems (IS) have been extensively applied in the health sector worldwide, few initiatives have addressed the health and safety of health workers, a group acknowledged to be at high risk of injury and illness, as well as in great shortage globally, particularly in low and middle-income countries.

Methods

Adapting a context-mechanism-outcome case study design, we analyze our team’s own experience over two decades to address this gap: in two different Canadian provinces; and two distinct South African settings. Applying a realist analysis within an adapted structuration theory framing sensitive to power relations, we explore contextual (socio-political and technological) characteristics and mechanisms affecting outcomes at micro, meso and macro levels.

Results

Technological limitations hindered IS usefulness in the initial Canadian locale, while staffing inadequacies amid pronounced power imbalances affecting governance restricted IS usefulness in the subsequent Canadian application. Implementation in South Africa highlighted the special care needed to address power dynamics regarding both worker-employer relations (relevant to all occupational health settings) and North–south imbalances (common to all international interactions). Researchers, managers and front-line workers all view IS implementation differently; relationships amongst the workplace parties and between community and academic partners have been pivotal in determining outcome in all circumstances. Capacity building and applying creative commons and open source solutions are showing promise, as is international collaboration.

Conclusions

There is worldwide consensus on the need for IS use to protect the health workforce. However, IS implementation is a resource-intensive undertaking; regardless of how carefully designed the software, contextual factors and the mechanisms adopted to address these are critical to mitigate threats and achieve outcomes of interest to all parties. Issues specific to IS development, including technological support and software licensing models, can also affect outcome and sustainability – especially in the North–south context. Careful attention must be given to power relations between the various stakeholders at macro, meso and micro levels when implementing IS. North–South-South collaborations should be encouraged. Governance as well as technological issues are crucial determinants of IS application, and ultimately whether the system is seen as a tool, weapon, or white elephant by the various involved parties.

"You may call me a fool, But was there a rule The weapon should be turned into a tool? And what do we see? The first tool I step on Turned into a weapon. - Robert Frost"

"White (albino) elephants were regarded as holy in ancient times in Thailand and other Asian countries. Keeping a white elephant was a very expensive undertaking, since the owner had to provide the elephant with special food and provide access for people who wanted to worship it. If a Thai King became dissatisfied with a subordinate, he would give him a white elephant. The gift would, in most cases, ruin the recipient. - The Phrase Finder"

Ecosystem approach to promoting appropriate antibiotic use for children in indigenous communities in Ecuador

OBJECTIVE

To collect baseline data on infectious diseases and antibiotic use in two Andean indigenous communities in Ecuador in order to determine the feasibility and acceptability of applying an ecosystem approach to address associated problems.

METHODS

In visits to 65 households with children under age 5 years, environmental risk factors for infectious diseases were evaluated through rapid assessment. Caregivers' knowledge, attitudes, and practices related to antibiotic use were determined through a knowledge, practices, and coverage survey; antibiotic use was gleaned from inspection of medicine chests; and overall health of the 91 children (including nutritional status) was assessed. A workshop was held to share results and to craft a multicomponent intervention using an ecohealth framework.

RESULTS

Numerous environmental risk factors were identified, especially related to water and sanitation. Knowledge, attitudes, and practices revealed use of traditional and Western medicines and serious knowledge gaps. Antibiotics were present in 60.9% of households in Correuco and 46.8% in La Posta; malnutrition rates were 22.2% in Correuco and 26.1% in La Posta; diarrheic episodes were experienced in the previous month by 26.7% of children in Correuco and 47.8% in La Posta, with antibiotics prescribed in 50.0% and 47.1% of cases, respectively; and acute respiratory infections were incurred by 28.9% of children in Correuco and 47.8% in La Posta, with antibiotics prescribed in 53.8% and 50.0% of cases, respectively.

CONCLUSIONS

Environmental, social, and cultural factors must be addressed to prevent antibiotic resistance in addition to training health personnel. An ecosystem approach is well-suited for this goal.

Establishing a community of practice of researchers, practitioners, policy-makers and communities to sustainably manage environmental health risks in Ecuador

BACKGROUND

The Sustainably Managing Environmental Health Risk in Ecuador project was launched in 2004 as a partnership linking a large Canadian university with leading Cuban and Mexican institutes to strengthen the capacities of four Ecuadorian universities for leading community-based learning and research in areas as diverse as pesticide poisoning, dengue control, water and sanitation, and disaster preparedness.

METHODS

In implementing curriculum and complementary innovations through application of an ecosystem approach to health, our interdisciplinary international team focused on the question: "Can strengthening of institutional capacities to support a community of practice of researchers, practitioners, policy-makers and communities produce positive health outcomes and improved capacities to sustainably translate knowledge?" To assess progress in achieving desired outcomes, we review results associated with the logic framework analysis used to guide the project, focusing on how a community of practice network has strengthened implementation, including follow-up tracking of program trainees and presentation of two specific case studies.

RESULTS

By 2009, train-the-trainer project initiation involved 27 participatory action research Master's theses in 15 communities where 1200 community learners participated in the implementation of associated interventions. This led to establishment of innovative Ecuadorian-led master's and doctoral programs, and a Population Health Observatory on Collective Health, Environment and Society for the Andean region based at the Universidad Andina Simon Bolivar. Building on this network, numerous initiatives were begun, such as an internationally funded research project to strengthen dengue control in the coastal community of Machala, and establishment of a local community eco-health centre focusing on determinants of health near Cuenca.

DISCUSSION

Strengthening capabilities for producing and applying knowledge through direct engagement with affected populations and decision-makers provides a fertile basis for consolidating capacities to act on a larger scale. This can facilitate the capturing of benefits from the "top down" (in consolidating institutional commitments) and the "bottom up" (to achieve local results).

CONCLUSIONS

Alliances of academic and non-academic partners from the South and North provide a promising orientation for learning together about ways of addressing negative trends of development. Assessing the impacts and sustainability of such processes, however, requires longer term monitoring of results and related challenges.

Which new approaches to tackling neglected tropical diseases show promise?

This PLoS Medicine Debate examines the different approaches that can be taken to tackle neglected tropical diseases (NTDs). Some commentators, like Jerry Spiegel and colleagues from the University of British Columbia, feel there has been too much focus on the biomedical mechanisms and drug development for NTDs, at the expense of attention to the social determinants of disease. Burton Singer argues that this represents another example of the inappropriate "overmedicalization" of contemporary tropical disease control. Peter Hotez and colleagues, in contrast, argue that the best return on investment will continue to be mass drug administration for NTDs.

An integrated ecosystem approach for sustainable prevention and control of dengue in Central Havana

The authors developed and evaluated a comprehensive participatory ecosystem health approach for preventing the transmission of dengue, the most prevalent vector-borne disease in Cuba and the Latin America-Caribbean region. The integrated surveillance system central to this initiative encompassed three main subsystems (environmental; entomological; clinical-epidemiologic), relying on extensive community involvement. The study was conducted in Central Havana, Cuba. Indicators from each subsystem were selected and mapped using a GIS procedure providing instant visualization by city block in the municipality. To elucidate the factors affecting control and prevention efforts, perceived needs and risks, as well as knowledge, attitudes, and behaviors related to dengue, were assessed. Specific factors associated with the presence of mosquito breeding sites and risks of dengue were examined in a case-control study.

Social and environmental determinants of Aedes aegypti infestation in Central Havana: results of a case-control study nested in an integrated dengue surveillance programme in Cuba

OBJECTIVE

To characterize the social and environmental risk factors associated with the presence of Aedes aegypti in order to improve community dengue control.

METHODS

A case-control study with 'cases' being households with entomologically confirmed A. aegypti infestation; personal interviews in Central Havana, a densely populated inner city area characterized by overcrowded housing and irregular water service. The participants were residents of 278 houses with infestation and 556 houses without infestation.

RESULTS

Greater risk of infestation was associated with lack of preventive measures, such as no larvicide in the water tanks (OR = 2.21) and use of flower vases for religious practice (1.93), not being economically active (1.64), vulnerable populations with higher risks in households with older people (1.52) and households with children (1.94).

CONCLUSIONS

Efforts to reduce infestations should continue to focus on water tank sanitation and improving housing conditions, but also engage community religious leaders to help promote safe practices. Vulnerable populations should be especially targeted by prevention activities. A surveillance programme can produce evidence to guide interventions.

Understanding "globalization" as a determinant of health determinants: a critical perspective

The purpose of this article is to explain how globalization has evolved, in order to provide a context for assessing the health care restructuring that is occurring worldwide. The authors begin by defining globalization and introducing a framework for considering pathways that can affect social organization and health. They then draw attention to current trends, such as the GATS (General Agreement on Trade in Services), that promise to open health services provision to increased pressures of globalization.

Lessons from the margins of globalization: appreciating the Cuban health paradox

It is widely recognized that Cuba, despite poor economic performance, has achieved and sustained health indices comparable to those in developed countries--the Cuban Paradox. There has been, however, remarkably little scholarship evaluating how this has been accomplished, especially during a period of extreme economic hardship. Cuba's exclusion from the mainstream of "globalization," moreover, allows us to gain insights into the population health impact of policies that have accompanied globalization. Cuba's experience challenges the conventional assumption that generating wealth is the fundamental precondition for improving health. As peoples around the world search for cost-effective ways to improve well-being, they might want to learn how alternative public policy approaches, such as those used in Cuba, may be effective. We therefore reviewed the literature on the health-wealth relationship in this globalizing era; then systematically examined public policy in Cuba, not only for health services (financing, vertical and horizontal integration, prevention and primary-care focus, inter-sectoral linkages, etc.) but for non-medical determinants of health as well. These included education, housing, nutrition, employment, etc. plus the community mobilization and social cohesion that the Cuban system has generated. It appears that the active implementation of public policy affecting a wide variety of health determinants explains the Cuban paradox, and that the international community can learn from Cuba's experience. The prospect for healthy public policy can thus exist within, rather than only on the margins of globalization. The importance of monitoring how Cuba sustains such policies as it faces growing challenges in this globalizing era is increasingly worth observing.

Using willingness to pay to evaluate the implementation of Canada's residential radon exposure guideline

BACKGROUND

The objective of this investigation was to determine the effectiveness of Canada's residential radon exposure guideline in influencing individuals' health protection decisions.

METHOD

Homeowners with known exposure levels in a high residential radon area (Winnipeg, Manitoba) were surveyed to document what they had done and spent to reduce their exposure to radon. The 507 respondents were then re-surveyed to elucidate their response to hypothetical scenarios. Logistic regression was used to model risk reduction decisions as a function of exposure and other explanatory variables.

RESULTS

Homeowners were only likely to have taken action to reduce exposure at levels exceeding 1,100 Bq/m3, well above Canada's guideline of 800 Bq/m3. However, when informed of the guideline, respondents indicated they would act at exposures of 702 Bq/m3.

INTERPRETATION

The Canadian residential radon exposure guideline, as it has been implemented, has not effectively prompted homeowner actions to reduce exposures to radon.

Using willingness to pay to evaluate the implementation of Canada's residential radon exposure guideline

BACKGROUND

The objective of this investigation was to determine the effectiveness of Canada's residential radon exposure guideline in influencing individuals' health protection decisions.

METHOD

Homeowners with known exposure levels in a high residential radon area (Winnipeg, Manitoba) were surveyed to document what they had done and spent to reduce their exposure to radon. The 507 respondents were then re-surveyed to elucidate their response to hypothetical scenarios. Logistic regression was used to model risk reduction decisions as a function of exposure and other explanatory variables.

RESULTS

Homeowners were only likely to have taken action to reduce exposure at levels exceeding 1,100 Bq/m3, well above Canada's guideline of 800 Bq/m3. However, when informed of the guideline, respondents indicated they would act at exposures of 702 Bq/m3.

INTERPRETATION

The Canadian residential radon exposure guideline, as it has been implemented, has not effectively prompted homeowner actions to reduce exposures to radon.