Case 11 : The Case of the Long-Lived Orchestra Conductors

There may be no part of epidemiology more central to public health practice than the evaluation of causal claims about exposures that keep us healthy, make us sick, and help us get better again. Some causal claims are sufficiently self-evident that we learn them as toddlers: hot stoves cause “owwies”. But causal questions in public health are much more complex, and to approach them we need to learn to ‘think like an epidemiologist’. This requires us to think critically about causal claims as we develop our skills in applying the logic of causal inference. When faced with a causal claim most epidemiologists immediately question the source of data, the appropriateness of the measures, and the soundness of the analysis underlying the causal claim. Epidemiology is firmly grounded in the scientific method, but the components of the scientific method have been modified for use outside the laboratory, as applied to large groups of ‘free range’ humans. Learning these adaptations can be challenging. This case introduces causal critical appraisal using, as an example, the claim that orchestra conductors live longer than members of other occupational groups because they are conductors. It is a suitable introductory case because it does not require subject matter expertise in theories of longevity or causes of death. Learners progress from basic to higherlevel concepts, beginning by recalling parts of the scientific method (e.g. control groups), and thinking about how each might be applied to this causal question. A mid-level objective is evaluating the appropriateness of the outcome measure, which requires understanding how average age at death is a poor measure compared to average life expectancy at birth, which in turn is less appropriate than average life expectancy at the age people typically become orchestra conductors. The case concludes by introducing confounding and confirmation bias

The Underreporting Of Suicide In Canada, 1950--1982: An Exploration Of The Adequacy Of Official Statistics For Epidemiologic Purposes

This study addresses the issue of the underreporting of suicide in Canadian vital statistics, and specifically asks whether the degree of underreporting can be assumed to be even across levels of commonly studied sociodemographic variables, across time, and among the ten provinces.;The analysis involves a series of comparisons between cause-specific accident and suicide rates and the same rates with deaths of undetermined origin added, over time. Data pertaining to these latter deaths have been collected in Canada since 1969; research in other jurisdictions has demonstrated that most of these deaths could be considered misclassified suicides for research purposes in psychiatric epidemiology.;The results tend to confirm the findings of other researchers, specifically that suicide is probably underreported more among females and in cases of drowning and poisoning; the findings suggest as well that some provinces account for a disproportionate share of deaths of undetermined origin which may be sufficient to introduce regional differences in underreporting. The potential underreporting of suicide was found to peak in the mid to late 1970s in Canada, and was found not to vary significantly across age groups within the same sex and cause.;With the exception of age, the assumption of a constant error in the underreporting of suicide seems to be unjustified. This lack of constancy is argued to pose a negligible threat to most descriptive epidemiologic uses of official suicide statistics. Examples are given in which suicide statistics, corrected for potential underreporting, yield the same general conclusions regarding relative prevalence between groups as do the uncorrected statistics.;By contrast, the uneven underreporting is argued to represent a potential threat to some inferences derived from explanatory studies that use suicide statistics, because of the widespread testing of hypotheses using probability statistics. One simple method to strengthen some statistical inferences is presented, and its limitations are discussed

Case 1 : Vanishing Volunteers: The Use of Implementation Research to Improve Support for Community Drug Distributors in Cote d\u27Ivoire

To be implemented successfully, most large-scale public health interventions, such as mass drug administration (MDA) campaigns for the elimination of lymphatic filariasis, require a large extent of human health resources. For several reasons, health workers and volunteer community drug distributors (CDDs) sometimes feel overwhelmed and unsupported in their work, which can cause them to give up their essential roles. In lower middle-income countries such as Côte d’Ivoire, where volunteers tasked with the distribution of antifilarial medications are already in short supply, losing valuable human health resources can ultimately cause MDA programs to fail. As such, it is crucial for implementers to recognize and address any issues with their health intervention plan that may lead to increased attrition among their workforce. Dr. Emmanuel Koffi, one of the neglected tropical disease program managers at Côte d’Ivoire’s Ministry of Health and Public Hygiene, recognizes that research is needed to investigate the factors contributing to increased stress and attrition rates among his volunteer CDDs. The steps that he should take to conduct an effective research project, however, remain uncertain. After reaching out to Dr. Myriam Kouamé at the University of Abidjan, Emmanuel has decided that applying an implementation research strategy may be best for this project. Having little experience with this type of research, he has enlisted Myriam’s assistance to develop a research plan that will help him identify how he can better support his volunteers. Emmanuel knows that time is short—the 2020 deadline to eliminate lymphatic filariasis in Côte d’Ivoire is fast approaching, and he must act quickly to ensure that the CDDs are well supported if they are to achieve this elimination goal

Case 2 : Teleophthalmology Screening: Economic Evaluations in Health Care Decision Making

This case presents a dilemma that can happen to anyone with an intervention to offer, which they are confident would alleviate a problem they believe is worth addressing. Many public health professionals will find themselves in one of two positions. The first, a position of believing so much in a proposal but not sure of how to make it go through. The second, a position of a decision maker who would be faced with more than one needed, effective, feasible, and sustainable proposal but could implement one or a few due to limited resources. The case is meant to shed light on both situations with more focus on Dr. Hodge’s position, wanting to advocate for a teleophthalmology screening program. Through introduction of this situation the case presents vision care status in Canada, economic evaluation concepts, costeffectiveness analysis, and health care decision-making. This case would be suitable for use in a health economics course, to provide real life situations that facilitate understanding of its dominant theoretical content. Health economics is an essential aspect of decision making that can be utilized in most public health career positions. At one point or another money will be scarce and the ability to understand costs in relation to public health will be a necessary skill

Case 13 : Preparing for the Tickpocalypse

The blacklegged tick population is increasing within the Realike region, and this has been associated with the emergence and increase of Lyme disease cases in the area. Zachary Smith, the Manager of the Safe Water and Rabies Prevention & Control, and Vector-Borne Disease team at the Realike Health Unit’s Environmental Health Department, has been notified by Public Health Ontario of a potential Lyme disease outbreak in the area. Lyme disease is a vector-borne disease caused by bites from blacklegged ticks, also known as deer ticks, that are infected with Borrelia burgdorferi bacteria. The disease was once mostly endemic to the United States, Europe, and parts of Asia. However, due to the uncertainty and negative impacts induced by climate change, the Realike region is now an endemic Lyme disease risk area. As per Ontario’s Emergency Management and Civil Protection Act, all municipalities should be prepared for emergencies such as disease outbreaks and, therefore should develop an emergency management program (Government of Ontario, 1990b). Further, the latest amendment of the Ontario Public Health Standards includes the addition of emergency management as one of the four foundational standards (MOHLTC, 2018a). This mandates that public health programs and services delivered by Ontario public health units incorporate all four of these foundational standards. The province’s public health standards state that emergency management plays a critical role in public health programming as it enables boards of health to ensure that they possess the capacity to respond to emerging and re-emerging threats within the community. Compliance with the standards also ensures that health units maintain adaptability and are resilient during times of high stress and in the presence of disruption. Currently, Ontario does not have any guidelines or emergency management plans for Lyme disease. Zachary must consider all elements of the problem and apply a systems-thinking approach to develop an efficient emergency preparedness plan for Lyme disease. This plan will provide a safe and healthy environment for the residents of the Realike region by ensuring that they are aware of the increased level of Lyme disease within the region

Case 1 : Policy Change and Public Health: Obstacles to Advocating for Public Health Interventions

Robin Scherbatsky, a public health nurse at Lambton Public Health in Sarnia, Ontario, plans to advocate for public funding of the more accurate interferon-gamma release assay (IGRA) test for latent tuberculosis infection (LTBI). She wants the IGRA to be covered by the Ontario Health Insurance Plan the same way the tuberculin skin test, which also tests for LTBI, is covered. Although IGRA tests are more expensive than tuberculin skin tests, IGRAs are very accurate and effective at reducing unnecessary treatments given to people falsely diagnosed with LTBI, and this results in cost savings for the public payer. Given that the Ontario government is regarding preventative health interventions as soft targets for reduced funding, Robin is worried about whether her future advocacy activity will be successful. Robin has formed working relationships with local stakeholders such as health facilities, physicians, general practitioners, and nurses through advocating to them about how to test and treat LTBI and tuberculosis. She has to decide how to best advocate for this issue, making sure she has used all available and potential resources. The case aims to provide foundational knowledge of relevant political models and theories by applying them to Robin’s example

Case 8 : “I Know You Want It”: Preventing Sexual Aggression in Bars

Brian Patterson is the owner of The Judge & Jester Tavern (JJ’s), a fictitious bar in London’s downtown entertainment district. JJ’s is popular with students from Western University, but a viral Facebook post describing an experience of assault at the bar has generated negative publicity. Coordinators at Western University, Christine Bellis and Maria Lopez, reached out to ask Patterson if he would be interested in partnering with them and the London Police Service to develop a strategy to prevent sexual violence in London’s bars and clubs. Patterson has a deep sense of ownership over JJ’s and is interested in making his bar safer but is also concerned about the response from his bar staff and the success of his business. He begins to brainstorm a list of ideas, drawing from programs that have been implemented around the world. How should they approach this problem within the London community? What will their intervention look like? What resources do they have? What do they need to know in order to proceed

Case 10 : Changing the Service Delivery Model: How to Make it Happen?

The case follows Ruksana Kadam, the 2SLGBTQ+ Programs and Community Engagement Manager at the HIV/AIDS Caring Communities (HACC). She has been tasked with developing and implementing a new service delivery model to be adopted at the HACC. The board and executive director are seeking change in order to improve services and care for its diverse clients. The new service delivery model would involve dissolving the current teams, which focused on priority populations such as people who have HIV/AIDS, 2SLGBTQ+ individuals, those who need harm reduction services, and African, Caribbean, and Black communities. The plan would involve creating two new teams – a health promotion team and a community engagement team. Where can Ruksana turn to learn more about organizational change? Have any similar agencies faced such a large change and how did they accomplish it? Are there known pitfalls that she should avoid? The goal of the case note is to allow students to understand the perspectives of stakeholders such as community members, funding organizations, and partnering organizations in a region with a very diverse population. The students will also be given an opportunity during class to formulate the exploratory stage of implementation