Posted in COVID19 Risk communication

When and how to wear a face mask

Even almost a year after the covid19 pandemic, reminding ourselves when and how to wear a face mask continues to become a life-saving activity.

Wearing a face mask alone is inadequate to combat this pandemic.

However, wearing a face mask is essential to combat this pandemic. This post reminds us of the basic rules of when and how to wear a face mask as recommended by the World Health Organization.

How to wear a medical or surgical mask

  • Wash hands before touching the mask
  • cover nose, mouth, and chin (my emphasis: at all times; it cannot be below the nose! not an easy task)
  • Wash hands after taking off the mask

What type of a mask?

Medical or surgical masks, if you are,

  • over 60
  • have a medical condition
  • feeling unwell
  • looking after an ill family member

Who should wear medical or surgical mask, when and where?

Otherwise, you can wear a fabric mask.

How to wear a fabric mask

How to wear a fabric mask (source: World Health Organization)

What type of fabric?

When and how children should wear a mask

Posted in COVID19publichealthresearch

Face mask compliance: A simple study design

This face mask compliance observational study attracted my attention because of its simplistic nature and reader-friendly presentation. I must thank Assistant Professor Susan Parham and Dr. Matthew Hardy for publishing the study on The Centre for Evidence-Based Medicine website.

About the location

Researchers have chosen a small tourist city in Paris for this face mask compliance study. Their reason for choosing this place is because of its popularity among both tourists and the local population. Wearing of face coverings became mandatory in this place by the time they conducted the observation.

Location selection

Professor Susan Parham and Dr. Matthew Hardy have chosen their place for observation off the main street. They cite two reasons for the selection: 1) It was a busy place so that they can count people and observe accurately gather more information; 2) They expected people to behave more naturally due to less expectation of official surveillance of face covering.

The observation method

They have observed the people for 30 minutes at lunchtime on two separate days at the same place: One weekday and one weekend day. On the first day, they have observed adults and children and on the second day, they have observed adult men and women separately.

Day 1mask wearing behavior of adults and children
Day 2mask-wearing behavior of male and female

Data collection tool

What attracted me about their presentation of this study was that they have pictured their actual data documentation tool as follows;

Source: The Center for Evidence-based Medicine, University of Oxford

How they tabulated findings:

Data tabulations

I created two blank tables that mimic their actual tables. Those interested can read their actual data through the link I have cited at the end of this post.

Day 1 data tabulation table

maskedunmaskedsemi-maskedmasked childunmasked child
total (273)
% of adults
Adapted from The Center for Evidence-based Medicine, University of Oxford

Data 2 data tabulation table

masked male masked femaleunmasked maleunmasked male semi-masked malesemi-asked female
%of all adults
% of each sex


Day 1:
  • Of the total of 272 adults observed, 82 percent were adhering to face mask compliance as recommended.
  • Of the rest who were not complying, 12.5 percent were unmasked 8.5 percent were semi-masked (mask-wearing under the nose).
Day 2:
  • Of the 218 adults observed, 74.3 percent were wearing masks with 26.7 percent were either unmasked (16 percent) or semi-masked (9.7 percent).
  • Of them, 76.9 percent of women and 71.3 percent of men were wearing masks.

The authors of this face mask compliance observational study bring forward an interesting discussion about social norms conformity using the findings that were really critical in creating messages and social marketing campaigns.

Those interested can read the full paper through this link;

Posted in message framing storytelling in science

The “Plastic Bag”; a short film by Ramin Bahrani

“They told me it’s out there: The Pacific Vortex. Paradise”; The “Plastic bag” anticipates his destiny through Werner Herzog’s voice.

“No one needs me here anymore, Not even my Maker”; the “Plastic bag” laments while observing the sunset on the beach. “He” is about to dive into the deep ocean heading for “paradise”: the gigantic plastic garbage dump that sits deep Pacific Ocean Vortex.

Ramin Bahrani opens his “Plastic bag” (2010), an 18 minutes long film with the above narration. It premiered at the Venice Film Festival and later screened at the New York Film Festival.

Ramin is an acclaimed Iranian-American filmmaker.

The technique of anthropomorphism

Ramin anthropomorphizes a plastic bag into a human; rather the bag thinks and feels like a human. This technique is called anthropomorphism, an excellent creative writing technique. It “transports” us into an imaginary world for a short period. After the visit, we return to the world where we lived prior to the journey with changed beliefs and attitudes. It helps to retain the message in our minds for a long time. We can find the same technique in Franz Kafka’s “metamorphosis”, Lewis Carrol’s “Alice in Wonderland”, and George Orwell’s “Animal Farm” and Markus Zusak’s “The Book Thief”.

The long journey begins

Soon after the opening scene at the beach, Ramin takes us to a place where the plastic bag begins his long journey to the Deep Pacific ocean vortex. The starting place is the store’s cashier countertop from where his Maker, a young woman, places her bought- stuff into the bag. Besides carrying stuff to the woman’s home, the bag carries various kinds of duties for the woman from going with her to the tennis court, helping her with ice to ease her ankle pain, and even bagging her pet dog’s shit. However, it feels abandoned when the woman dumps him and ends up at a large garbage site.

From this garbage site until he sets into the deep Pacific ocean vortex, Ramin makes the bag traveling through the land, sky, forests, buildings, houses, and the ocean. Throughout this journey, the bag meets animals, fish, and even a “girlfriend” bag.

Human emotions

The bag voices its human feelings through Werner Herzog’s voice: love, hope, loss, frustration, and the yearning for reaching the ultimate destiny.

Intimate moments with the young woman

He feels happy for being “part of her life” and joy when he intimates with the lady’s skin to ease her ankle pain with ice.

“I made her happy and she made me happy”, the bag thinks. And, he yearns to be with her, “we would be together forever”.

Then, he feels despair when she abandons her and finds himself at a dumping site.

At the large garbage site

“Nothing could destroy me”, boasts the bag even after a large garbage truck running over it several times. Then, the wind takes him out of the site and the destiny.

Meeting his “girlfriend”

During his resumed journey, he meets his red-colored “girlfriend” plastic bag. He moves and dances gracefully with her.

You can watch the full movie here.

“Plastic bag” short film by Ramin Bahrani

Ramin’s laser-beam focus on the main narrative does not deviate even for a second to bring forward the bigger picture of the plastic pollution crisis. He is strictly disciplined about it. The focus directs at the plastic bag’s goal: Re-uniting his Maker or else finding its ultimate destiny – the 100 million tons gigantic garbage dump deep inside the Pacific Ocean vortex.

Iranian-American filmmaker, Ramin Bahrani (Source:
Posted in spin in science writing

Spin in writing-6: A critic of a case-control study

This post is a follow-up to my previous post on the same topic, which was inspired by a journal club podcast that dealt with a research paper on Cannabis use and psychosis.

The podcast was presented by Matt. Chris, and Don at the Population Health Exchange of the Boston University School Health Public Health.

Delving into the subject, in this post, I am deconstructing the paper with an emphasis on “spin in science writing”.

About the study

This was a case-control study conducted in several countries. It appeared in The Lancet Psychiatry in 2019. Its title is “the contribution of cannabis use to variation in the incidence of psychotic disorder across Europe (EU-GEI): “A multicenter case-control study”: You can access the full paper by clicking this link.

About the study design

In the abstract’s methods section, the authors write: “We included patients aged 18–64 years who presented to psychiatric services in 11 sites across Europe and Brazil with first-episode psychosis and recruited controls representative of the local populations.”

My comment: The cases were the first-episode psychosis. They are the ideal choice to explore incident (new) cases. However, another research reveals that the median time between the first appearing of symptoms and the diagnosis of first-episode psychosis is 2-2.5 years and the median age at diagnosis is 30 years in the UK. Further research reveals that as many as 64 percent who first experienced the first-episode psychosis have used cannabis and 30 percent of them had a cannabis use disorder. These facts resonate with one of the inherent problems in the retrospective case-control design: The problem of recall bias. It is troubling because the relationship between cannabis use and first-episode psychosis could be bi-directional.

Moreover, as the journal club podcast presenters point out cannabis may be just unmasking psychosis among those who are genetically predisposed.

Because of these reasons, the temporality – whether cannabis use precedes the first-episode psychosis – is very difficult to adduce.

Causality assumption:

In the abstract’s methods section, the authors write: “Assuming causality, we calculated the population attributable fractions (PAFs) for the patterns of cannabis use associated with the highest odds of psychosis and the correlation between such patterns and the incidence rates for psychotic disorder across the study sites.”

Assuming causality: The authors “assume causality” in their study based on findings from previous studies. As podcast presenters highlight, this assumption is a huge part because case-control study design, by definition, does not allow a causality assumption. After assuming causality, they have gone further and calculated population attribution fraction (PAF).

Causality language cannot be used in case-control study designs.

Causality language

Case-control study designs are observational by nature. They allow us to conclude associations, certainly not causations. In other words, we cannot use words or phrases that allude to causality; which means no declarative verbs. Instead, we should ideally use “descriptive” verbs to describe associations.

You can find more details about what declarative and descriptive verbs mean by reading this post.

In this post, I search and highlight the sections, sentences, and phrases that I consider containing declarative and descriptive words and verbs.

However, I request readers to contribute to this post and am willing to correct myself if my facts and arguments are incorrect as per your opinion.

In the study’s title:

The authors write: “The contribution of cannabis use to variation in the incidence of psychotic disorder across Europe (EU-GEI): a multicenter case-control study”.

My comment: Case-control study designs may prove association but not causation. The phrase – “contribution” of cannabis use to the “incidence” of psychotic disorder – alludes to a causative relationship. However, the word, “contribution” may mean an association also.

In the abstract:

Findings section: The authors write: “Daily cannabis use was associated with increased odds of the psychotic disorder compared with never users (adjusted odds ratio [OR] 3·2, 95% CI 2·2–4·1)”.

My comment: This is a correct characterization of the study findings because the case-control study designs warrant using the phrase, “associated with”.


Findings section: The authors write: “The PAFs calculated indicated that if high-potency cannabis were no longer available, 12·2% (95% CI 3·0–16·1) of cases of first-episode psychosis could be prevented across the 11 sites, rising to 30·3% (15·2–40·0) in London and 50·3% (27·4–66·0) in Amsterdam.”

My comment: They claim that by removing high-potency cannabis in these 11 sites 12.2 percent of cases of first-episode psychosis could be prevented. And, in some sites – London and Amsterdam – it could be as much as 30.3 percent and 50.3 percent. This claim goes way beyond the study design warrants because it is based on causality.

Interpretation section: The authors write: “Differences in frequency of daily cannabis use and in use of high-potency cannabis contributed to the striking variation in the incidence of psychotic disorder across the 11 studied sites. Given the increasing availability of high-potency cannabis, this has important implications for public health.”

My comment: Is it possible to use the phrase, “contributed to the incidence of psychotic disorder” because it alludes to, again the causality?

In the main text:

Results section: The authors write: “The use of high-potency cannabis (THC ≥10%) modestly increased the odds of a psychotic disorder compared with never use.”

My comment: In this sentence, the use of the word, “increased” suggests causality.

The authors write: “Adjusted logistic regression indicated that daily use of high-potency cannabis carried more than a four-times increase in the risk of a psychotic disorder (OR 4·8, 95% CI 2·5–6·3) compared with never having used cannabis.”

My comment: The phrase: ” four-times increase in the risk of psychotic disorder” suggests causality.

Discussion section: The authors write: “The strongest independent predictors of whether any given individual would have a psychotic disorder or not were daily use of cannabis and use of high-potency cannabis.”

My comment: The word, “predictor” suggests causality.

The authors write: “The odds of the psychotic disorder among daily cannabis users were 3·2 times higher than for never users.”

My comment: I believe that this is a correct characterization of the findings.

The main focus of this post is to highlight reporting practices of a case-control study with special reference to the causality language. However, there are several other areas that we can discuss here; one such issue is the recruitment of controls and their comparability.

The problem of recruiting controls:

Ideally, the recruited controls should be “potential cases”. In other words, should they experience first-episode psychosis, they are expected to be included in the study as cases. Therefore, both groups’ basic characteristics should be more or less similar. However, according to Table 1, we find statistically significant differences between cases and controls in age, ethnicity, education status; the cases were younger, lower educational status, and non-whites. That means the control group did not represent the local population from where the potential cases of first-episode psychosis should originate.

I found another excellent account based on this paper written by Suzanne H. Gage to The Lancet. It also enriches this discussion. And, I found another excellent write-up by Kristen Monaco written to MedPage TODAY.

Extended Parallel Process Model
Posted in message framing

Extended Parallel Process Model (EPPM)

Whenever we craft a message we need to have a clear idea of how we are going to evaluate the efficacy after releasing the message. The Extended Parallel Process Model (EPPM) provides a useful model exactly for that.

Let first us see what it is and then how it helps us.

We need to keep in mind that this model particularly applies to fear- arousing messages.

What is EPPM?

The EPPM forces us to look at it from the message recipient’s point of view. According to the model, the message recipients process a message in two stages. in the first stage, the message recipients appraise the threat level; based on this initial appraisal, they proceed into stage two: To take action; it could either the danger control (appropriate/adaptive) or fear control (inappropriate/maladaptive).

Stage 1: Appraising the threat

First, as soon as we receive a fear-arousing message, we appraise its “perceived” threat level. Here the keyword is “perceived”. What matters most is the message recipient’s perceived threat level, not the message sender’s perceived threat level. Often, message senders who tend to be more knowledgeable than the message recipients become disappointed because the message senders think the recipients do not perceive to the level that the senders perceive. Being at a higher position in the social ladder, message framers put the blame on the message recipients.

What does the “perceived threat” refer to?

Although we employ here the fear appeal as the strategy, according to Kim Witte the threat differs from fear;

Fear is an emotion; the threat is a cognition

According to the, two criteria should fulfill to perceived the threat; the message recipients should perceive severity and susceptibility.

What does it mean by perceived severity?

Think of COVID 19 virus. First, the recipients assess how severe the problem is. In the first wave, our perceived severity became very much higher than now. Isn’t it? In other words, the perceived severity can vary with time.

What does it mean by perceived susceptibility?

Next, the recipients assess how much they are vulnerable in contracting the COVID 19 virus.

The perceived threat consists of the perceived severity and perceived susceptibility to the problem.

If the recipients perceive the problem is not severe enough and they are not vulnerable, they are very unlikely to do something about it. In contrast, if they perceive the problem is severe enough and they are susceptible, they feel they are under threat and think of doing something about it.

According to the EPPM, they switch into the next stage: Action. Here, the message recipients evaluate the actions they can resort to: Appraising the efficacy of the proposed action/s.

Stage 2: Appraising the efficacy

In this stage, they evaluate two dimensions of the proposed action/s.

Perceived self-efficacy

First, they evaluate whether the proposed action is doable. For example, in regards to COVID 19 pandemic response, the key messages we receive are “stay at home”, “wear a face mask”, “wash hands”, and “keep the distance”.

Perceived response efficacy

This is the final element; perceived response efficacy. Here, the recipients evaluate whether the proposed actions do really work for them.

Our message satisfies all the above-mentioned four criteria, according to the EPPM, the message recipients are highly likely to engage in the recommended behavior change. Obviously, we cannot expect one message can satisfy all these criteria for all the people. That is why we first have to define the target audience and study their socio-demographic and psychographic characteristics before crafting the message.

Danger control versus fear control

Whenever our message meets the four perceptions of the target audience, they delve into “danger control”. This is what we want them to do. The experts view this as a cognitive process.

However, there are many situations that our messages do not meet all the above criteria.

What will happen if some members of the target audience perceive a higher threat level with a lower level of perception that they are not capable of engaging in the suggested action?

According to Michael Basil and Kim Witte, in such situations message recipients will resort to “fear control” methods; this is an emotion control process. Here, they will ignore the message and somehow find reasons to justify their course of inaction.

What arguments they are likely to put forward? According to Michael Basil and Kim Witte, those are;

  • They may the risk is overstated unnecessarily.
  • They may the threat is not that severe.
  • They may, Whatever happens, may happen; we cannot do anything; this is life.
  • They may this is a deliberate attempt to limit their freedom.

What we have to do in message framing is to promote message recipients to adopt danger control actions not fear control ones.

EPPM elements against control strategies

This is only an introduction to the EPPM. There is much more to it. And, researchers have addressed the limitations of the model too. For example, this model only deals with the process of dealing with fear. However, fear is not the only emotion messages invoke. They can invoke anger and frustration too.

Researchers firmly advocate the self-efficacy and response efficacy perception levels should be higher than the problem severity and susceptibility perception levels for the message recipients to resort to danger control behaviors. If the reverse takes effect, they will resort to maladaptive fear control behaviors.

I will discuss its applications in another post.

Posted in Risk communication

Avoid traps in risk communication

As an individual who closely follows pandemic communication, I have been observing some communication “traps” that the communicators fall into. During my research on this, I found excellent advice from the US CDC website with regard to this topic. I am sharing relevant pieces from that post here.

This post details out dos and don’ts when we communicate events related to an outbreak.

DosDo not s
define technical terms in plain languageUse language that even a small section cannot understand
Ask whether you have made the information clear.Do not assume that everything is clear.
use examples or analogues to explain a complex topicDo not assume they understand everything.
Focus on facts at handDo not speculate
Promise only what you can deliver Do not make promises you cannot deliver
Take responsibility of your share of the problem; use empathyDo not blame or shame others
Simpson's paradox
Posted in Paradoxes

Simpson’s paradox: A trap in data interpretation

In 1934, two researchers – Morris Cohen and Ernst Nagel – tabulated death rates due to pulmonary tuberculosis in two cities – New York and Richmond. They found higher death rates in Richmond City than in New York City; 226 per 100,000 population versus 187 per 100,000 population.

However, they disaggregated the rates by ethnic groups; Caucasians versus African Americans. Interestingly, their previous finding was reversed. It was the complete opposite: for each ethnic group, the death rates became higher in New York than in Richmond (Look at the table below).

Death rates due to pulmonary tuberculosis

EthnicityNew YorkRichmond
African American560/100,000332/100,000
The detailed data set is available through this source:

This conundrum is known as “Simpson’s paradox”.

How did this happen?

When we disaggregate data into two different sub-groups, the real situation appears; in extreme instances, it becomes reverse.

Those situations are identified as “Simpson’s paradox” because Edward Simpson explained the phenomenon using hypothetical data as far back as 1951. However, prior to him, Yule demonstrated the bias again using hypothetical data set much earlier: in 1903.

According to statisticians, Simpson’s paradox, by definition, is not a true paradox; rather, it is a statistical illusion and could also be called aggregate bias. It is also a manifestation of confounding effects.

Its practical implications could well be devastating, particularly when we make decisions based on aggregate data.

In the above example, if the decision-makers were not aware of this, they would have allocated resources erroneously to Richmond instead of New York City to reduce the death rate due to pulmonary tuberculosis.

This bias seems to have been occurring much commoner than earlier thought.

Here are few more examples;

Hospital admissions of men with psychiatric illnesses over the years; gone up or down?

I created the following table using data that appeared in a short paper in the British Medical Journal.

According to the first table, the admission rates of men with psychiatric illnesses out of all admissions with such illnesses have declined slightly from 1970 to 1975.

Admission rate46.4% (343/739)46.2% (238/515)

Now, look at the following disaggregated data by age. The pattern reversed; the male admission rates have gone up.

Those aged <=6559.4% (255/429)60.5% (156/258)
Those >6528.4% (88/310)31.9% (82/257)
Overall46.4% (343/739)46.2% (238/515)

Another example from a hospital setting

The data that appears below is from a paper published based on a study about the use of prophylactic antibiotics in eight hospitals in the Netherlands. According to the first table, it seems better prophylactic use of antibiotics because the urinary tract infection rate is lower when using it rather than not using it.

Prophylactic antibioticsNo prophylactic antibiotics
Urinary tract infection rate (UTI)3.3% (42/1279)4.6% (104/2240)

Since the researchers were skeptical about the finding, they dis-aggregated data by grouping hospitals based on UTI infection rates; low-incident and high-incident hospitals using 2.5% as the artificial cut-off rate. Now, the first observation was reversed; the rates were higher when prophylactic antibiotics were used.

UTI ratesProphylactic antibioticsNo prophylactic antibiotics
Low incident (<=2.5%) hospitals1.8% (20/1113)0.7% (5/720)
High-incidence (>2.5%) hospitals 13.2% (22/166)6.5% (99/1520)
Overall UTI rate3.3% (42/1279)4.6% (104/2240)

The above study appeared on the Royal Statistical Society website when it discusses Simpson’s paradox.

Paulo Freire
Posted in health education

Paulo Freire’s critical consciousness

Photo source:

Paulo Freire, a Brazilian, who lived between 1927 – 1997, is still popular for his revolutionary ideas about adult education, particularly with “critical consciousness”. He was a “pedagogue”; the term, according to dictionaries, refers to someone who goes by-the-book.

He became influential with his community work in educating adults and published his seminal work -“The pedagogy of the oppressed” – in 1970. You can have free access to the book through this link;

He metaphors the traditional classroom teaching method to the “banking” concept in which the teacher “deposits” knowledge into the student’s head and the students, in turn, are expected to use it, probably with some adaptations depending on the context.

Sounds familiar?

Anyway, what is wrong with that?

“Education for liberation”

Freire theorized the purpose of education as to “liberate human potential” and education is a part of the process.

The purpose of education should be to liberate human potential”.

Paulo Freire

Dialogue versus discussion

The meanings of these two words contrast each other. Oscar Graybill and Lois Brown Easton explain, citing Robert Garmston and Bruce Wellman (1999), the difference between the dialogue and discussion as follows;


Dialogue engages the participants to gain an understanding of the topic without the “pressure” of arriving at a decision. In a dialogue, we can hear frequently the “why” questions and the phrases such as, “I am wondering”, “I am curious”, “I am interested”, and “what if” etc.

A dialogue may result in action to gain further understanding such as conducting a survey, focus group discussions, interviews, etc.

We can plan a dialogue by giving the topic beforehand, setting ground rules and guidelines for the event. To learn more about this, I recommend reading the post I cited above.


Discussion is a talk with the purpose of arriving at a decision; it may begin with brainstorming ideas and exploring possibilities. However, later the discussants will choose sides, similar to a debate, and attempt to arrive at a decision. It will not build on ideas and frequently mentions one’s opinions and holds on to them.


The praxis is another term used by Freire. It is not enough to have a dialogue to understand reality. We must act upon and reflect to experience reality.

According to Keith Popple and Anne Quinney in their paper says that Freire found

Culture of silence

He relates the problem of this “banking” concept to the “culture of silence”. In other words, the process ensures the maintenance of the status quo and may only result in a very limited form of system improvement. He uses here a very strong language: the method allows the oppressor to continue the oppression onto the oppressed.

So, what exactly was the Freire’s prescription?

His prescription for teaching is grounded on “liberation” from oppression; he preaches that education should liberate the learner. How could we do that, according to him?

That is when he brings forward the concept of “critical consciousness”.

Critical consciousness

To begin with, the teacher should acknowledge that the learner does not attend with an empty bank account.

The learner should not be considered an empty vessel.


The learner brings a wealth of ground-level experience and some knowledge into the discussion; it should be respected. After all, they are the ones who are going to use the “new” knowledge in real life. It needs to be merged and adapted. Therefore, they need to be consulted. While I was working at the Health Promotion Bureau, I used to name the “training” sessions for health education officers and other healthcare professionals as “consultative meetings”. And, I made sure that the “class” arrangement in a circular fashion, not as a traditional classroom. These things matter, in fact, matters a lot. I even explained why I did that.

The above preparations set the ground for the next step; knowledge should be produced during the interaction between the facilitator and the participants. Ideally, it needs to be problem-based learning. During my time I always encouraged the participants to carry out the presentations. They came with their preparations based on the topics that we agreed upon prior to the session. In fact, these were self-reflective encounters promoting “critical consciousness”. It always boosted their self-esteem as well as entered into a dialogue about how we need to meet real-life challenges.

How to design workshops

While I was researching about Paulo Freire and his work, I stumbled on this link that describes how to run a workshop based on his concepts;

Paulo’s influence seems to have spread all over the world; several institutions, organizations, and projects have been launched under his name. one of them is here:

In fact, Freire’s critical consciousness is almost similar to the following quote by Lao Tsu (China 700 BC).

Live with them,

Love them,

Start with what they know,

Build with what they have,

But with the best leaders

When the work is done,

The task accomplished,

The people will say, “We have done this ourselves” –

– Lao Tsu (China 700 BC)

from Goodreads

Posted in Infection control research

WHO’s Multi-modal Hand Hygiene Strategy

In 2009, the WHO published its hand hygiene promotion strategy. It was a multi-modal strategy and consisted of five modes. These were as follows;

WHO’s multi-modal hand hygiene strategy

  • System change,
  • Training and education,
  • Evaluation and feedback,
  • Reminders in the workplace,
  • and institutional safety climate.

Moreover, the WHO published a guide and toolkit to facilitate the implementation of those strategies. I summarized it below.

Component 1: System change

Contrary to my expectation, it is not about a systems change per se; rather, it refers to availability and accessibility to products that are required handwashing: alcohol-based hand rub at the point of care; access to a safe, continuous water supply, soap, and towels.

Component 2: Training and education

This refers to the training and education on the “my 5 moments for hand hygiene” which is depicted below. However, this should include the exact hand hygiene technique too.

My 5 moments for hand hygiene
Component 3: Evaluation and feedback

Under the evaluation and feedback, the strategy begins with monitoring hand hygiene practices and infrastructure, along with related perceptions and knowledge among health-care workers. The implementation of this component alone surely requires a research unit because monitoring hand hygiene practices are not easy and could be marred with biases including the Hawthorne effect.

Component 5: Sending reminders at the workplace

Yes, reminders help to promote the practice; however, regular changes to the messages are necessary since “message fatigue” surely will settle in with time. I am not sure why this “activity” takes such a prominent place in the multi-modal strategy.

Component 6: Institutional safety climate

I believe this is the most crucial strategy in any behavior change effort since it is the immediate environment we live in that ensures sustainability. However, the challenge is how to create it. The toolkit is not clear about its road map in this regard.

The 2015 expert review: An important milestone

Due to the absence of significant improvements, a European expert group updated the previous recommendations based on the evidence that surfaced between 2009 and 2012. Their recommendations were based on a systematic review which included 92 studies published between 1996 and 2012. The Lancet published its report in 2015. Their focus was mainly directed on hospital organization and management structure under which they identified ten key components.

Of those ten components, I am here highlighting the critical issues that need to be emphasized in the current context according to my opinion.

Number of beds per infection control nurse ratio

Traditionally, this ratio has been static during the past 30 years: 1 nurse to 250 hospital beds. The experts were of the view in this paper that it should be reduced to 1 nurse to 100 beds in acute care settings and 1 nurse to 150-250 beds in long-term care settings.

Limitation of the infection control teams

The experts seem to be very clear on this; that the presence of effective infection control teams, although essential, inadequate to achieve infection control goals. Furthermore, it also depends on;

  • Hospital organization
  • Bed occupancy
  • Staffing
  • Workload

In fact, this is common sense too. How can one adhere to complete hand hygiene procedures whenever they are pressured by a fewer number of staff members and a higher workload? It all depends, in turn, on the hospital organization and management.

Easy access to materials and the presence of ergonomics experts

Surprisingly, the hospital authorities seem to have overlooked this dimension altogether according to the paper.

Education and training

Quite correctly, they recognize that education and training should be accompanied by relevant leadership engagement and environmental modification. They go further by underlying that whatever the training should include interventions with strong “behavioral component aimed at removing barriers and helping the learners to manage their workload without compromising the quality”. We all know this is not an easy task.

More importantly, they too seem not to be having a clear road map either. The study authors claim that positive organizational culture can “only” emerge with a genuine interest in “leaders”. According to my thinking, this is unlikely to happen without a “paradigm shift” of thinking.

Paulo’s “critical consciousness”

This is where Paulo Freire’s “critical consciousness” should come into play. What is being used in education and training programs so far is the traditional “banking” model in which the teacher/trainer “deposits” the knowledge on the learner and the learners are expected to practice those without question.

I will write about it later.

2017 update: new WHO recommendations

In 2017, Julie Storr and her colleagues updated the previous report with new evidence. According to them, these recommendations were for acute care settings although its core components could be applicable to any healthcare setting, potentially including long-term care settings too. It included eight components, unlike the previous five components.

It seems that the WHO has yet to develop its new implementation strategy and tools.

Posted in spin in science writing

Spin in science writing – 5: Psychiatry and psychology

Earlier we saw how distorted abstract reporting – a form of spin – occurs in health research. This post dives into a specific subject area: Psychiatry and Psychology.

In 2019, Samuel Jellison and his team published an excellent paper on this exact topic in the British Medical Journal. They looked at the frequency of distorted reporting in the abstracts of randomized controlled trials (RCTs) with non-significant primary endpoints, irrespective of the funding source, published in the Psychiatry and Psychology journals between January 2012 – December 2017.

They identified 116 papers and determined 65 papers (56 percent) with distorted reporting in the abstracts. And, they further found that it has no statistically significant association with the funding source whether it is industry-funded or otherwise; that is also very interesting.

How spin occurs

Samuel and his team described how spin occurs in the abstracts.

Spin in the results section of the abstracts
  • Focusing on statistically significant secondary endpoints while omitting statistically non-significant one or more primary endpoints
  • Focusing only on statistically significant primary endpoints while omitting statistically non-significant other primary endpoints
  • Claiming equivalence to statistically non-significant primary endpoints
  • Using phrases like “trending towards significance”
  • Focusing on statistically significant sub-group analyses of the primary endpoint

Spin in the abstract conclusions

  • Claiming benefit based on statistically significant secondary endpoints
  • Claiming equivalence versus comparator for a statistically non-significant endpoint
  • Claiming benefit using statistically significant sub-group analysis

In 2017, a Japanese group of researchers published a paper in the PLOS One exactly about that. They compared the conclusions written in the abstracts with the results of the expected primary outcomes of 60 papers. These papers reported effective interventions in the mental health and psychiatry field.

They determined that twenty out of sixty papers included “overstatements”. And, nine papers reported in the abstracts statistically significant results of secondary outcomes or subgroup analyses when none of its primary outcomes showed positive results.

Let us see few details as it appeared in the paper.

Not reporting non-significant results of the primary outcomes, instead reporting significant results of secondary outcomes

Example 1:

This study compared the efficacy of (web-based – this was not mentioned in the abstract) counselor-assisted problem-solving intervention method (n=65) with access to internet resources (n=67). It was a randomized clinical trial involving adolescents between 12 – 17 years admitted to a hospital with traumatic brain injuries. The interviewers were blinded to the intervention method. The primary outcome was measured using the child behavior checklist (CBCL) as reported by their parents before and after the intervention.

The result for the primary outcome – CBCL for the adolescent 12 – 17 years – was not statistically significant. They have not reported it in the abstract; instead, the abstract includes significant results for its sub-group analyses – late adolescents versus early adolescents.

Example 2:

This was a randomized controlled trial aimed at evaluating the effectiveness of depression intervention for women screen-positive for major depression, dysthymia, or both. The primary outcome was to change in depression symptoms and functional status 12 months after the intervention. The secondary outcomes were at least 50% reduction and remission in depressive symptoms, global improvement, treatment satisfaction, and quality of care. They have compared this intervention with the usual care.

According to the results reported in the main text, of both expected primary outcomes, symptom reduction had been statistically significant at 12 months but not their functional status at the end of 12 months; however, the secondary outcomes had achieved statistically significant results.

In the abstract, the authors have mentioned only the positive results.

Their advice:

Scrutinize the full-text results; Do not rely only on the abstracts

Shinohara, K., Suganuma, A. M., Imai, H., Takeshima, N., Hayasaka, Y., & Furukawa, T. A. (2017). Overstatements in abstract conclusions claiming the effectiveness of interventions in psychiatry: A meta-epidemiological investigation. PLoS ONE12(9).

Relationship with journal impact factor and sample size

The authors of this study reported a very interesting relation of abstract”overstatements” with the published journal’s impact factor and the study’s sample size; they found that the journal’s impact factor fewer than 10 and the sample sizes fewer than 300 are more associated with abstract “overstatements”.

Not reporting abstracts in the structured format

As early as 2013, the CONSORT recommended that all randomized controlled trials’ abstracts need to be reported in a structured format; however the study authors had noted that a number of studies had not followed the recommendation.