Naunyn-Schmiedeberg’s Archives of Pharmacology has become the target of a massive attack of fraudulent papers originating from paper mills. This editorial highlights 20 important features we observed with paper mills and explains how the journal is responding to this serious threat to restore the integrity of science. Hopefully, this editorial is also helpful for editors of other scientific journals.Fraudulent papers from paper mills are a serious threat to the entire scientific community.  Paper mills are commercially motivated malicious enterprises apparently operated by knowledgeable “scientists” that produce custom-designed papers containing no real scientific data but only fake data. Depending on the amount of money the customer is willing to pay, paper mills also offer manuscript submission and manuscript revision services and take care of all correspondence with the journal (full-service premium package). The purpose of paper mills is to promote the “academic career” of their customers by delivering publications in prestigious scientific journals.https://forbetterscience.com/2020/01/24/the-full-service-paper-mill-and-its-chinese-customers/).Two recent excellent papers have summarized several major (sad) features of paper mills  email address.Uneventful peer review process: All papers passed the routine text similarity check with the iThenticate software without any problem. With very few exceptions, the peer review of papers was very uneventful and went smoothly. Editors handled paper mill papers without noting anything unusual. In this context, it must be noted that we do have an excellent reporting system in place should anything unusual happen during peer review. These safeguards were bypassed effectively by the paper mills. This is indicative of the “professionalism” behind paper mills. It can be assumed that experienced “scientists” (or more precisely misguided ex-scientists) with extensive and in-depth experience in the scientific publication process and familiarity with professional plagiarism software are the core of paper mills. It is likely that employees of paper mills have worked with real scientific journals before. Consequently, in our revised editorial guidelines, we request an explicit statement by authors that no paper mill was used.“Scientific” focus of the fraud: Most paper mill papers in our journal deal with chemically defined natural compounds, mostly from plants in the context of “highly important,” “highly relevant,” or “medically underserved” diseases for which there is “no cure yet” and a “high medical need.” Often, paper mill papers advertise a breakthrough in a given pharmacological field. Thus, it can be assumed that customers are not just interested in getting “a” publication but a “medically important” publication. This is compatible with the assumption that the primary purpose of paper mills is to facilitate rapid “academic career” advancement and professional rewards for the “customer.” Since most paper mill papers allude to high clinical relevance, it can be assumed that “premium” customers of paper mills are clinicians who have no scientific experience. This assumption is corroborated by the fact that in many cases, authors list clinical departments as their affiliation.No reporting of service laboratories: Several papers included data from so-called service laboratories, but the papers did not mention this fact in the Materials and Methods section. Therefore, in our revised editorial guidelines, we request an explicit statement that all data were generated in-house.Elusive “service laboratories”: Authors blame the “service laboratories” of having provided “problematic data,” but we never obtained any information about the precise nature of the “problematic data.” In no case, the authors admitted that the data from “service laboratories” are fake, and not a single service laboratory could be localized physically . In no case, the name of a person behind a “service laboratory” was provided. Thus, it appears that paper mills do their very best to prevent identification of the “service laboratories” because they are an integral part for their business to be successful.No data at all: In all cases, the authors were unable to provide original data (raw data). Sometimes no reason was given; sometimes ridiculous reasons were given (the COVID-19 pandemia being the most popular “excuse”). The pandemia was blamed to have caused lack of access to data files or complete loss of data. This is a hitherto unknown facet of the pandemia that SARS-CoV-2 also infects computer hard disks and USB sticks. In an extreme case, an author’s child was blamed of having spilled coffee into the computer, resulting in total data loss with no back-up of data, “unfortunately.” Thus, in addition to having no data, the authors of paper mill papers have no clue how to properly store and back-up data. Because of the lack of original data in all fraud cases, in our revised editorial guidelines, we request original data already upon initial submission. Otherwise, no peer review will take place. The request of original data right from the beginning is the most effective measure to fight paper mills.Cut and paste beautiful images: The fraud data particularly concerned flow cytometry experiments, fluorescence cell images, western blots, and histology. We noted several types of fraud: images were flipped. The same data  were used in experimentally totally different contexts, not just within one paper but also within completely different papers unrelated to each other. Most notably, in western blots, only “regions of interest” without molecular mass markers were shown, never full-length blots. Thus, it appears that paper mills arbitrarily collaged “impressive” data sets from a library of “data modules.” As a precaution against fraud of this type, in our revised editorial guidelines, we now request submission of full-length western blots with molecular mass markers. This is also a very effective measure to fight paper mills.No email signatures: In no case, the corresponding authors used professional  email signatures in the emails. Apparently, an important element of paper mills is disguising the precise origin of the email and rendering it virtually impossible to localize the fraudulent author. Evidently, this substantially reduces the risk of negative academic consequences for the author.Extremely poor English in emails: The English language used in email correspondence was extremely poor and, astonishingly, much worse than in the respective papers. In the papers, the English, in general, was decent and passed the English language check. This discrepancy indicates that the paper mill employees “polishing” papers  are much more proficient in English than the employees taking care of the journal correspondence that will not be published.Rapid informal agreement to retraction: Most surprisingly, when confronted with the suspected fraud, quite often the corresponding authors very quickly  agreed to a retraction without actually admitting the fraud openly. Often, authors mentioned the global term “problem with the data” without being specific what the problem is.Blaming others: In some cases, corresponding authors blamed one of their graduate students (unnamed) of having generated “problematic” data, and that the respective student had already faced consequences (“punishment”) by the academic institution. In no case, we received any official evidence that a student was “punished” and what the precise academic misconduct and “punishment” was. Evidently, the corresponding authors do not recognize that they also bear a major responsibility for the entire group.Painful formal retraction process: The formal retraction process was very sluggish from the side of the authors and lacked professional conduct.Communication without content: Evasiveness and disinformation tactics prevailed in email communication with the corresponding authors. Often, the content of the emails was close to zero when it came to answering specific questions of the Editor-in-Chief or the publisher SpringerNature. Apparently, the authors wished to convey the impression that their English is “unfortunately” too poor to understand the questions of the Editor-in-Chief or the publisher.Puzzling email clusters: Strikingly, in several fraud cases, the Editor-in-Chief received emails from authors from apparently different groups within a short period of time (minutes to hours!) as if the emails were sent by one and the same person under different email addresses. It was also noted that the text was rather similar. Thus, it can be assumed that a single paper mill employee is handling multiple fake submissions in one and the same “work session.”Sluggish email communication (if any): Sometimes, there was no communication at all, because email addresses  did not work or because authors did not respond. Sometimes, we had to wait for up to 6 (!) months to get an answer. Blocking of emails by servers was used as another common “excuse” for not responding quickly. However, we never received any message from email servers that a message could not be delivered, unless an email address was invalid. The sluggish email communication is the major reason why it took so long to publish the retraction notes. We would have liked to proceed much faster, but we could not because the Editor-in-Chief and SpringerNature had to play the formal retraction process by the formal rules. Most unfortunately and to our dismay, fraudulent authors only care about rapid publication of their papers but not about rapid procedurally correct retraction. This is highly unethical and unprofessional conduct.No academic institutions: In two cases, it turned out to be impossible to get into contact with the respective academic institutions from which the papers were generated.No ORCID IDs: Very few authors used ORCID IDs. This is an effective method of disguising the identity of an author, particularly when first names and family names are very common in the literature.Fake reviewers: When Editors used reviewers proposed by authors in fraud cases, in some cases, reviews were delivered in unusually short time (minutes!). In general, these reviews were very brief, uninformative, and written in extremely poor English. In all cases, these “fake reviewers” were not used as first-choice referees by the editors but as “very last-choice” when multiple attempts (up to 10) to recruit trusted referees failed. In this context, it must be noted that several of our trusted referees got extremely exhausted by the large number of review requests and, accordingly and understandably, declined. In fact, we received several complaints by referees for the high workload. We can only apologize to our referees. We were simply not aware of the problem. Thus, paper mill authors intentionally exploit and exhaust honest and trusted referees as a most valuable resource of a scientific journal so that desperate editors, as last-resort, use the author-suggested fake reviewers.s-mediated cognitive improvement in a mouse model of Alzheimer’s type: A key role of BDNF-H2S-Nrf2 signaling versus . Changing the term “aldosterone receptor “against “mineralocorticoid receptor” points to the paper mill employees having solid pharmacological knowledge. Thus, it can be assumed that the paper declined in our journal was sold de novo to new “authors” without informing them that this paper has been flagged as fake already before. When the editor of Fundamental & Clinical Pharmacology was contacted by us, we were notified that the paper underwent regular (uneventful) peer review and that there is no need for action. We had the impression that the editor of Fundamental & Clinical Pharmacology was not aware of the severity of the problem. It is very likely that this example is not an isolated case because there is no generally accessible data base of rejected fake papers. Thus, paper mills can aggressively exploit this lack of data base on rejected fake papers and the fundamental assumption of author honesty for their business model. This type of fraud can only be detected by chance. As a minimalistic precaution against detection of this type of fraud, paper mills slightly change the paper title, barely disguising the identity of the content.Same paper, different authors: In one particularly egregious case, a paper administratively withdrawn from our files because of suspected fraud was submitted shortly thereafter to another pharmacological journal, the only major difference being that the list of authors was totally different. The title of the paper was slightly modified  reminders. The respective papers were then all administratively withdrawn by the Editor-in-Chief prior to acceptance or rejection. All authors from fraudulent papers were flagged to prevent future submissions to the journal.Once the Editor-in-Chief of Naunyn-Schmiedeberg’s Archives of Pharmacology was considered to be a highly desirable and attractive target for “academic promotion,” both by customers and paper mills. With an average of about 1,000 submissions per year to our journal in 2019 and 2020, we come to the sad conclusion that around 5% of the submissions to our journal were from paper mills. Probably, this high percentage is related to the fact that the journal traditionally publishes many papers on natural compound pharmacology and that career incentives to publish in this field in the target country and in this journal must be very substantial.A total number of 10 paper retractions in a single journal within 1 year is quite a large. Even more dramatic, the high number of submissions (40) from paper mills caught prior to online publication illustrates that the problem was massive and that Naunyn-Schmiedeberg’s Archives of Pharmacology probably would have experienced a further dramatic increase in paper mill submissions. Paper mills could have advertised the journal as “easy prey,” charging higher prices for customers for higher publication success rates. We may have stopped the fraud wave at the beginning of an exponential growth phase.If the Editor-in-Chief had not reacted immediately, Molecular Brain) in a somewhat different scientific field reports a substantial quantitative problem with fake submissions as well  presented in tables and figures in a generally readable format. Excel files are preferred. Pdf and Prism files are acceptable as well. Supplemental data must be cited in the main text. These data will be made available to the reviewers and published if the paper is accepted.Request of supplemental immunoblot data. Specifically, full-length immunoblots with molecular mass markers are requested. Supplemental immunoblot data must be cited in the text. These data will be made available to the reviewers and published if the paper is accepted.Authors must include the following statement in the section “Authors Contributions”: The authors declare that all data were generated in-house and that no paper mill was used.These measures are meant to protect the scientific integrity of your work and the scientific integrity of our journal.Papers that do not follow these guidelines upon submission are administratively rejected but can be resubmitted when the formal requirements are met.Naunyn-Schmiedeberg’s Archives of Pharmacology. To our delight, from several authors, we received very positive comments about the new editorial guidelines.The new editorial policies have been in place now for more than 6 months. The overwhelming majority of authors abides to the rules and considers them as a quality criterion for their work and Only very few authors expressed concerns that original data could be “stolen” by peer reviewers. We take this concern extremely seriously and select only trustworthy reviewers with a proven track record and prefer referees whom the editors know personally. The Editor-in-Chief is not aware of a single case in which data from an author have been “stolen” by another scientist. We would react immediately if such scientific misconduct from the side of reviewers ever occurred. As a result of the paper mill attack, we are very reluctant at using author-proposed referees whom we do not know personally.Naunyn-Schmiedeberg’s Archives of Pharmacology had become an “attractive” target for paper mills, we had no other choice than to massively tighten our editorial guidelines to protect the integrity of our authors, the editors, the referees, the journal, and the publisher SpringerNature. In addition, we want to ensure that at its 150th anniversary in 2023, Naunyn-Schmiedeberg’s Archives of Pharmacology enjoys the status of a leading and rigorous pharmacological journal, promoting scientific integrity and quality. Interestingly, Molecular Brain also proposes that the inclusion of raw data along with the initial submission is the only solution to eradicate paper mills effectively (Miyakawa We realize that the updated editorial guidelines may appear “harsh” as compared to other scientific journals. However, due to the fact that Miyakawa .Naunyn-Schmiedeberg’s Archives of Pharmacology are based on honest science. We have weeded out a total of 50 fraudulent papers from the publication pipeline at various stages during the last year and will rigorously continue this path.The Editor-in-Chief, associate editors, reviewers, and the publisher SpringerNature do their very best to ensure that papers published in Finally, the Editor-in-Chief hopes that this editorial may be helpful to editors of other scientific journals how to handle the paper mill problem that has the malicious potential to cause a long-lasting and serious contamination of the scientific track record.


Popular perception of people who sell drugs is negative, with drug selling framed as predatory and morally reprehensible. In contrast, people who use drugs (PWUD) often describe positive perceptions of the people who sell them drugs. The “Satellite Sites” program in Toronto, Canada, provides harm reduction services in the community spaces where people gather to buy, use, and sell drugs. This program hires PWUD—who may move into and out of drug selling—as harm reduction workers. In this paper, we examine the integration of people who sell drugs directly into harm reduction service provision, and their practices of care with other PWUD in their community.Data collection included participant observation within the Satellite Sites over a 7-month period in 2016–2017, complemented by 20 semi-structured interviews with Satellite Site workers, clients, and program supervisors. Thematic analysis was used to examine practices of care emerging from the activities of Satellite Site workers, including those circulating around drug selling and sharing behaviors.Satellite Site workers engage in a variety of practices of care with PWUD accessing their sites. Distribution of harm reduction equipment is more easily visible as a practice of care because it conforms to normative framings of care. Criminalization, coupled with negative framings of drug selling as predatory, contributes to the difficultly in examining acts of mutual aid and care that surround drug selling as practices of care. By taking seriously the importance for PWUD of procuring good quality drugs, a wider variety of practices of care are made visible. These additional practices of care include assistance in buying drugs, information on drug potency, and refusal to sell drugs that are perceived to be too strong.Our results suggest a potential for harm reduction programs to incorporate some people who sell drugs into programming. Taking practices of care seriously may remove some barriers to integration of people who sell drugs into harm reduction programming, and assist in the development of more pertinent interventions that understand the key role of drug buying and selling within the lives of PWUD. Research examining drug selling  has found that it is a common income generation strategy among people who inject drugs, particularly among people who report daily drug use , 2. In fWith few exceptions, harm reduction programs have focused on their clients as consumers of drugs, and little attention has been paid to the ways in which people who engage in drug selling—often the very same people—could be integrated into harm reduction efforts. In the context of the North American overdose crisis, multiple interventions have been scaled up including overdose education and naloxone distribution programs, overdose prevention and supervised consumption sites, and drug checking programs –15. WhilIn this paper, we present and analyze qualitative data from interviews and ethnographic observations of the Satellite Site program—a low-threshold, peer-led harm reduction program operating within community spaces—frequently apartments—where people gather to buy, use, and sell drugs. The Satellite Site program hires PWUD to be Satellite Site workers (SSW), who are chosen because they are well-known in their communities, and want to work as a type of community-based harm reduction worker. To do so, they are trained to offer harm reduction services to other PWUD in their social networks, and work primarily from their own homes. The Satellite Sites become community access points for harm reduction equipment and information, overdose education, and naloxone distribution, and, in some sites, monitoring of drug consumption , 17. OneFocusing on drug selling within harm reduction programming is not a new idea. A key early example of this is provided by Grove , who argWhile many key components of public health interventions for PWUD (such as needle and syringe distribution programs) started out as survival strategies among PWUD, their uptake and operationalization by public health authorities (who may have little to no connection with communities of PWUD) can lead to services that are not accommodating nor reflective of the needs of people who use drug . A primeThe difficulties in ensuring that the institutional rules and regulations that surround the delivery of harm reduction services are low threshold and reflect the local culture among PWUD are amplified in any attempt to work with people who sell drugs, despite the frequent acknowledgment that engaging in low-level drug selling is common for people with high frequency or daily drug use , 2. AlteThis paper explores the practices of care that SSWs engage in as part of their harm reduction work, with a focus on the practices of care that circulate around drug selling. Drawing on Foucault’s ethics as well as more recent work on pleasure in drug use , Duff exMuch of the concern with care stems from the work of feminist scholars in science and technology studies, and stems from the feminist concern with devalued labor . Here, tPractices of care in harm reduction proliferate, yet have only recently begun to be described as such. Examining the practices of care among PWUD builds off research that has repeatedly documented the mutual aid among PWUD. This includes the ways that PWUD  support others within harm reduction programs and overdose prevention sites, with more recent research exploring their experiences reversing overdoses in housing and community settings , 47–51. Increased attention is being paid to how a strong focus on risk and harm in research on drug use may obscure the wide variety of drug use experiences , 38, 40.This research was conducted with the “Satellite Site” program, implemented in Toronto, Canada. The Satellite Site program started informally in 1999, as an outgrowth of a peer-developed and peer-run harm reduction program operating inside a community health center. The founder of the program, who ran the harm reduction program at the community health center and who openly identified as a person who injected drugs, began to provide home delivery of sterile injection equipment to increase access for community members outside the hours of operation at the community health center. Noticing that many people maintained communal spaces where people gathered to use illicit drugs, he began asking the people running these spaces if they wanted to keep extra harm reduction supplies around for others who might need them; this was the beginning of the Satellite Site program . The SatA community-based research approach was used to guide the data collection in this ethnographic study. The lead author was well-known to SSWs due to previous involvement in an evaluation of the program , as wellSSWs were invited by the lead author to participate in site visits and/or one-on-one semi-structured interviews. SSWs who expressed interest in participating provided informed consent for observations at their site prior to the first visit. The consent process included a discussion of how they could opt out of site visits, ask the researcher to leave at any time, or withdraw from the study completely. As part of the consent process, SSWs were asked to inform any Satellite Site clients who were at the site at the time of a visit about the research study using a short script. Ethnographic observation at the Satellite Sites occurred over a period of 7 months, from September 2016 to March 2017. In total, 57 observation visits were conducted. Sampling was guided by the sequential approach described by Small . Visits Seven Satellite Sites were visited on a regular basis. Two of these Satellite Sites were in privately owned apartment buildings, and five were located in subsidized social housing complexes. The closest Satellite Site was located 2 km from the sponsoring community health center, and the farthest was located 11 km away. The SSWs running these seven sites included six individuals and one couple; three men and five women, all between the ages of 45 and 70 years old who injected drugs regularly , and who received much of their income from government social assistance programs.One-on-one, semi-structured interviews were also conducted to complement the information gathered during observation visits. SSWs were interviewed twice; once prior to the beginning of observation visits in the Satellite Sites, and once following the completion of visits. In the first interview, they were asked about general issues relating to their work as a SSW, such as how they became part of the program, challenges they faced, and benefits of being a SSW. The second interview was used to expand on issues and themes that emerged from the observation visits. Clients and supervisory staff were each interviewed once only. Clients were recruited from the Satellite Sites, where the researcher would discretely approach them to determine interest in participating in a confidential interview in a spare room in the Satellite Site (if available), or at another location . They were asked about the experience of visiting the Satellite Site, and their use of other health or harm reduction services. Community health center staff were also interviewed; staff were all involved in different aspects of administering or supervising the Satellite Site program. They were asked about institutional factors associated with running the program, such as challenges faced in implementation or program expansion. All interview participants gave verbal informed consent to be interviewed, and were offered $20CAD honorarium.In total, 15 participants were interviewed, including five SSWs, four Satellite Site clients, and six staff members from the community health center who administered and worked in supervisory roles over the program. Two of the SSWs who were interviewed were men, and three were women, and all were between the ages of 51 and 70 years old. They all injected drugs regularly, with four injecting daily, and four lived in subsidized housing complexes, with the remaining SSWs living in a privately owned apartment building. For Satellite Site clients who participated in formal interviews, three out of four were male, between 20 and 30 years of age, with the fourth participant in the 50–60-year age range. One client was homeless, with the remaining three living in subsidized community housing.Data analysis was guided by a theoretical approach that aimed to foreground the ways in which a marginalized group of people engage in harm reduction work in community settings, with a focus on how structural and social forces shape actions that are often viewed (and framed) as individual-level risk behaviors –62. ThisThe Satellite Site program integrates the distribution of harm reduction materials directly into the spaces in the community where people are already gathering to buy and use drugs, and helps make sterile drug injection and unused inhalation equipment more widely available in these community settings. During the observations for this study, people were repeatedly observed visiting Satellite Sites to get harm reduction supplies and to make use of the sterile equipment available. No instances of needle or syringe sharing were noted. Clients of the sites recognized the health-related benefits of the widespread availability of sterile injection equipment at the Satellite Sites. As one client indicated: “It's probably allowed me to avoid certain health complications. Like, I don't have Hep C, right? I don't have HIV or anything like that. So that's a positive” (interview with Satellite Site client 1). This client also stated that he had never accessed a formal harm reduction program, and accessed all his injection equipment at a Satellite Site where drugs were being sold. This speaks to the long history of secondary distribution within harm reduction, where PWUD maintain a reserve of harm reduction materials to distribute to people who may not otherwise be accessing formal harm reduction programs , 64, 65.[of heroin] too?” He goes into the kitchen, grabs an empty grey plastic bag, and passes it to her, gesturing to the stack of plastic drawers holding all the harm reduction supplies. She opens the top drawer, takes a bunch of injection kits , and then grabs a handful of crack pipes, putting them all in the bag. Phil heads to the bed, and, sitting on the edge, he pulls out a scale and a tiny Ziploc bag. The woman sits on the floor in front of him, watching intently as Phil shakes a little bit of heroin powder onto a small square of paper that he’s placed on the scale. He’s going slow, tipping powder out of the baggie, carefully weighing the drugs out. Once he gets to the right number on the scale, he looks up at her, and she nods, before he carefully folds up the little piece of paper. She passes him some money, says thanks, and nods a goodbye at us. (Field note 2016-11-19)There is a knock at the door, and Phil walks over, opening the door a crack. He speaks quietly for a moment to the person at the door, before letting a woman in. Phil asks her what she needs, and she quietly says, “Can I get some kits, and a point Satellite Sites are not required to allow either drug use or drug selling within their sites: SSWs decide for themselves how they wish to run their sites. The Satellite Site program goes beyond the traditional public health focus on the distribution of harm reduction equipment and moves towards “real harm reduction” by acknowledging the ways that buying, using, and sometimes selling drugs are intertwined within the lives of PWUD . Unlike Increasing access to sterile injection equipment within the spaces where people are buying and using their drugs can facilitate the important public health goal of preventing transmission of HIV and hepatitis C. Additionally, combining the provision of sterile injection equipment with drug purchasing can enable small practices of care in the lives of people who may not be accustomed to receiving care around their drug use.[client] will say, 'Oh, what's the junk like?' And I'll say 'I don't know. Which one did you get?' and they’ll show me: 'This one’. And I can tell them, ‘Be careful, it's a little strong. You can always do more'. But also, they know, ‘Don't worry’, you know, ‘I'll keep an eye on you’. (Interview with SSW 8)They Another example of a practice of care occurs when SSWs use their personal knowledge of drug potency and translate it into harm reduction education. Adrienne is a long-time harm reduction worker in her 50’s, and runs a Satellite Site out of her apartment. Her clients are mostly friends and family members, and she knows their drug use habits very well. She injects opioids but does not sell them, and mobilizes her personal experience to attempt to prevent overdose among clients:[the SSW] has all the supplies and everything. For example, like, when people overdose, she has everything ready. And she’s actually used it [naloxone]. (Interview with Satellite Site client 2)I like that it's a place that's safe and you know nothing's going to happen to you. And shit, Adrienne Here, Adrienne references both her knowledge of drug potency and her ability to intervene in case an overdose occurs. The Satellite Site program formalizes overdose response as a practice of care by providing SSWs with training in overdose intervention and equipping the sites with naloxone kits that could be used onsite or distributed to their clients . For cliThe Satellite Sites were developed as a way of building on the practices of care that exist between PWUD surrounding the distribution of sterile needles and syringes. In the context of the overdose crisis, SSWs also mobilize practices of care to improve overdose prevention and response in the community.I arrive at Tommy’s place with Sonia, who is looking to buy some heroin from him. After knocking for almost 10 minutes, Tommy finally answers the door. He is clearly very intoxicated, sedated. His speech is disconnected, and he is walking slowly around his apartment running a hand through his hair, barely able to keep his eyes open. “I think I was totally unconscious. I did some dope, Sam brought some new dope over, and it was crazy. You know me, I’m no lightweight, but it just knocked me out. And I only had half a point! That stuff is crazy strong.”Hearing this story, Sonia pipes up and says, “Hey, Tommy, could I get a bit of that from you? I’ve got 40 bucks. I’ll take some of that good stuff that knocked you out. I can take that off your hands, if you want.” Tommy shakes his head, and says, “No way! There’s no way I’m selling that – it’s too strong. Maybe it’s cut with fentanyl, but it doesn’t feel heavy like fentanyl – it had the smooth, gradual start like good junk. But it’s really too strong. That could kill someone, and I don’t want to be responsible for that.” He takes a dime bag out of his pocket, and takes out a small chunk of beige heroin, putting it on the table. It looks a bit like silly putty, and he takes a kitchen knife from the table and cuts a small chunk off the end, saying, “But don’t worry, this stuff is good too.” Over the period of field work for this study, the contamination of the illegal heroin supply with illicitly produced fentanyl and fentanyl analogs translated into an increase in the frequency of overdoses within Canada; this increase in overdose was also seen within the Satellite Sites , 68. TheThis field note complicates the simplistic narratives that portray people who sell drugs as reckless and indifferent to the wellbeing of their clients. Here, Tommy is troubled by the strength of the heroin he has just consumed, and is unwilling to sell it to Sonia, as he worries that it might cause a fatal overdose. This field note points to the potential benefits of integrating people who sell drugs into harm reduction programs within the context of the current opioid overdose crisis.SSW: And I pick up for people too, so. By me picking up, I'm usually, you know, I'm in and out, in and out, in, I'm surprised I haven't got nabbed yet, knock on wood. (laugh)Interviewer: And what's in it for you for picking up for them?SSW: It depends. From the dealers, I get, you know, some extra. From the people themselves, they'll throw me something. I usually go if I'm making money. (laugh) If I'm not making money, I don't want to go. (laugh) I mean, it's not a lot of money but it helps.” (Interview with SSW 7)The example in the field note above is an illustration of a practice of care in relation to drug selling. However, the heavy stigma surrounding drug selling can make it difficult to recognize this and other common practices of care that circulate around drug buying and selling. Common, normative narratives frame people who sell or procure drugs in almost exclusively negative terms, as reckless, predatory, and unconcerned about their clients , 21. ThePooling money for a pickup was mutually beneficial, both from an economic perspective as the people putting in money would receive a better deal, and because assisting with these transactions helped sustain and cement social relationships. There is also risk involved in providing this help due to criminalization. These helping behaviors are complex, as they comprise elements of assisting others to procure drugs and self-interest in acquiring free drugs.Service users know that I do have a good rapport with dealers, and good credit. So sometimes, that will come up, like, you know, 'Oh, well, you get it and then I'll pay you’. (Interview with SSW 10)Additionally, some SSWs were observed helping their clients to negotiate the vagaries of drug markets that lack formal dispute resolution procedures. For example, Sandra, a SSW who did not formally sell drugs, explains how she would often help to procure drugs for Satellite Site clients who were unable to buy drugs due to disputes or unpaid debts with drug sellers:It’s Saturday night and we are at Bobby’s place, sitting in the living room with the TV on in the background. It’s been busy, with people coming in and out all night, picking up both injection kits and crack smoking kits. There is a knock on the door, and Bobby comes back with Stella. She says hello to me, as we hadn’t seen each other in a while. She turns to Bobby and somewhat sheepishly says, “Bobby, can I ask a favour? Would you mind getting some crack for me, a 40 piece? Your guy, it’s good stuff?” Tom perks up, and answers, “Oh yeah, it’s good. It’s a little grainy right now, like, it’s not big rocks, but it’s good.”Stella, looking visibly relieved, replies, “Okay, would you mind? My guy, he usually comes to me, he delivers. But he’s not working right now. And I know someone else, but we have to meet on the street. And I hate that. I hate standing out on the street, waiting, not knowing if there are cops around. I get so nervous, I hate it. And I feel like the guy I’m seeing now, that he’s shorting me. Maybe it’s just paranoia, but it seems like the bags are getting smaller and smaller.” Stella hands $40 to Bobby, and he gets up, heading towards the door to his apartment, saying, “No problem, I’ll be right back.”)Stella and I make small talk and watch TV while we wait. About 10 minutes later, Bobby comes back, and hands her a little baggie. Stella looks at it quickly, saying, “Thanks. This is 40?” She’s looking closely at the rocks in the bag, and I can tell that she is unsure about the quantity, and probably wondering if she is getting ripped off. Bobby replies to her, “Yeah, this is good stuff. See what I mean, it’s a little grainy? But that’s the same stuff I had earlier. It’s good. Do you need pipes?” Stella, still looking at the bag, and probing it with her nail, replies, “Yeah, that would be great, thanks.” Tom packs up a bag of new crack pipes, filters, and push-sticks for her to take. . The following field note from a busy Satellite Site provides an example of how social supply networks function, and how a SSW was motivated to assist in the procurement of drugs out of a desire to provide assistance to community members:The importance of ensuring an adequate supply of good quality drugs, while also avoiding getting ripped off and being criminalized for drug use is highlighted as a key concern within “real harm reduction” . HoweverThe findings from this ethnographic research document the practices of care occurring around drug buying, using, and selling within a community-based harm reduction program staffed by SSWs—some of whom are actively engaged in drug selling alongside their harm reduction roles. Common portrayals of PWUD, and particularly people who sell drugs, as solely predatory, lacking in self-control, or as careless obscure the practices of care that were observed in this study. These negative portrayals also make it difficult to integrate these practices of care—and the people who sell drugs who practice them—into public health programming to facilitate harm reduction goals. Harm reduction programs are well-placed to work with people who sell drugs due to their philosophy of meeting PWUD “where they’re at,” of integrating PWUD within program development and delivery, and of highlighting the health harms associated with the criminalization of drug use. Our findings suggest that there is potential to expand the relevance and reach of harm reduction programming by recognizing the practices of care that occur around drug selling, and integrating them into harm reduction. The criminalization of behaviors that we observed as common among people who use drugs  contributes to the difficulty in making visible the practices of care circulating within drug buying and selling. The criminalization of drug selling has also rendered these behaviors highly stigmatized. While the idea of integrating PWUD into harm reduction programming and service delivery in the response to the overdose crisis is not new , there hSome of the practices observed in this study are easily recognizable as “care”  because they align with traditional framings of affective care work as a form of looking after another, or “caring for” someone [46)]. These practices of care are already well-established and practiced within harm reduction programming, particularly in harm reduction programming that utilize “peer” workers , 72. OffHowever, other practices we identified are frequently overlooked as “care” because they are often associated with criminal acts . Our results underline how behaviors such as buying drugs together, buying for another person, and pooling money to buy and share a larger quantity of drugs are common within the social networks of PWUD. Despite their frequency, as well as their role in decreasing and sometimes preventing overdose, these behaviors are nonetheless heavily criminalized as drug distribution or trafficking under current drug laws. The criminalization of commonplace behaviors contributes to alienating people who use and sell drugs from the health and social service system, and results in missed opportunities to engage people who are selling drugs in potentially beneficial public health interventions , 54. TheA key feature of the Satellite Sites is that the drug selling sometimes occurring within them is not seen as a liability, but is utilized to achieve public health goals like increasing access to sterile equipment for drug use. Secondary distribution programs have long been used to increase the reach of more formal harm reduction programs –57. By sMobilizing PWUD as peer workers within harm reduction programming and in response to the overdose crisis is an important strategy to expand service delivery and improve engagement with harm reduction services . HoweverCare must be taken when attempting to extrapolate the findings from this study to other geographical settings, as not all environments or contexts would be amenable to this type of intervention. For example, ethnographic research in Montreal, Canada, exploring “piaules”  found that these spaces were closely tied to and often operated by criminal organizations, rendering the integration of harm reduction programming into them very difficult . The SatThe increased prevalence of fentanyl in the illicit opioid market in most parts of North America has led to a massive increase in overdose deaths in the USA and Canada , 70, 75.


In the published article, there was an error regarding the affiliation for Bishoy Morcos. As well as having affiliation 2, they should also have “Chemistry Department, Faculty of Science, Alexandria University, Alexandria, Egypt” which has been added as affiliation 3.The authors apologize for this error and state that this does not change the scientific conclusions of the article in any way. The original article has been updated.


Climate change is acknowledged to be a major risk to public health. Skills and competencies related to climate change are becoming a part of the curriculum at schools of public health and are now a competency required by schools in Europe and Australia. However, it is unclear whether graduates of public health programs focusing on climate change are in demand in the current job market. The authors analyzed current job postings, 16 years worth of job postings on a public health job board, and survey responses from prospective employers. The current job market appears small but there is evidence from job postings that it may be growing, and 91.7% of survey respondents believe the need for public health professionals with training in climate change may grow in the next 5–10 years. Current employers value skills/competencies such as the knowledge of climate mitigation/adaptation, climate-health justice, direct/indirect and downstream effects of climate on health, health impact assessment, risk assessment, pollution-health consequences and causes, Geographic Information System (GIS) mapping, communication/writing, finance/economics, policy analysis, systems thinking, and interdisciplinary understanding. Ensuring that competencies align with current and future needs is a key aspect of curriculum development. At the same time, we recognize that while we attempt to predict future workforce needs with historical data or surveys, the disruptive reality created by climate change cannot be modeled from prior trends, and we must therefore adopt new paradigms of education for the emerging future. Climate change is acknowledged to be a major threat to public health ,2. Just A 2008 report by the Association of Schools and Programs of Public Health (ASPPH) mentioned climate change as a key, new area of public health education . The 201Many competencies required for environmental health science students, such as “approaches for assessing, preventing and controlling environmental hazards that pose risks to human health and safety”  are applTo further identify existing research on the skills, competencies, and job market for individuals with training in both public health and climate change, we conducted a brief narrative review of the literature, primarily focusing on a keyword search of Google Scholar of “climate change” AND “public health” AND “workforce”, which yielded 28,100 results, and “climate change” AND “public health” AND “jobs”, which yielded 86,000 results; we also conducted a search of Pubmed.com for “public health education” AND . Inclusion criteria included a focus on expected hiring needs for professionals with training in both climate change and public health. Articles that did not include information related to issues with workforce or training needs were excluded.To identify competencies needed in a future workforce, and to ensure training aligns with labor market demand, it is accepted practice to rely on input from public health employers and organizations. Many ASPPH competencies are based on “blue ribbon panels” of employers , as are Through our analyses, we can attempt to estimate current and future hiring trends for public health professionals with training in climate change-related competencies, as well as continue to identify the training needed to help address the threat of climate change. For those institutions creating new training programs focusing on both climate change and public health, it will be important to assess whether their graduates will be in demand in the labor market, and if so, which sectors are most interested in hiring candidates with these skills. We attempt to address the questions: Which employers currently seek graduates with training in both climate change and public health; and is the demand for such graduates likely to grow?In order to best discern whether there is a growing need for professionals with a combination of training in both public health and climate change, the researchers conducted an analysis of current job postings; and to create projections into the future, we conducted an analysis of 16 years worth of job postings in a public health job board. Finally, we conducted a survey of potential employers of public health graduates focusing on climate change to ask for their projections of the skills needed for this future workforce.In order to determine what types of organizations are currently hiring candidates in the USA with a combination of skills or experience in both public health and climate change, on 14 December 2019, the authors conducted a search of Indeed.com, a job board aggregator, which “crawls” multiple job posting websites to gather millions of job postings into one, searchable database . The ratThe resulting Excel file of organizations, job titles and descriptions, were then analyzed using the National Cancer Institute’s SOCcer  system , “a publThe industries/sectors of the employer organizations were also hand-coded, using a taxonomy in alignment with the new ASPPH employment outcomes data collection . For conThe authors were provided access to 32,093 job postings posted into the free job board managed by ASPPH, publichealthjobs.org  dating from 17 July 2003–23 April 2019 . This joIn order to assess the views of current employers who are likely to need candidates with training in both public health and climate change, the authors created an online survey using Qualtrics . The surAdditional, new contacts were identified by using specific keyword searches on LinkedIn such as: Job Title search for (sustainability OR resilience OR mitigation OR adaptation OR carbon) and the general keywords of “Climate Change” AND “health”; and attempts were made to diversify industries of respondents. This allowed the authors to identify 100 new contacts; of these contacts, 12 were directly contacted via LinkedIn “InMail” messages and 51 by using publicly available information; 37 could not be contacted directly. Twenty-one alumni of the Columbia School of Public Health’s Climate Change and Health Certificate program were also surveyed. Three contacts were referred by faculty at Columbia. A total of 537 active contacts were identified from all sources; contacts were primarily based in the USA.The survey was distributed in January, 2019, with two reminders sent, once in January and once in March, 2019, and the survey was closed on 9 April 2019. Survey respondents were offered an opportunity to win a $50 gift card as an incentive for responding to the survey, and they were also encouraged to forward the survey to others in their network. Ninety seven individuals responded. Ten respondents were excluded because they were current graduate students or postdoctoral researchers, as opposed to professionals employed in the field. In addition, the survey was forwarded to other contacts in many cases, and a link to the survey was also posted on several online discussion boards including the Planetary Health Online Community and Planetary Health Education Subgroup on Hylo . ContrasA statistical analysis of the responses was conducted. To evaluate the perceived usefulness of skills among employers in the public health field, we designed a mixed version of questions in which the responses are ordinal consisting of seven levels or text. The survey questionnaire comprises fourteen Likert-scale items to assess the usefulness of specific skills; in the later analysis stage we removed the “other” category, so only thirteen were left for the factor construct. We used qualitative methods to analyze the information from the open-ended responses. For the ordinal Likert-scale data, we first measured the internal consistency of the questionnaire, which was performed using the whole sample with Cronbach’s analysis  is made analysis  and R [3analysis .Overall, there are many articles on the intersection between “climate change” and “public health,” but relatively little on labor market projections. Several articles directly mentioned how public health nurses or health professionals can become involved in climate change response, prevention, adaptation, and mitigation, policy , risk maSeveral articles provided action plans related to climate change and public health, which would require workforce training ,51. ThesThe search of job postings from Indeed.com yielded the following distribution by industry:corporation 32 (20%); nonprofit 76 (47.8%); government 17 (10.7%); and university/academia 34 (21.4%). In terms of occupational codes, the occupations with the largest numbers represented in the data set are listed in It is worth noting that the Standard Occupational Classifications do not include “community organizer”, “grassroots activist”, or “campaign organizer” as categories, so positions with these titles—the largest single group of positions in the data set—were coded as “Community and Social Service Specialists, All Other”. There were a total of 17 faculty positions, 12 within schools of public health, and 5 in environmental or biological sciences. Environmental and occupational health roles—those most likely to be a fit for graduates with a Master’s degree in public or environmental health—totaled 14 positions out of 159. Other common occupations included attorneys , public relations and fundraising, sales, and engineering roles. These data suggest that pursuing doctoral-level education, or combining a public health degree with either law or engineering, might best qualify candidates with an interest in both public health and climate change in today’s job market, at least in the USA.p < 0.0001, Poisson regression). Cross validation found this trend to be positive and statistically significant for all 12-year or longer continuous subset time periods. The data can be seen in The proportion of the 32,093 jobs from publichealthjobs.org from July 2003–April 2019, which mention either “climate change” or “global warming” consistently was a very small percentage of the total, but the percentage increased over this time period  of the responders who answered the question, “Has your organization hired people with a Master of Public Health or PhD in Public Health in the past” responded “yes”. Eighty six individuals responded to the question, “Do you expect the need to hire people with a background in climate and public health to grow in your organization in the next 5–10 years?” and of these, 33 indicated “yes”, 34 “maybe”, 6 “no”, and 13 “don’t know”. Excluding the “don’t know” responders, we could determine that 91.7% of respondents believed that there might be a need for public health and climate change-trained individuals in their organizations in the future.In addition, an analysis of the thirteen-item Likert scale questions regarding skills, which would be useful to the employer organization, was conducted. See the frequency of responses in To standardize the questionnaire data, we considered the numeric data and text data separately. For numeric data, we found that the 13-item Likert scale response shows a high internal consistency of 0.879, which is described by Cronbach’s alpha. From A three-factor solution  showed the best model fit to the survey data set. The Scree plot of the final exploratory factor analysis (EFA) solution is shown in Only two items had a cross-loading on more than one item with loadings >0.50 (Item 9 and Item 10), and we followed guidelines and discarded them in the final model. As shown in After the psychometric validation, we finalized the model with a 3-factor structure, with 11 items, and labeled them according to the theoretical context of each question. The first category was labeled as Population Health Exposure, included six items covering a range from population health analytical skills to general understanding of research methods, and also had a strong consistency of 0.83 . The secOpen-ended comments in response to the question “What expertise or skills do you think will be needed to address the issue of climate change and human health in the next 10–20 years?” were coded using qualitative analysis methods, using categories identified by two of the authors , and were independently coded by two research assistants to improve inter-rater reliability. Themes that emerged are listed in Survey question: “What expertise or skills do you think will be needed to address the issue of climate change and human health in the next 10–20 years?” .The current state of the job market for public health graduates with training in climate change can be described as “emerging”. From the Indeed.com job description data analysis, we can see there are relatively few roles—even in search results from a broad-based job board with keywords focusing on public health and climate change—currently available for a graduate with a master’s level public health degree and a focus in climate change. Notwithstanding, it is likely that graduates would benefit from training in climate change-related competencies, even if the overt focus of their job is not directly related to climate change. Additionally, resonating with Wals, Corocoran, and others who frame educational institutions as change leaders, graduates with training in both climate change and public health can influence their institutions from within, to create systemic change in grappling with global warming.p < 0.0001) increase over the last 16 years. This trend should be monitored by those involved in public health education and career placement of public health graduates, bearing in mind that while prior trends are often used to predict the future, they are not always the best indicator of future trends in a quickly changing world.The analysis of publichealthjobs.org data seemed to show that while jobs within public health that mention climate change or global warming were a very small proportion of the total, the fraction of such job postings had shown a statistically significant . While the response rate of 14% appears to be low, it is comparable with other employer surveys in the public health field, where studies have included rates as low as 13.4%  and 19.5Climate change is a growing threat to human health. While the current job market for candidates with training in both climate change and public health is relatively small, it appears to be growing; and it is likely that training in climate change competencies will increasingly benefit a range of public health organizations as climate change impacts continue to grow. Schools of public health can incorporate the skills and competencies related to climate change into their curricula and consider making them an integral/foundational part of the curriculum, if such training is not yet currently required. Employers, too, may benefit by taking note of the special intersection of skills and competencies offered by public health graduates with training in climate change-related issues. Graduates with such training can bring their paradigm-shifting lens to the work they do within any public health-related organization. Future research, including analyzing job postings, graduate employment outcomes, labor market projections, and employer surveys, could benefit curriculum development for educational institutions in countries around the world, and educational institutions could also remain at the forefront of the paradigm-shifting change that impacts the future public health workforce. By listening to the voices of current employers and assessing labor market trends, while also taking a wider view regarding the role of educational institutions in creating a sustainable world, these institutions can develop the skills and mindset needed to protect the public’s health from emerging challenges such as climate change.


We analyze the use of nine-item Patient Health Questionnaire (PHQ-9), aninstrument that is widely used in diagnosing and determining theseverity of depression. Using conversation analysis, we show how thedoctor deploys the PHQ-9 in response to the patient’s doubts aboutwhether she is depressed. Rather than relaying the PHQ-9 verbatim, thedoctor deviates from the wording so that the response options areselectively offered to upgrade the severity of the patient’s symptoms.This works in favor of a positive diagnosis and is used to justify atreatment recommendation that the patient previously resisted. Thiscontrasted with the rest of the data set, where diagnosis was eithernot delivered (as patients are presenting with ongoing problems) ordelivered without using the PHQ-9. When clinician-administered, thePHQ-9 can be influenced by how response items are presented. This canlead to either downgrading or upgrading the severity ofdepression. Diagnosing and determining the severity of depression is seen as an importantelement of practice in primary care. Multiple scales and questionnaireshave, as a result, been developed to this end, one of which is the nine-itemPatient Health Questionnaire PHQ-9; . A patieHowever, as There is little research on how such diagnostic questionnaires are used inpractice. In other contexts, there is a body of work on how questionnairesare introduced, deployed, and influenced by what is happening in the giveninteraction, that is, the interactional context. Most prior research on theinteractional context of standardized instruments has focused on surveyinterviews. The most extensive study is the one by However, there has, to our knowledge, been no published research on the in situuse of depression diagnostic questionnaires. The objective of this study,therefore, is to use recorded primary care consultations to explore (a) thediagnostic use of the PHQ-9 in practice and (b) how this contrasts withdiagnosis without the PHQ-9 and cases where there is no diagnosis.7This study was developed as part of the DeStress Project on mental healthin low-income communities . Theconn =21), whereas in others the patient was presenting with both physicaland mental health problems (n = 31). Most patientshad some prior history of mental health problems, although they wereat varying points in the treatment process: Some had come to the GPseeking treatment, whereas others were already taking treatment andwere visiting their GP for a follow-up.Some of the 52 recordings were consultations where the patient waspresenting with mental health problems alone  and analyzedusing conversation analysis (CA). CA is a micro-analytic approach thatfocuses on what speakers say , how theysay it , and the pointat which they say it. Applied to medical interaction, it has been usedto study, among other things, how patient concerns are elicited , a consultation inwhich a diagnosis is present prior to treatment discussion(n = 1), and the case where the doctor uses thePHQ-9 to diagnose the patient with depression (n =1).Our data set can be divided into three groups: consultations in which nodiagnosis is present . In others, though, one could say that diagnosis isnoticeably absent. This is because they involve the doctorrecommending that the patient initiate a treatment, and suchrecommendations typically directly follow diagnosis in the primarycare consultation .This is not the case for most of the data set, however, largely becausemost of the consultations involved follow-up rather than new visits.An illustration of this can be seen in increasingly difficult”) makes itclear that this is not a new problem.The doctor’s treatment recommendation here can be seen at Lines 7–8,where she raises the possibility of the patient having “something topick [her] up a bit with [her] mood.” However, in a deviation fromFifty of the consultations in the data set do not feature a diagnosis.This leaves two consultations in which there was a diagnosis. Thefirst of these can be seen in This diagnosis at Lines 15 and 17–18 follows the patient’s (and hiswife’s) problem presentation and the patient’s wife’s candidatediagnosis of depression (Line 5). This is accepted by the patient(yeah) in Line 19. Following intervening talk about how the patient’swife had entreated the patient to come and the patient’s reluctance tocome, the diagnosis is followed by the doctor’s initiation oftreatment discussion at Lines 34–35. Earlier in this consultation, thedoctor has made an explicit reference to this being a new problem forthe patient ,hence the diagnosis: “It sounds like depression.”The case we now focus on features a diagnosis after treatment discussion,rather than a diagnosis followed by treatment discussion. The GP inthis consultation is a man in his 50s who has worked at the practicefor more than 10 years. The patient is a woman in her 70s sufferingfrom a variety of problems, both physical (vertigo and breathingproblems) and psychosocial . The patient was previously taking Valium to help withfeelings of anxiety.An extract of the patient describing her psychosocial problems, takenfrom about a minute into the consultation, can be seen in 1 After around 8 minutes, the doctor suggests that they focus onthe patient’s breathing. The patient agrees, and the next 10 minutesof the consultation are focused exclusively on physical healthissues.While short, this extract captures the focus of the first 8 minutes ofthe consultation, with the patient describing the various issues withwhich she is struggling. With the stress of Christmas coming up, sheindicates at Line 8 that she would like some more Valium rather thananything long-term .Around 18 minutes into the consultation, the doctor and patient wrap updiscussion about physical health matters and the doctor brings thediscussion back to mental health. The moment at which he does so canbe seen at the start of Figure 5pressants” if she is “still feelinganxious.” Notably, the doctor alsoacknowledges the patient’s aforementioned reluctance expressed ino:w you’re not kee:n,”. Notealso that the doctor has transitioned into treatment discussionwithout issuing a diagnosis, in line with the pattern in The doctor starts this extract at Lines 1–3 by suggesting that thepatient might “think about . . .antide2 First, at Lines 4 and 6, she expresses concern about the amountof time that she would be on them: “Well (.) the thingi:s (.) once yougo on those, . . . Then you’reon them (0.6) atleast six months (yeah.)” , then, have been occasioned by a localinteractional reason, that is, the need to get buy-in from the patienton the proposed treatment.The doctor, at Lines 1, 3, and 7–8, suggests using a questionnaire tohelp. This is seemingly in line with options, he begins diverging from the writtenversion. While he reads out verbatim the first two low-scoring answersfrom Lines 3–4 , for example, at Line 4 he offersan answer that is not on the questionnaire: “mostda:ys,”. This appears to be a gloss ofthe final two high-scoring responses , and the patient responds affirmatively to it atLine 5. The doctor then offers only the higher scoring of the twoofficial answers at Line 7 , and the patientagain, at Line 9, answers in the affirmative.The doctor’s reading of the beginning of the questionnaire from Lines 1–4and the first item at Line 3 (“Little pleasure in doing things”) isvirtually verbatim. However, as he reads out the responseBased on the first item alone, we can see that the doctor is not simplyacting as a “relayer” for the o:wndepre:ssed or hopeless,”. However, ratherthan providing the full list of possible response options, he insteadleaves a space for the patient to respond at Line 2. This response (anaspirated and laughter-inflected “yes”) is not a response option onthe questionnaire but indicates that the “not at all” option would notbe relevant. Rather than reading out verbatim the three remainingpossible responses, though, the doctor again offers only one possibleresponse  that is not present on the questionnaire andsuggests a severity beyond that indicated by any of the officialresponses (the most severe of which is “Nearly every day”).3 The patient once again confirms at Line 4.This extract begins similarly to Extract 5, with the doctor reading Item2 verbatim at Line 1: “Feeling ditems of the questionnaire but being selectivein offering possible responses to those items. Theseselective readings seem to favor a positive diagnosis of depression,as the options he is offering are typically from the higher frequencyend of the spectrum. Moreover, he is not doing this in a vacuum but isbuilding upon the patient’s own spontaneous responses to his readingof the items, which themselves favor a positive response.The preceding two extracts are indicative of how the rest of the PHQ-9 isadministered, with the doctor reading almost verbatim theOccasionally, the doctor’s loose reading is merely selective. Consider,for example, his reading of the fourth item .In this case, the doctor does, at Line 3, read out verbatim one of theofficial responses on the PHQ-9: “Nearly every day?” Again, though,this is only the highest scoring of three possible responses , the other two of which would contribute less to the patient’soverall score. This can be attributed, again, to the information thatthe patient has already given about her state of mind.In some cases, it is the patient who offers responses that are notofficially part of the questionnaire, as can be seen in the doctor’sreading of the sixth item .::m. M:::m.(0.3). Sometimes.” “Sometimes” is not an official answer on the PHQ-9,yet the doctor does not attempt to clarify or translate it into theterms of the questionnaire (cf. hay.”) before moving onto the next item atLines 6–7.At Line 5, after some hesitation, the patient offers a mildly affirmativeresponse to the doctor’s reading of the item:“Maire cf. .Instead4To summarize, the doctor here has taken the patient’s statements abouther condition and fitted them to the symptom categories in the PHQ-9.In doing so, however, he has not acted simply as a neutral “relayer” you have- (.) youare depressed.” The doctor offers his diagnosis based on the PHQ-9 at Line 1: “Well (.)hea:h”). Suchminimal responses are typical when it comes to diagnoses which, unliketreatment recommendations, do not call for patient endorsement beforethe consultation can proceed  and 6 (“Y proceed . Given t proceed  of his o proceed .doit.” (Line 20). The talking therapy option is thus abandoned, and thedoctor returns, at Lines 25–26, to offer the same treatment that heoffered in After the patient’s acceptance of the diagnosis, and after an extendedperiod of silence, the doctor does indeed proceed to recommendtreatment. He first offers “talking therapies” at Line 10, but thepatient in Line 11 states that she has “done that before.” (Lines12–14) but had trouble “getting up here to 5 In the following extract , and after further discussion, they agree at Lines 21–22 thatthe patient will try a different antidepressant that will help her tosleep. Although there is still negotiation about what antidepressantwill be prescribed, the patient has gone from strongly resisting anantidepressant, to negotiating about an antidepressant, to ultimatelyagreeing to take an antidepressant that is sedative—a common form ofturnaround in this context (The doctor’s first suggestion in this extract is that the patient try“fluoxetine” (Line 4) or, as he clarifies at Line 6, “Prozac.” Thepatient responds very negatively to this suggestion at Line 8(“.hhhhha:h No: context . A key t context  to suppoThe objective of this study was to explore (a) the diagnostic use of the PHQ-9in primary care and (b) how this contrasts with diagnosis without the PHQ-9and cases where there is no diagnosis. We found that the PHQ-9 was deployedin response to the patient’s expressed resistance to treatment, which wasitself grounded in her uncertainty about whether she was depressed. The wayin which the PHQ-9 was administered was not neutral. Rather, the way thatthe response options were offered and the patient’s answers interpreted wereinfluenced both by the person administering the questionnaire and by thepatient’s initial verbal and nonverbal responses. The response optionsoffered were on some occasions modified to present response options not inthe questionnaire and/or were presented to upgrade the severity of thepatient’s symptoms. This provided evidence for a diagnosis of depressionwhich, in turn, was used to support a recommendation for antidepressantscf. , ultimatThis is, to our knowledge, the first published study on the in situ use of thePHQ-9 questionnaire in a mental health context. Although the doctor’s use ofthe PHQ-9 is not suggested as typical, it is clear that how it was usedinfluenced the diagnostic outcome. Specifically, we have shown how thedoctor’s presentation of response options was modified and/or slanted infavor of upgrading the severity of the patient’s symptoms and generating ahigher score. This finding has important implications for practitioners whouse the PHQ-9 and other such questionnaires, highlighting how subtle ways inwhich they administer an instrument affect the diagnostic outcome.Before analyzing the case featuring the PHQ-9, we considered both cases wherethere was no diagnosis  and a caresponse options to thequestions.This article contributes to the existing body of qualitative research on mentalhealth questionnaires  and, morThere are also differences in the motivation for the editing and outcome ofsuch questionnaires. Our in-depth analysis has shown how subtle differences in how the responseoptions of the PHQ-9 are offered positively favor a diagnosis of depression.However, there were insufficient cases to consider other uses of the PHQ-9and similar questionnaires. Further research could collect furtherconsultations where the PHQ-9 and other diagnostic instruments are used andconsider both the range of ways in which they are deployed and the impactthat this has on the outcome when it is used to establish a diagnosis ofdepression.In conclusion, the PHQ-9 is a widely used tool in primary care for diagnosingdepression and determining depression severity. For practitioners, it canprovide an appealing numerical and “objective” diagnosis . HoweverClick here for additional data file.Supplemental material, sj-pdf-1-qhr-10.1177_1049732320924625 for Use ofthe Patient Health Questionnaire (PHQ-9) in Practice: Interactionsbetween patients and physicians by Joseph Ford, Felicity Thomas,Richard Byng and Rose McCabe in Qualitative Health Research


COVID‐19 has halted research around the globe and forced researchers out of their laboratories. Non‐emergency medical appointments were canceled. Ongoing clinical trials were challenged to create new modes of operation while public pressure mounted to find therapeutic options against COVID‐19. Yet, the inability to conduct research during COVID‐19 was overcome with cooperation, resource sharing, and compassion, which provides important lessons on how to improve health related research as we enter a new normal. The COVID‐19 crisis necessitates and unprecedented level off cooperation and sharing in biomedical research. It should inspire science policies and funding post‐COVID to help drive forward Open Science. However, it takes 10–20 years to turn a basic discovery into a new drug via the typical translational path , patients, and patient advocates to address patient anxieties and clinical priorities by developing new protocols. In Toronto and medical clinics worldwide, clinicians adapted by moving medical visits and clinical trial appointments online. Using video calling, physicians saw their patients in their home environment as well as other family members who joined the call. Although these interactions provided a broader view of the patient, their health, and their environment, careful retrospective analyses of the safety, reliability, and effectiveness of virtual patient assessments are still needed to determine if this approach is sustainable.Harnessing lessons learned during COVID‐19 to improve health research requires joint action to further improve research infrastructure, integrate parts of the translational pathway, and support the people who do the work. Here, we build upon those lessons to propose a framework for the “new normal” after the first phase of COVID‐19 (Table foster cooperation, we need to assemble team members of the broader research and translation community around a shared goal. During COVID‐19, researchers, industry professionals, and regulators were each determined to find solutions that benefit patients right away. Maintaining this shared focus going forward requires that we rebuild activities to support cooperation. In Toronto, we started by restructuring hospital grand rounds, the institute‐wide clinical seminars, to educate the community on a relevant medical topic. Clinicians and researchers from different fields now give joint talks to highlight the larger problem and possible solutions from their perspective. This was particularly helpful during COVID‐19 as infectious‐disease clinicians discussed the newfound pediatric presentation of COVID‐19 and immunologists explained the immune response and how that informs vaccine development. Moving forward, collaborative research should become a model for trainees and other researchers to strive for as they see the fruitful outputs of teamwork.To support cooperation and build partnerships, we need to invest in research clusters that are grouped by disease or clinical question instead of methods. Each cluster would include basic science, health services, implementation, engineering, and clinical expertise. Seminars within each cluster would describe different facets of the problem, as per the expertise of the speaker. This provides researchers and trainees a shared view of the big picture so that they can readily come together to solve the problem. These collaborative clusters should also include patient advocates and industry to open communication and help different groups to understand each other and facilitate a shared culture. In such a disease‐focused research cluster, the role of each member will be clearly understood, reducing the number of barriers to producing research that benefits patients.To further encourage resource sharing and to move research discoveries closer to patients, research institutions need to value and reward teamwork. Yet, the current academic structure does not always reward team science or the building of collaborative networks. In the medium‐term, we should change how we evaluate scientific contributions and create promotional metrics that recognize team science. In Toronto, we acknowledge that success may not always result in a publication but in the adoption of a new policy, better clinical guidelines, a new partnership with industry or the clinical validation and implementation of a diagnostic test. In the long term, we should provide more grants that promote collaboration akin to the European Union's Research Programmes that provide long‐term funding for collaborations between multinational research groups.To et al, Supporting long‐term development relieves the pressure to publish quickly and often and encourages teams to tackle big problems. Given the time and resource needed to bring new interventions to the clinic, the funds for these grants should come from government‐industry partnerships, and there should be an option of applying for additional funding if pre‐specified milestones are met (van Dijk humanize research. During COVID‐19, there was a shift from thinking about research as something that eventually trickles down to a “patient”, to understanding that we all may benefit. This makes it more natural to think of patients as the reason and focus of our scientific inquiries. In Toronto, we previously started shifting toward patient‐centered research by involving patients and families in advisory committees, ethics boards, and research teams as charitable foundations have been doing for years (Stevens, Producing research that is meaningful to patients also requires that we Stevens, .We can further strengthen this partnership by creating pathways for students, the researchers‐of‐tomorrow, to learn from patients directly. In these pathways, students will spend more time in the clinic, meet patients and caregivers, write REB proposals, analyze the flow of information between health professionals, and observe medical procedures (DelNero & McGregor, Now is the time to harness the lessons learned from COVID‐19 and shape a new era of innovation that more effectively brings the benefits of research to patients. We cannot let the positive changes be lost. First, we need to continue to create joint goals between all members of the translational path. Sharing must continue to extend beyond reagents and funding. These actions can be strengthened by restructuring our institutions to reinforce “open science”, developing broad data‐sharing agreements and creating collaborative work spaces. Second, we need to value and reward teamwork. This involves creating new measures of academic success and collaborative grants. The validation of new diagnostic tests, the implementation of a new workflow or pharmacokinetic studies for a new treatment is not considered high‐impact science, but it is needed to improve quality of life and clinical practice. Third, funding must be shared between immediate clinical need and continuous support for basic science to enable the biological understanding of disease. The rapid development of diagnostics and vaccines for COVID‐19 was based on years of basic research in virology, therapeutics, and engineering. Lastly, we must remember that people are at the heart of research. We must work to make sure all team members are supported and that patients are engaged in research. Together, we can create a new era of medical research, where knowledge moves fluently between patients, researchers, industry, regulators, and policy makers in order to generate solutions that are used in the clinic.H.N.K. and N.D.R. conceived the idea, wrote and edited the manuscript; all authors contributed content and reviewed the final manuscript.ADS has received research funding from Takeda Pharmaceuticals and Medivir AB and consulting fees/honorarium from Novartis, Jazz, and Otsuka Pharmaceuticals. ADS also holds stock in Abbvie. UT, LR, MF, MI, HK, and NDR have no relevant relationships to disclose.


British Medical Journal published an editorial entitled “The Scandal of Poor Medical Research” ? Most people would agree that such behaviour was unprofessional, arguably unethical, and certainly unacceptable.“1 2 3 4 5 6 7What, then, should we think about researchers who use the wrong techniques (either wilfully or in ignorance), use the right techniques wrongly, misinterpret their results, report their results selectively, cite the literature selectively, and draw unjustified conclusions? We should be appalled. Yet numerous studies of the medical literature, in both general and specialist journals, have shown that all of the above phenomena are common. …..Why are errors so common? Put simply, much poor research arises because researchers feel compelled for career reasons to carry out research that they are ill equipped to perform, and nobody stops them. Regardless of whether a doctor intends to pursue a career in research, he or she is usually expected to carry out some research with the aim of publishing several papers. …. A common argument in favor of every doctor doing some research is that it provides useful experience and may help doctors to interpret the published research of others. Carrying out a sensible study, even on a small scale, is indeed useful, but carrying out an ill designed study in ignorance of scientific principles and getting it published surely teaches several undesirable lessons….Many people think that all you need to do statistics is a computer and appropriate software. This view is wrong even for analysis, but it certainly ignores the essential consideration of study design, the foundations on which research is built. Doctors need not be experts in statistics, but they should understand the principles of sound methods of research.”http://www.consort-statement.org/about-consort) pertaining to randomized controlled trials or the STROBE statement (https://www.strobe-statement.org/index.php?id=strobe-home) pertaining to observational studies. Twenty-five years later, warnings about “poor medical research”  medicine is a demanding task: it requires adoption of a myriad of facts and skills, ability of analytical and associative thinking, some common sense combined with trained intuition, and some talent – to result in sound clinical judgment and action. Our modest experience has been that quite commonly colleagues with a high level of expertise in their art do not adopt the same approach when it comes to conducting research; commonly, they tend to rely upon “common sense and intuition,” disregarding the fact that research methodology is a trade on its own that needs to be mastered. To illustrate some of the traps associated with relying (solely) on common sense and intuition, we here outline the main points of an imaginary research composed of elements of different reports that we have come across over the years.A group of researchers have formulated a cream containing an otherwise well-known active substance that has been widely used topically as a compounded simple hydrogel in children to improve healing of superficial skin wounds, ie, scrapes/abrasions. The new formulation contains well-established inactive ingredients but is expected to yield an effect with only a single application. In an animal model, it showed an effect of accelerated healing. Scrapes/abrasions are minor ailments that heal spontaneously with only sporadic complications. However, they are extremely common in children and do interfere with some aspects of daily activities over a certain period of time: it might be practically useful if healing could be speeded-up by a simple single administration instead of repeated administrations over several days. A double-blind randomized placebo (simple hydrogel excipients)-controlled trial is planned in children 5-12 years of age as an initial evaluation of the new treatment. It aims primarily to evaluate safety, while assessment of efficacy is considered a secondary aim. The only known safety issue associated with repeated application of the existing formulation is a local transient hypersensitivity reaction manifested as light edema, redness, and itching of the surrounding skin. It is observed in around 2% of the treated children, and the researchers wish to assess whether the tested formulation is within this range. Hence, several visits are planned at which the wound would be inspected, and standardized high-quality photographs would be taken. Three researchers not involved in patient recruitment and follow-up would then, blinded to the treatment and patient, assess digital photos  to adjudpost hoc, since the number of enrolled patients was too small to look at the proportion of “healers.” It appeared intuitive to grade the stage of “healing” at the two pre-defined time points. Several instruments have been developed to assess healing of chronic wounds, such as pressure ulcers or diabetic foot . They reported no hypersensitivity reactions in either arm, but proceeded to an extensive evaluation of efficacy. The initial plan was changed tic foot , but nonThe researchers then proceeded to evaluate treatment efficacy by using averages (9 treated and 9 placebo patients) in a repeated-measures ANOVA. http://www.consort-statement.org/about-consort). In respect to the outlined imaginary research , we will focus on only a few points.Randomized controlled trial (RCT) is a clinical experiment with a wide range of methodological particulars – all research methods  have their own “technical” particulars. The aim of an RCT (as a research method) is to provide an unbiased estimate of a  treatment effect. This can only be achieved if its methodological principles are appreciated and followed. A number of books have been written on the concept and methodology of RCTs, in general and about a variety of its aspects eg ,6,, and 1. As a general concept, it may be acceptable to re-define/modify the outcomes and sample sizes in an ongoing trial . Such modification has to be approved by the same body that approved the initial trial proposal. One condition has to be met: this has to happen before trial outcomes are evaluated. We made no comments on whether this condition was met in the outlined imaginary trial, where researchers could have been particularly eager to demonstrate the functionality of their invention; the proposed changes have to adequately fit the purpose of the trial. In this respect, note: (i) the trial was reduced to around 20% of the initially planned sample size. This disabled any sensible safety assessment, which was originally depicted as a primary objective; (ii) the focus was completely shifted to efficacy. The initially defined outcome – proportion of “healers” – was straightforward, well defined, and practically relevant. The initially planned trial had a reasonable probability of “sensing” a certain potentially relevant treatment effect – had it existed. The “revised” trial version was reduced to a sample size not likely to detect even a huge effect. Moreover, rating was introduced. Rating scales are commonly used in many aspects of medical research, but in order to consider them reliable indicators of the process that is intended to be measured, they need to be validated, ie, assessed for content  validity (that they do embrace different facets of the phenomenon intended for quantification), criterion and concurrent validity (extent to which the yielded results indeed measure the underlying process and extent of agreement with results obtained by a more accurate measurement means), sensitivity (ability to detect changes over time not due to measurement error), and inter- and intra-rater reliability (extent to which the same rater and different raters obtain similar results) . In the 2. No particular methodological knowledge –just some common sense – suffices to see that the approach with averaged scores is questionable. It might have been intuitive to opt for it, from a pragmatic standpoint, but it would not sustain even a simple superficial logical assessment. Only 3 numerical values have their descriptive counterparts: 0 (“none”), 1 (“some”), and 2 (“obvious”). What is a descriptive counterpart of a score of, eg, 2.33 or 3.66? Or of any non-integer score? What is the meaning of an average of 0.33 obtained for a patient who was scored: 0, 0, 1? Patient 1, in the placebo arm, at the first assessment  was repr3. Each set of 3 numbers (by rater-by-patient-by time point) or 9 numbers (by patient-by time point) depicted in 4. What is the meaning of a difference of 0.09 points of some arbitrary score?P values were addressed previously  modest methodological training that we get during medical education, it is more intuitive to us to search for “continuous-like variables”, ie, “something that could be analyzed by a t-test,” or ordinary least-squares regression-based techniques, such as repeated measures ANOVA. In this respect, it should be noted that the researchers in this imaginary trial did have an option to choose an outcome that would “fit this intuition.” Wound area reduction expressed as a percentage of the initial wound surface  is a well established part of many of the chronic wound assessment instruments ,9. For tBMJ editorial from 1994 (The rom 1994 , and inc