Previous research on the determinants of pneumonia and influenza has focused primarily on the rol... more Previous research on the determinants of pneumonia and influenza has focused primarily on the role of individual level biological and behavioural risk factors resulting in partial explanations and largely curative approaches to reducing the disease burden. This study examines the geographic patterns of pneumonia and influenza hospitalizations and the role that broad ecologic-level factors may have in determining them. We conducted a county level, retrospective, ecologic study of pneumonia and influenza hospitalizations in the province of Ontario, Canada, between 1992 and 2001 (N=241,803), controlling for spatial dependence in the data. Non-spatial and spatial regression models were estimated using a range of environmental, social, economic, behavioural, and health care predictors. Results revealed low education to be positively associated with hospitalization rates over all age groups and both genders. The Aboriginal population variable was also positively associated in most models except for the 65+-year age group. Behavioural factors (daily smoking and heavy drinking), environmental factors (passive smoking, poor housing, temperature), and health care factors (influenza vaccination) were all significantly associated in different age and gender-specific models. The use of spatial error regression models allowed for unbiased estimation of regression parameters and their significance levels. These findings demonstrate the importance of broad age and gender-specific population-level factors in determining pneumonia and influenza hospitalizations, and illustrate the need for place and population-specific policies that take these factors into consideration.
Introduction The COVID-19 pandemic has amplified pre-existing challenges to health promotion and ... more Introduction The COVID-19 pandemic has amplified pre-existing challenges to health promotion and care across the world, and particularly in low- and middle-income countries (LMICs). This qualitative study draws on data from a panel of immunisation experts and uses a novel framework of vaccine delivery domains to explore perspectives from those who live and work in these settings on the challenges to implementing COVID-19 vaccine programs in LMICs. Methods We conducted a thematic content analysis of 96 participant free text replies to questions from Round I of a three-round Delphi consensus study amongst global experts on COVID-19 vaccine implementation. Results Participant responses highlighted challenges to vaccine program implementation including issues related to equity; governance, decision-making, and financing; regulatory structures, planning, and coordination; prioritisation, demand generation, and communication; vaccine, cold chain, logistics, and infrastructure; service del...
BackgroundTask shifting and sharing (TS/S) involves the redistribution of health tasks within wor... more BackgroundTask shifting and sharing (TS/S) involves the redistribution of health tasks within workforces and communities. Conceptual frameworks lay out the key factors, constructs, and variables involved in a given phenomenon, as well as the relationships between those factors. Though TS/S is a leading strategy to address health worker shortages and improve access to services worldwide, a conceptual framework for this approach is lacking.MethodsWe used an online Delphi process to engage an international panel of scholars with experience in knowledge synthesis concerning TS/S and develop a conceptual framework for TS/S. We invited 55 prospective panelists to participate in a series of questionnaires exploring the purpose of TS/S and the characteristics of contexts amenable to TS/S programmes. Panelist responses were analysed and integrated through an iterative process to achieve consensus on the elements included in the conceptual framework.ResultsThe panel achieved consensus concern...
BackgroundEffective communication is integral to the delivery of goal-concordant care for older a... more BackgroundEffective communication is integral to the delivery of goal-concordant care for older adults and their family caregivers, and yet, it is uncommon in people with serious illness. This study explores the challenges of integrating end-of-life communication into heart failure management from the perspectives of older adults and family caregivers.MethodsIn a qualitative study of older adults with heart failure and their family caregivers, fourteen semi-structured interviews were conducted with 19 participants in Ontario, Canada. The interviews were transcribed verbatim and thematic analysis was applied to analyze the data.ResultsFour themes were identified in the context of participants’ understanding of illness: 1) trivializing illness-related challenges, 2) positivity in late life, 3) discomfort in having end-of-life conversations, and 4) reluctant to engage despite need. These challenges often intertwine with one another. Most participants had not engaged in end-of-life disc...
BACKGROUND Cardiovascular disease (CVD) is the leading cause of death globally and in Canada. Dia... more BACKGROUND Cardiovascular disease (CVD) is the leading cause of death globally and in Canada. Diabetes and hypertension are major risk factors for CVD events. Despite the increasing availability of effective treatments, majority of diabetic and hypertensive patients do not have adequate blood pressure and glycemic control. One of the major contributors is poor treatment adherence. OBJECTIVE This study aims to evaluate the impact of treatment adherence for patients with both diabetes and hypertension on acute severe CVD events, and intermediate clinical outcomes in Canadian primary care settings. METHODS We will conduct a population-based retrospective cohort study of patients living with both diabetes and hypertension in Ontario, Canada between January 1 2008 and March 31 2018. The Social Cognitive Theory will be used to explain the reciprocal relationship between treatment adherence, personal factors and environmental determinants, and how this interplay impacts CVD events and clin...
Journal of the American Geriatrics Society, Jan 27, 2017
To compare the effect of a 6-month community-based intervention with that of usual care on qualit... more To compare the effect of a 6-month community-based intervention with that of usual care on quality of life, depressive symptoms, anxiety, self-efficacy, self-management, and healthcare costs in older adults with type 2 diabetes mellitus (T2DM) and 2 or more comorbidities. Multisite, single-blind, parallel, pragmatic, randomized controlled trial. Four communities in Ontario, Canada. Community-dwelling older adults (≥65) with T2DM and 2 or more comorbidities randomized into intervention (n = 80) and control (n = 79) groups (N = 159). Client-driven, customized self-management program with up to 3 in-home visits from a registered nurse or registered dietitian, a monthly group wellness program, monthly provider team case conferences, and care coordination and system navigation. Quality-of-life measures included the Physical Component Summary (PCS, primary outcome) and Mental Component Summary (MCS, secondary outcome) scores of the Medical Outcomes Study 12-item Short-Form Health Survey (...
Inappropriate antibiotic prescribing contributes to the generation of drug resistance worldwide, ... more Inappropriate antibiotic prescribing contributes to the generation of drug resistance worldwide, and is particularly common in China. We assessed the effectiveness of an antimicrobial stewardship programme aiming to reduce inappropriate antibiotic prescribing in paediatric outpatients by targeting providers and caregivers in primary care hospitals in rural China. We did a pragmatic, cluster-randomised controlled trial with a 6-month intervention period. Clusters were primary care township hospitals in two counties of Guangxi province in China, which were randomly allocated to the intervention group or the control group (in a 1:1 ratio in Rong county and in a 5:6 ratio in Liujiang county). Randomisation was stratified by county. Eligible participants were children aged 2-14 years who attended a township hospital as an outpatient and were given a prescription following a primary diagnosis of an upper respiratory tract infection. The intervention included clinician guidelines and train...
Naturalistic theories of disease appeal to concepts of biological function, and use the notion of... more Naturalistic theories of disease appeal to concepts of biological function, and use the notion of dysfunction as the basis of their definitions. Debates in the philosophy of biology demonstrate how attributing functions in organisms and establishing the function-dysfunction distinction is by no means straightforward. This problematization of functional ascription has undermined naturalistic theories and led some authors to abandon the concept of dysfunction, favoring instead definitions based in normative criteria or phenomenological approaches. Although this work has enhanced our understanding of disease and illness, we need not necessarily abandon naturalistic concepts of function and dysfunction in the disease debate. This article attempts to move towards a new naturalistic theory of disease that overcomes the limitations of previous definitions and offers advantages in the clinical setting. Our approach involves a re-evaluation of concepts of biological function employed by naturalistic theories. Drawing on recent insights from the philosophy of biology, we develop a contextual and evaluative account of function that is better suited to clinical medicine and remains consistent with contemporary naturalism. We also show how an updated naturalistic view shares important affinities with normativist and phenomenological positions, suggesting a possibility for consilience in the disease debate.
Journal of evaluation in clinical practice, Jan 7, 2015
The aim of this article is to create a space for historical thinking in medical practice. To this... more The aim of this article is to create a space for historical thinking in medical practice. To this end, we draw on the ideas of R.G. Collingwood (1889-1943), the renowned British philosopher of history, and explore the implications of his philosophy for clinical medicine. We show how Collingwood's philosophy provides a compelling argument for the re-centring of medical practice around the patient history as a means of restoring to the clinical encounter the human meaning that is too often lost in modern medicine. Furthermore, we examine how Collingwood's historical thinking offers a patient-centred epistemology and a more pluralistic concept of evidence that includes the qualitative, narrative evidence necessary for human understanding. We suggest that clinical medicine can benefit from Collingwood's historical thinking, and, more generally, illustrates how a philosophy of medicine that draws on diverse sources from the humanities offers a richer, more empathetic clinical...
Evidence-based medicine has been defined as the conscientious and judicious use of current best e... more Evidence-based medicine has been defined as the conscientious and judicious use of current best evidence in making clinical decisions. This paper will attempt to explicate the terms "conscientious" and "judicious" within the evidence-based medicine definition. It will be argued that "conscientious" and "judicious" represent virtue terms derived from virtue ethics and virtue epistemology. The identification of explicit virtue components in the definition and therefore conception of evidence-based medicine presents an important starting point in the connection between virtue theories and medicine itself. In addition, a unification of virtue theories and evidence-based medicine will illustrate the need for future research in order to combine the fields of virtue-based approaches and clinical practice.
Previous research on the determinants of pneumonia and influenza has focused primarily on the rol... more Previous research on the determinants of pneumonia and influenza has focused primarily on the role of individual level biological and behavioural risk factors resulting in partial explanations and largely curative approaches to reducing the disease burden. This study examines the geographic patterns of pneumonia and influenza hospitalizations and the role that broad ecologic-level factors may have in determining them. We conducted a county level, retrospective, ecologic study of pneumonia and influenza hospitalizations in the province of Ontario, Canada, between 1992 and 2001 (N=241,803), controlling for spatial dependence in the data. Non-spatial and spatial regression models were estimated using a range of environmental, social, economic, behavioural, and health care predictors. Results revealed low education to be positively associated with hospitalization rates over all age groups and both genders. The Aboriginal population variable was also positively associated in most models except for the 65+-year age group. Behavioural factors (daily smoking and heavy drinking), environmental factors (passive smoking, poor housing, temperature), and health care factors (influenza vaccination) were all significantly associated in different age and gender-specific models. The use of spatial error regression models allowed for unbiased estimation of regression parameters and their significance levels. These findings demonstrate the importance of broad age and gender-specific population-level factors in determining pneumonia and influenza hospitalizations, and illustrate the need for place and population-specific policies that take these factors into consideration.
Introduction The COVID-19 pandemic has amplified pre-existing challenges to health promotion and ... more Introduction The COVID-19 pandemic has amplified pre-existing challenges to health promotion and care across the world, and particularly in low- and middle-income countries (LMICs). This qualitative study draws on data from a panel of immunisation experts and uses a novel framework of vaccine delivery domains to explore perspectives from those who live and work in these settings on the challenges to implementing COVID-19 vaccine programs in LMICs. Methods We conducted a thematic content analysis of 96 participant free text replies to questions from Round I of a three-round Delphi consensus study amongst global experts on COVID-19 vaccine implementation. Results Participant responses highlighted challenges to vaccine program implementation including issues related to equity; governance, decision-making, and financing; regulatory structures, planning, and coordination; prioritisation, demand generation, and communication; vaccine, cold chain, logistics, and infrastructure; service del...
BackgroundTask shifting and sharing (TS/S) involves the redistribution of health tasks within wor... more BackgroundTask shifting and sharing (TS/S) involves the redistribution of health tasks within workforces and communities. Conceptual frameworks lay out the key factors, constructs, and variables involved in a given phenomenon, as well as the relationships between those factors. Though TS/S is a leading strategy to address health worker shortages and improve access to services worldwide, a conceptual framework for this approach is lacking.MethodsWe used an online Delphi process to engage an international panel of scholars with experience in knowledge synthesis concerning TS/S and develop a conceptual framework for TS/S. We invited 55 prospective panelists to participate in a series of questionnaires exploring the purpose of TS/S and the characteristics of contexts amenable to TS/S programmes. Panelist responses were analysed and integrated through an iterative process to achieve consensus on the elements included in the conceptual framework.ResultsThe panel achieved consensus concern...
BackgroundEffective communication is integral to the delivery of goal-concordant care for older a... more BackgroundEffective communication is integral to the delivery of goal-concordant care for older adults and their family caregivers, and yet, it is uncommon in people with serious illness. This study explores the challenges of integrating end-of-life communication into heart failure management from the perspectives of older adults and family caregivers.MethodsIn a qualitative study of older adults with heart failure and their family caregivers, fourteen semi-structured interviews were conducted with 19 participants in Ontario, Canada. The interviews were transcribed verbatim and thematic analysis was applied to analyze the data.ResultsFour themes were identified in the context of participants’ understanding of illness: 1) trivializing illness-related challenges, 2) positivity in late life, 3) discomfort in having end-of-life conversations, and 4) reluctant to engage despite need. These challenges often intertwine with one another. Most participants had not engaged in end-of-life disc...
BACKGROUND Cardiovascular disease (CVD) is the leading cause of death globally and in Canada. Dia... more BACKGROUND Cardiovascular disease (CVD) is the leading cause of death globally and in Canada. Diabetes and hypertension are major risk factors for CVD events. Despite the increasing availability of effective treatments, majority of diabetic and hypertensive patients do not have adequate blood pressure and glycemic control. One of the major contributors is poor treatment adherence. OBJECTIVE This study aims to evaluate the impact of treatment adherence for patients with both diabetes and hypertension on acute severe CVD events, and intermediate clinical outcomes in Canadian primary care settings. METHODS We will conduct a population-based retrospective cohort study of patients living with both diabetes and hypertension in Ontario, Canada between January 1 2008 and March 31 2018. The Social Cognitive Theory will be used to explain the reciprocal relationship between treatment adherence, personal factors and environmental determinants, and how this interplay impacts CVD events and clin...
Journal of the American Geriatrics Society, Jan 27, 2017
To compare the effect of a 6-month community-based intervention with that of usual care on qualit... more To compare the effect of a 6-month community-based intervention with that of usual care on quality of life, depressive symptoms, anxiety, self-efficacy, self-management, and healthcare costs in older adults with type 2 diabetes mellitus (T2DM) and 2 or more comorbidities. Multisite, single-blind, parallel, pragmatic, randomized controlled trial. Four communities in Ontario, Canada. Community-dwelling older adults (≥65) with T2DM and 2 or more comorbidities randomized into intervention (n = 80) and control (n = 79) groups (N = 159). Client-driven, customized self-management program with up to 3 in-home visits from a registered nurse or registered dietitian, a monthly group wellness program, monthly provider team case conferences, and care coordination and system navigation. Quality-of-life measures included the Physical Component Summary (PCS, primary outcome) and Mental Component Summary (MCS, secondary outcome) scores of the Medical Outcomes Study 12-item Short-Form Health Survey (...
Inappropriate antibiotic prescribing contributes to the generation of drug resistance worldwide, ... more Inappropriate antibiotic prescribing contributes to the generation of drug resistance worldwide, and is particularly common in China. We assessed the effectiveness of an antimicrobial stewardship programme aiming to reduce inappropriate antibiotic prescribing in paediatric outpatients by targeting providers and caregivers in primary care hospitals in rural China. We did a pragmatic, cluster-randomised controlled trial with a 6-month intervention period. Clusters were primary care township hospitals in two counties of Guangxi province in China, which were randomly allocated to the intervention group or the control group (in a 1:1 ratio in Rong county and in a 5:6 ratio in Liujiang county). Randomisation was stratified by county. Eligible participants were children aged 2-14 years who attended a township hospital as an outpatient and were given a prescription following a primary diagnosis of an upper respiratory tract infection. The intervention included clinician guidelines and train...
Naturalistic theories of disease appeal to concepts of biological function, and use the notion of... more Naturalistic theories of disease appeal to concepts of biological function, and use the notion of dysfunction as the basis of their definitions. Debates in the philosophy of biology demonstrate how attributing functions in organisms and establishing the function-dysfunction distinction is by no means straightforward. This problematization of functional ascription has undermined naturalistic theories and led some authors to abandon the concept of dysfunction, favoring instead definitions based in normative criteria or phenomenological approaches. Although this work has enhanced our understanding of disease and illness, we need not necessarily abandon naturalistic concepts of function and dysfunction in the disease debate. This article attempts to move towards a new naturalistic theory of disease that overcomes the limitations of previous definitions and offers advantages in the clinical setting. Our approach involves a re-evaluation of concepts of biological function employed by naturalistic theories. Drawing on recent insights from the philosophy of biology, we develop a contextual and evaluative account of function that is better suited to clinical medicine and remains consistent with contemporary naturalism. We also show how an updated naturalistic view shares important affinities with normativist and phenomenological positions, suggesting a possibility for consilience in the disease debate.
Journal of evaluation in clinical practice, Jan 7, 2015
The aim of this article is to create a space for historical thinking in medical practice. To this... more The aim of this article is to create a space for historical thinking in medical practice. To this end, we draw on the ideas of R.G. Collingwood (1889-1943), the renowned British philosopher of history, and explore the implications of his philosophy for clinical medicine. We show how Collingwood's philosophy provides a compelling argument for the re-centring of medical practice around the patient history as a means of restoring to the clinical encounter the human meaning that is too often lost in modern medicine. Furthermore, we examine how Collingwood's historical thinking offers a patient-centred epistemology and a more pluralistic concept of evidence that includes the qualitative, narrative evidence necessary for human understanding. We suggest that clinical medicine can benefit from Collingwood's historical thinking, and, more generally, illustrates how a philosophy of medicine that draws on diverse sources from the humanities offers a richer, more empathetic clinical...
Evidence-based medicine has been defined as the conscientious and judicious use of current best e... more Evidence-based medicine has been defined as the conscientious and judicious use of current best evidence in making clinical decisions. This paper will attempt to explicate the terms "conscientious" and "judicious" within the evidence-based medicine definition. It will be argued that "conscientious" and "judicious" represent virtue terms derived from virtue ethics and virtue epistemology. The identification of explicit virtue components in the definition and therefore conception of evidence-based medicine presents an important starting point in the connection between virtue theories and medicine itself. In addition, a unification of virtue theories and evidence-based medicine will illustrate the need for future research in order to combine the fields of virtue-based approaches and clinical practice.
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Papers by Ross Upshur