The use of herbal supplements in the United States has become increasingly popular. The prevalence of herbal use among primary care patients varies in previous studies; the pattern of herbal use among urban racially/ethnically diverse primary care patients has not been widely studied. The primary objectives of this study were to describe the use of herbs by ethnically diverse primary care patients in a large metropolitan area and to examine factors associated with such use. The secondary objective was to investigate perceptions about and patterns of herbal use.Data for a cross-sectional survey were collected at primary care practices affiliated with the Southern Primary-care Urban Research Network (SPUR-Net) in Houston, Texas, from September 2002 to March 2003. To participate in the study, patients had to be at least 18 years of age and visiting one of the SPUR-Net clinics for routine, nonacute care. Survey questions were available in both English and Spanish.A total of 322 patients who had complete information on race/ethnicity were included in the analysis. Overall, 36% of the surveyed patients (n = 322) indicated use of herbs, with wide variability among ethnic groups: 50% of Hispanics, 50% of Asians, 41% of Whites, and 22% of African-Americans. Significant factors associated with an individual's herbal use were ethnicity other than African-American, having an immigrant family history, and reporting herbal use by other family members. About 40% of survey respondents believed that taking prescription medications and herbal medicines together was more effective than taking either alone. One-third of herbal users reported using herbs on a daily basis. More Whites (67%) disclosed their herbal use to their health-care providers than did African-Americans (45%), Hispanics (31%), or Asians (31%).Racial/ethnic differences in herbal use were apparent among this sample of urban multiethnic adult primary care patients. Associated factors of herbal use were non-African-American ethnicity, immigrant family history, and herbal use among family members. Whereas Hispanics and Asians reported the highest rates of herbal use, they were the least likely to disclose their use to health-care professionals. These findings are important for ensuring medication safety in primary care practices. The use of complementary and alternative medicine (CAM) in the United States gained greater popularity in the 1990s. Two national telephone surveys of 1,539 and 2,005 adults, respectively, demonstrated an increasing trend in the use of CAM, including relaxation techniques, herbal medicine, massage, chiropractic, and acupuncture[Efficacy studies of herbal supplements are on the rise, but most data published to date are preliminary and do not provide strong evidence for the clinical effectiveness of herbs. Nevertheless, about 15 million American adults 18%) are thought to use prescription medications concurrently with herbal or vitamin products, and as % are thoThe prevalence of herbal use among racially/ethnically diverse primary care patients varies from study to study-7,10-12,We implemented this cross-sectional study within the Southern Primary-care Urban Research Network (SPUR-Net) from September 2002 to March 2003. SPUR-Net is a practice-based research network in Houston, Texas, that consists of five constituent member organizations affiliated with a county health system, a managed care organization, or a private practice clinic. SPUR-Net clinicians provide care to patients from diverse ethnic and socioeconomic backgrounds, with approximately one million patient visits per year. A total of six primary care clinics were included in this study that varied according to socioeconomic status (SES) of their patients as measured by income level and insurance type. For the purposes of this study, we defined "clinic SES" according to the insurance status of the majority of patients; "high SES" means that most patients have insurance (i.e., private insurance and/or Medicare), and "low SES" means most patients are indigent . Human subject approvals were obtained from the Institutional Review Boards at all of the SPUR-Net constituent organizations. Permission to conduct the study was also obtained from the medical directors and applicable patient advisory groups at each of the six participating clinics.To be eligible for participation in the study, patients had to be at least 18 years of age and to be visiting one of the participating clinics for routine, nonacute care. A target of 50 surveys in each of the six clinics was collected from a convenience sample of patients. The decision regarding the number of patients to be surveyed was limited by our resources, including availability in funding and personnel. A research assistant approached potential subjects in the clinic setting to determine their willingness to complete a 23-item questionnaire about herbal use in either English or Spanish. Those patients who consented to participate were either given the survey to complete on their own or had the survey administered to them by the research assistant. Research assistants were available on-site to answer any questions the patients had, helping to improve patients' understanding of the terms used in the survey. Recruitment methods were the same in all of the participating clinics. The research assistants stopped recruiting patients when a minimum of 50 surveys was collected in each clinic.Survey questions were adopted and modified from previously developed and validated surveys on CAM use, including national telephone surveys conducted by Eisenberg et al.,2,13, a The final survey instrument had three components. First, all participating patients answered questions regarding sociodemographic characteristics . Immigrant family history and spoken language were elicited with the following questions: "Are your family members immigrants to the United States (Y/N)?," and "Do you speak another language other than English?" After completing the demographic questions, respondents answered a series of questions regarding their belief in herbal use and their herbal information sources. The questions pertained to their personal use of herbs (Y/N); their belief in the benefit of herbal remedies (Y/N), the source of their herbal information (physician, pharmacist, family, friends, etc.); their preferred content of herbal information (e.g., effectiveness, side-effects, interactions with other medications), and their preferred methods for obtaining herbal information from physicians or pharmacists (e.g., handout, World Wide Web site, consultation). Patients who reported using herbal supplements answered additional questions related to their patterns of and reasons for herbal use. In open-ended questions, the participating patients were asked about the herbs they specifically used and the health conditions for which they took the herbal products. Related questions included frequency of herbal use ; duration of use (< 1 year, 1–2 years, 3–5 years, > 5 years); expenditure on herbal products; reported concomitant use of prescription medications; disclosure of herbal use to physicians or pharmacists; and any experiences of adverse reactions from using herbs.For the purposes of this study, we used the definition of dietary supplements stipulated in the 1994 Dietary Supplement and Health Education Act (DSHEA) to differentiate herbs from vitamins and minerals. Herbal use was defined as having ever used herbal products or natural medicines for health maintenance or treatment of health conditions. To measure herbal use, we asked the following question: "Do you use any of the following?" Response options included: herbs/herbal products or natural medicine (e.g., echinacea, St. John's wort, ginseng, ginkgo biloba, soy supplements), folk medicine or home remedy, vitamins, minerals, or none. Herbal use did not include the use of folk medicine, home remedies (such as honey), vitamins, or minerals.Data from the paper-based survey were entered into an ACCESS database and were imported into SAS 9.1 for Windows. The study variables were summarized by using one-way frequencies to examine the sociodemographic characteristics of the study sample, the belief in and information source for herbal use, and the patterns of and reasons for herbal use among urban multiethnic primary care patients. The frequencies of use of specific herbs were counted, and the health conditions for which herbs were used were further coded into three types—acute, chronic, and health maintenance.p value ≤ 0.05 was considered to be statistically significant. In order to assess factors associated with herbal use, all hypothesized variables  were included in both the univariate and the multivariate logistic regression analyses. These independent variables were entered as dichotomous variables in the model: gender , age (< 50 years, ≥ 50 years), ethnicity (African-American vs. other, including Whites and Hispanics), education (less than college vs. college and greater), immigrant family history (yes vs. no), herbal use by family members (yes vs. no), and clinic clientele (high SES vs. low SES). Significant variables identified by backward elimination of the main effects from the multivariate analysis were further evaluated in two-way interactions. Thus, the final model contained all of the significant main effects and the two-way interaction terms. Odds ratios and 95% confidence intervals were calculated to determine the effects of the significant variables on herbal use. Since the sample size for Asians was small, Asians were not included in the logistic regression analyses. Furthermore, the language variable was excluded from the regression analyses because the survey question was not clearly answered by many patients; for example, 10 Spanish-language forms had "no language other than English" indicated. In addition, some answers were possibly indicative of an exclusive language other than English instead of the bilingual capability of the respondent.Based on findings from previous studies, we used the following independent variables as reference variables for both the univariate and multivariate logistic regression analyses: male gender, age less than 30 years, African-American ethnicity, less than a college education, no immigrant family history, no herbal use by other family members, and visiting a high SES clinic. A Chi-square test of proportions was used to determine the association between herbal use and each of the independent variables related to demographic characteristics; a Of the 327 patients who agreed to participate in the survey, only 322 completed the race/ethnicity information and were included in the analysis. The characteristics of the study sample are summarized in Table p < 0.05). Nearly half of the patients who reported using herbs (46%), particularly Hispanics (63%) and Asians (57%), also reported taking prescription medications concomitantly with the herbs . Patients who reported using herbs indicated that they received information about those herbs mainly from family members and relatives. Nevertheless, most patients reported that they preferred receiving herbal information (e.g., on effectiveness, side-effects, and drug interactions) through handouts or brochures from their physicians or pharmacists, followed by having access to a consultation service or a Web site. About 40% of all of the survey respondents, but especially Asians (55%) and Whites (47%), believed that taking prescription medications and herbal medicines together was more effective than taking either alone. About 41% of Hispanic respondents believed that herbal medicines were superior to prescription medications, as compared to 12% of Whites. These differences in beliefs about herbal use among the ethnic groups were found to be statistically significant (p < 0.05) with herbal use were ethnicities other than African-American, immigrant family history, and herbal use by other family members (Table p < 0.05). In addition, interactions between immigrant family history and herbal use by other family members were found to be significant terms in the model , the desire to try alternative therapies (33%), and preference for having their own methods to care for their health (20%). Among the herbal users, 32% reported taking herbs on a daily basis, and 60% reported using herbs for longer than three years. Usage varied by race/ethnicity; for example, 48% of Whites reported taking herbs on a daily basis, and 79% of Hispanics reported using herbs for longer than three years.Even though Hispanics and Asians used herbs more frequently, they were the least likely to disclose their herbal use to their physicians or pharmacists. More Whites (67%) told their health-care professionals about their herbal use than did the African-Americans (45%), Hispanics (31%), or Asians (31%). The reasons given for nondisclosure generally fell into two main categories: 1) "They (the provider) never asked," and 2) "It wasn't important for them to know." While few respondents (5.3%) reported having experienced an adverse reaction to herbs, many of them (43%) did not inform their physicians of it.The specific herbs used by the patients covered a wide spectrum and varied by ethnicity. The herbs used most commonly by White patients were echinacea (32.1%), St. John's wort (21.4%), ginkgo biloba (14.3%), and chamomile (14.3%). Hispanic patients most often reported using chamomile (61.2%), aloe vera (44.9%), and garlic (20.4%). African-American patients reported primarily using garlic (40%), ginseng (30%), and ginkgo biloba (10%). The herbs used by Asian patients were garlic (50%), ginkgo biloba (30%), and ginger (30%). Other herbs that were reported by patients—albeit infrequently—included Yun Zhi, black cohosh, dong quai, guggle phosphate, bee pollen, cat claws, and "a shot of whiskey." The patients who reported using herbs used them for a wide range of health problems, such as boosting the immune system, improving memory, and treating insomnia, depression, or diabetes. For conditions considered to be chronic, 44% of the White patients reported herbal use versus 32% of African-American patients. For conditions considered to be acute, 71% of Hispanic patients used herbs versus 10% of Asians. For health maintenance, 50% of Asian patients used herbs versus 16% of Hispanic patients.Our data show that herbal use is common 36%) among urban multiethnic primary care patients, but has a wide variability among racial/ethnic groups. Hispanics and Asians reported the highest rates of herbal use 50%), and African Americans reported the lowest 22%). Previous research conducted in the western United States found that the prevalence of herbal use among racially/ethnically diverse primary care patients varies[2%. Previ6% among 0%, and AAs expected, factors associated with herbal use included race/ethnicity, having an immigrant family history, and herbal use by other family members. In addition, we found interactions between having an immigrant family history and herbal use by other family members. Previous studies did not examine such interactions and found age to be predictive of herbal use,6,7. Unl® (warfarin sodium) and cause an increase in bleeding time[®, Parnate®) and potentiate the effects of selective serotonin reuptake inhibitors (e.g., Paxil®, Prozac®, Zoloft®)[® (digoxin)[® [We found that nearly half of herbal users (46%) reported taking herbal medicines and prescription medications concomitantly. More importantly, 43% of herbal users reported not disclosing their herbal use to their physicians or pharmacists. Interestingly, Hispanics and Asians used herbs the most frequently but disclosed their herbal use to their physicians or pharmacists less often than did Whites and African Americans. This lack of communication about herbal use is an area of concern because of the potential for medication errors and untoward reactions to herb-drug interactions. Adverse drug-herb interactions pose a great danger for patients. For example, ginkgo biloba, garlic, and ginseng all may interact with Coumadinding time,16. Echiding time,18. The ding time-23. St.  Zoloft®). Moreove(digoxin). In addi(digoxin) and has prazolam). As thesprazolam)-33.Two-thirds of the patients we surveyed reported wanting to receive information on herbal medicines from their physicians or pharmacists, preferably in the form of a handout or a brochure. These findings suggest that future studies are warranted to develop and test educational materials to 1) deepen our understanding of racial/ethnic variation in herbal use among primary care patients; 2) educate health-care professionals about the variations in the use patterns and the rationales for use that may help to reduce medication errors and increase the quality and safety of medical care; and 3) educate patients regarding evidence-based herbal information and encourage patients to communicate their herbal use to their physicians/pharmacists.Our study results should be interpreted in the context of several limitations. First, our estimates of herbal use frequency are imprecise because we used a convenience sample instead of identifying patients by randomized sampling. Secondly, even though we adopted the DSHEA definition of herbs, some patients had difficulty understanding this definition. Specifically, a small group of patients thought that herbs were equivalent to prescription medications such as digoxin and aspirin; the patients' level of understanding of herbs was improved after the research assistants provided further explanation and clarification. Third, we discovered that asking questions, such as "What do you take when you run out of your medications?," was more effective in eliciting answers from the study subjects than when asking them, "Do you use herbs, herbal products or natural medicine?." For these reasons, we had research assistants on-site to help facilitate the survey process. Fourth, the patients surveyed reported their concomitant use of herbs with prescribed medications based on their perceptions and memories. Last, we did not include measures of quality of life or questions about patient satisfaction with herbal use, which would be helpful in future studies, especially when comparing multiethnic and socioeconomically diverse patient groups.Despite these limitations, our findings confirm the increasing frequency of herbal use as reported in previous studies. Our study also gives a unique perspective by focusing on factors associated with reported herbal use among an urban multiethnic primary care patient population. In particular, we found that patients with immigrant family history—especially those with family members who use herbs—are most likely to report herbal use. Perhaps most disconcerting was our finding that while an increasing number of primary care patients report taking herbal medicines concomitantly with prescription medications, many of them do not disclose their herbal use to their physicians or pharmacists. These findings suggest that primary care clinicians need to understand the extent and patterns of herbal use by their multiethnic patients and efforts to elicit information from patients about herbal use may be warranted. Future studies are needed to develop effective interventions for primary care health-care professionals and patients to improve medication safety by eliminating potential adverse herb-drug interactions and medication errors.The author(s) declare that they have no competing interests.GMK conceived of the study, designed the survey questionnaires, coordinated and managed the data-collection process, directed data analysis, and drafted the manuscript. STH participated in drafting the manuscript and helped with data analysis. LTW performed the statistical analysis and participated in drafting the manuscript. RB helped with data analysis. RJV reviewed the questionnaires and data analysis, and participated in drafting the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:


In response to the Kosovo crisis, Canada received 5,500 Albanian Kosovar refugees in 1999 as part of the emergency humanitarian evacuation and settlement effort. This study attempts to describe the experiences of service providers at the international, national, and local levels, involved in the organization and delivery of health and settlement services in Canada for the Kosovar refugees.A qualitative case study design using key informant interviews was used. Nominated sampling was used to identify 17 individuals involved in the organization and delivery of health and settlement. Key themes were identified and recommendations made to provide a framework for the development of policy to guide response to future humanitarian emergencies.Six themes emerged: (1) A sense of being overwhelmed, (2) A multitude of health issues, (3) critical challenges in providing health care, (4) access to health and settlement services, (5) overall successes and (6) need for a coordinated approach to migration health.For those involved, the experience was overwhelming but rewarding. Interviewees' major concerns were the need for a more comprehensive and coordinated approach to the flow of medical information and handling of specific health problems. The Kosovo crisis resulted in the largest population displacement in Europe since World War II. During this time, over 300,000 Albanian Kosovars were expelled from Kosovo,  resultinCanada received approximately 5,500 refugees in 1999, with approximately 500 arriving to the city of Hamilton, in southern Ontario. Some Kosovars stayed temporarily in military bases and arrived after sponsorship housing had been arranged, while others arrived directly to temporary reception "houses" established at two Hamilton hotels. The reception in Hamilton included the organized provision of health services by physicians, nurses, dentists and optometrists, and settlement services from the Settlement and Integration Services Organization (SISO).This HEP was unique for many countries, including Canada, and involved a complex coordinated effort on the part of international, national, and local organizations traditionally involved with immigrants and refugees, settlement, and health. This event was an important opportunity for health and settlement organizations operating at international, national, and local levels to critically examine and reflect on their efforts to organize and deliver health and settlement services to new immigrants and refugees.The goal of this study was to explore the main challenges and successes of the Kosovar arrival, from international, national, and local perspectives and to develop recommendations to advise and guide planning of the future complex humanitarian emergencies, using interviews with key informants.A qualitative case study methodology was used with semi-structured interviews of key informants who were involved in the humanitarian evacuation at the international, national and local levels in Hamilton, Canada. This method was deemed most appropriate to provide a framework for understanding the challenges and successes associated with Complex Humanitarian Emergencies and generate recommendations for future efforts. The background of research team members was diverse. Medicine, nursing, anthropology, sociology and settlement were represented. Some members had been directly involved with the Kosovar settlement process at the local level (NF, SR, MJ).A purposive sampling strategy was used, in which appropriate key informants known to the researchers were approached for participation first. Snowball sampling, whereby additional participants were identified by the initial respondents, was used to increase the diversity of respondents. These sampling approaches are used when certain known individuals are likely to have in-depth information on a topic . IndividInterviews were conducted in English between April and July 2001. The interviewer (EM) took extensive field notes to supplement the taped and transcribed interviews. Of the 17 key informant interviews, the three international and national ones were conducted by telephone, and 14 were in person at the workplace of the interviewee. Six participants were male and 11 were female. Interviews were approximately 30 minutes in length. The interviews were based on an interview guide and the main part of the interview focused on the organization and delivery of health services to the Kosovars. Questions were further refined during the study. Specific probes were used to follow up on open-ended questions, where appropriate.Consultation with the local settlement agency (SISO) took place throughout the research process. Key informants were told that the purpose of the study was to gather information that would help in planning for similar events in the future. All participants provided verbal consent and were assured of confidentiality of responses. All interviews were tape recorded with the participants' permission and all but one  was transcribed. Ethics approval for the study was received from McMaster University Research Ethics Board.Questions pertained to the participants' involvement in the process, challenges, flow of information and communication, and involvement in health care services and settlement.Two research team members (EM and NF) initially independently reviewed the transcripts, coded categories and themes, and then compared results. A third researcher with expertise in qualitative research, who was not involved in the project, also reviewed the transcripts using NVivo software version 2.0  and compared results. The interviewer's field notes were also used for comparison with the data. Ambiguities were resolved and themes were developed from categories through discussion among the research group members and re-reading of transcripts. This process continued until no new themes emerged from the interviews. It was felt that saturation was achieved after 17 interviews, and data collection was ended. The process was iterative, thus the later interviews probed new emerging themes identified in previous interviews.Six core themes emerged from the data analysis.There was agreement among the participants that the Kosovo crisis in 1999 was very unusual in nature. Participants stressed that there was a lot of "scrambling" to prepare the infrastructure to receive a large number of people in a very short period of time. Respondents/informants were surprised by the magnitude, immediacy, scope and scale of the response required. Most described feeling overwhelmed.Although the local settlement agency (SISO) had begun preparations by meeting with various local agencies and organizations weeks in advance, they were given only three days notice by national immigration authorities that the Kosovars were arriving locally. One Hamilton Social and Public Health Services representative noted "We had many community people come together to talk about how we could plan for this big influx of refugees... we knew were in dire straits". One settlement worker called it "organized chaos". One local health care professional explained the triage process and it was evident that a major organizational effort was required to process the arrivals."We had to do our own triage at the hotel to find out whether there was anybody needing medications, anyone with heart conditions, anyone with diabetes ... we had to scan the place to find out, and even then we didn't have medical records that came with them... We just went around asking: Do you know about anybody who is pregnant? Do you know about anybody who has heart conditions? Do you know about anybody who is diabetic? ... And we tried to identify those people or they presented in the little clinic".Participants described facing a multitude of challenges in responding to the health needs of Kosovar refugees. Women's health services, including pregnancy care and abortion services were required. Dental care, mental health services and general curative services were also required. Participants were struck by the poor oral health of the Kosovars. Many Kosovars had been deprived of any curative or preventative care in Kosovo for a number of years prior to the 1999 crisis. One local health care professional observed,"I noticed with the Kosovars...that a lot of them had not had any health care for a long time so they had many of the things that we take for granted. Immunizations being up to date and those sorts of things had not been done.... They only saw doctors if they were absolutely on their deathbed. So sometimes, you sort of had a lot of catching up to do in terms of getting their health up to date"Chronic and poorly managed conditions such as diabetes, hypertension and renal failure were common. An interviewee with an international perspective noted,"I think the world, from a health point of view, went into Kosovo thinking that all refugees were like the Great Lakes and Rwanda...The challenges [in Kosovo] were more of chronic diseases, diseases of socialization, hypertension, diabetes, renal failure...I think that people have learned to be a bit more comprehensive in their approach to conflicts and emergencies."The participants expressed three main challenges which made their work more difficult: (i) tuberculosis screening, (ii) the lack of medical records and tuberculosis test results and (iii) mental health issues.Several participants noted that the tuberculosis screening process was not optimally organized. One local healthcare professional lamented,"I was reassured, but without any documentation to back it, that everyone had been screened for TB...When I contacted Public Health, they had not received any notification ...Certainly I didn't know where or how to get that information, and it seemed to me that Public Health didn't either".Communication to local health care providers about test results (tuberculosis and radiographs) was often described as sub-optimal. Immigration officials in Europe attempted to keep medical information flowing. One interviewee from an international perspective explained that,"We provided by fax and e-mail a summary of the medical conditions on the aircraft, so that they can be dealt with appropriately on arrival in Canada...We also used colour-coded cards and things so that (when) people who got off the plane (who needed care) they did receive expedient care".However, many local respondents expressed concern over the location of medical records and the inability to access this information in a timely manner. A local healthcare professional expressed,"At no point did I receive any medical documents about people with serious or chronic medical conditions that required care...if that information was available, I never got it".It was clear among the participants that mental health concerns were prevalent and service providers struggled with the delivery of appropriate mental health services. One local healthcare professional explained,"...things like headaches presenting when really the underlying condition was one of stress and anxiety, distress. Most of them came under the umbrella of what we might call, presenting with trivial complaints, but really what was beneath it all was stress and anxiety..".The rapid settlement of the Kosovars resulted in the local collaboration and coordination of health and settlement services at a single geographic site. This multi-agency collaboration was thought to enhance access and provision of services. One local healthcare professional described,"[The Kosovars] had, I thought, very well organized access...The SISO organization provided chauffeurs and translators, and administrators to pull all those areas together. So...if a refugee needed to go to a lab, they were driven, they were translated for, and they were brought back...".Since translators organized through SISO were available at the local health care sites, language was not perceived as a significant challenge by local health care providers.There was an awareness that the care provided was transitional in nature. This created some hesitancy in initiating treatment, as frequently there was uncertainty about the medical follow-up arrangements. Mental health issues and the lack of opportunity for identification and communication with future care providers were identified as concerns.While the Kosovars received medical coverage through the Interim Federal Health (IFH) program, local health care providers felt that the amount and nature of coverage was inadequate for services such as home care, dental care and optometry. One local healthcare professional described the issues surrounding home care,"One access issue that came up was the fact that under their IFH coverage, IFH does not cover home care, and without special arrangements to be in place...they don't qualify for it...There were a lot of people...who had walked miles and miles...and I saw [some] who had really bad foot conditions, infections and ulcers requiring daily treatment, soakings, dressings, bandage changes... Normally, those are things in the community that we would involve home care in...".In several instances, both the optometrist and dentist interviewed provided services that were not covered, free of charge, but in general, there was much confusion and uncertainty regarding the payment scheme for professionals. A dentist explained,"..we were not informed as a health professional that if we were approached by people from Kosovo that plans were available for treatment...we knew absolutely nothing until we started asking the questions..".Specific examples of successes included provision of comprehensive onsite health care integrating both health and settlement services, the use of nurse practitioners to allow physicians to focus on more complex cases, the policy to keep families intact, and the positive media coverage that contributed to an atmosphere of acceptance. A local settlement provider observed,"The Kosovars was something that the whole nation took on...We saw what kind of role the media can play in making the host community aware what other people are going through, explaining that refugees are not to be seen as invaders but as people who are in need of welcoming, and the Kosovars received one of the best, I think at least in my experience, one of the warmest welcomes...".Services available to the Kosovar refugees were deemed better compared to that provided to other refugee groups. This was a concern to many participants. Some stated that all refugees should be offered the same standard of high quality settlement services as those made available to the Kosovars. Another local settlement provider noted,"Refugees, regardless from where, should be treated the same way because it creates resentment not just in other refugee communities that have come to Canada, but [it] creates resentment among the workers that are providing services and sometimes struggling to get resources for a group of people...The Kosovars should be an example of how refugees should be treated in general".A number of participants suggested that we should learn from this experience with the Kosovars and prepare to put a contingency plan in place for similar events in the future.Better communication and organization were repeatedly stressed. One participant used the term 'Migration Health' to describe such an overall coordinated approach. Several participants commented on the importance of the coordinated approach as a necessary societal investment. One interviewee from an international perspective noted,...a lot of people who are working on the receiving end are simply following the process for receiving refugees.... there may not be the resources to look at the longer term issues: primary health care, health education, explaining how the health systems work, looking at some of the parameters that may influence longer term mortality and morbidity: dietary counselling, smoking cessation counselling, primary preventive health care procedures that we do in Canada that may not take place in the developing world."Most participants suggested that health care and settlement providers need to enhance their cultural sensitivity and cultural competence and better understand the health conditions of the displaced individuals in their country of origin.Despite organized attempts to coordinate efforts at different stages of the migration process, communication gaps and the sheer size of the influx resulted in challenges at the local level. Officials and service organizers at the international/national levels were unaware of these local gaps at the time of the evacuation. The flow of medical information and health records is an example. Primary care health workers needed to have easy access to targeted health information about the Kosovars, however this information was not available. If this information had been more easily available, health care services may have been more streamlined, and unnecessary duplication of lab tests and radiographs could have been avoided.Health care providers did not know what to 'expect'. Mental health, dental care and communicable diseases  were identified as requiring further specialized planning. This finding is similar to other refugee experiences in Australia  and CanaThere was a consensus among participants that this international evacuation represented an improved approach and a good foundation on which to organize refugee health and settlement in the future. Informants' concerns about local preparedness and the need for future advanced planning was consistent with recent United Nations High Commission for Refugees (UNHCR) findings . ParticiA potential limitation of this study is the time elapsed between the refugees' arrival and the interviews. Asking people to recall events that took place approximately 18 months previously may have influenced the nature and detail of the information obtained. However, it may also have enabled informants to recover from the initial emotional reaction and to see these events from a different perspective.It must be stated that the 'success' as defined by key informants may be very different than 'success' from the refugees' perspective. This study examined the perceptions of those involved with the Kosovars. The majority  of the local health professionals and settlement workers interviewed had worked in the local 'settlement houses' site where there was a shorter notice of arrival of the refugees. This may have contributed to the sense of 'chaos' echoed in many of the comments.'Operation Safe Haven'). Triage questionnaires for primary health care based on International guidelines were developed [Operation Safe Haven produced a template for refugee "acute health response" system. Using the Australian template combined with findings from this study, we propose the following attributes for an International Rapid Response System (IRRS):Many of the participants in this study made observations about the diverse nature of complex emergencies. The importance of logistics and planning has also been described in other studies -10. Someeveloped . Operati1. Establish lead organizations at the different levels 2. Clearly define roles for different organizations involved3. Establish communication linkages between lead organizations at different levels4. Identify strategies for flow of information ("situation reports") from authorities to local organizations5. Establish a protocol for triage/rapid assessment of health, settlement needs and cultural preferences6. Establish a system of medical charts that follow individual refugees though the process7. Establish links to primary and specialized health care especially for urgent communicable disease and mental health issues8. Identify a plan for the provision of urgent dental and eye care9. Establish a surveillance/data-tracking system to collect essential health information, tack service use, and provide the ability to conduct quality assurance assessments10. Use information technology – key internet links; background data; briefing; high quality background and cultural information about refugee groups11. Introduce better training of professionals who will be dealing with refugees. Includes increasing cultural competence of health care and settlement providers, women's health, mental health, chronic illness, dental care and current health coverage for refugees. Global health issues should be introduced into health school curricula.12. Local health care professionals need access to better information regarding the background, circumstances and organizational arrangements relating to refugees. Regular, ongoing information sharing sessions with health professionals involved with refugees, public health and government would facilitate communication when the next refugee crisis occurs. There must be political commitment at all levels.For those involved in the Kosovar Humanitarian Evacuation Program, the experience was both overwhelming and rewarding. Many perceived that a superior effort was made for the Kosovars compared to other groups of refugees and that positive media coverage contributed to a warm and effectively organized reception. Interviewees' major concerns were the need for a more comprehensive and coordinated approach to the flow of information and handling of specific health problems.Complex Humanitarian Emergency: CHEUnited Nations High Commission for Refugees: UNHCRHumanitarian Evacuation Program: HEPSettlement and Integration Services Organization: SISOTuberculosis: TBInterim Federal Health: IFHInternational Rapid Response System: IRRSThe author(s) declare that they have no competing interests.NF and LRC designed and implemented the study, analysed the data and critically revised the manuscript. SR, MJ, MH, JK, SR critically revised the manuscript, EM conducted the interviews, assisted with study design and implementation, data analysis, and drafted the manuscript.


There is analytical potential for multiple cause of death data collected from death certificates. This study examines relationships of multiple causes of death as a function of factors available on the death certificate .Data from 326,332 Minnesota death certificates from 1990–1998 are examined. Underlying and non-underlying causes of death are examined (based on record axis codes) as well as demographic and death-related covariates. Associations between covariates and prevalence of multiple causes of death and conditional probability of underlying compared to non-underlying causes of death are examined. The occurrence of ischemic heart disease or diabetes as underlying causes are specifically examined.Both the probability of multiple causes of death and the proportion of underlying cause compared to non-underlying cause of death are associated with demographic characteristics of the deceased and other non-medical conditions related to filing death certificate such as place of death.Multiple cause of death data provide a potentially useful way of looking for inaccuracies in reporting of causes of death. Differences across demographics in the proportion of time a cause is selected as underlying compared to non-underlying exist and can potentially provide useful information about the overall impact of causes of death in different populations. In their 1986 paper Israel, Rosenberg, and Curtin . The resAcknowledgment of the potential for multiple cause of death data analysis is increasing in other countries as well ,4. For eMultiple cause of death data has been used to look at trends in certain diseases, e.g. HIV ,6 and luThe purpose of this article is to examine some straightforward relationships of multiple causes of death as a function of factors available on the death certificate . Using all death certificates issued by the state of Minnesota between 1990 and 1998 (326,332 deaths), the current study documents the relationship between these factors and the associated frequency of reporting of multiple causes of death as well as the associated frequency that a cause is considered underlying (after data processing) given that it is mentioned on the death certificate. The implication being that differences found are either due to actual differences in causes of death in these groups or due to systematic biases in the reporting of causes of death, or a combination of both. The study will not be able to discern which is the cause but hopes to contribute at the very least by providing an example of the potential relationships which can be examined with the rich multiple cause of death data.The data used are from the Minnesota Department of Health Mortality Database and include entries from 326,332 individual death certificates, which represent all deaths occurring in Minnesota during the period of 1990–1998. Record axis codes (those codes which have been completely data processed) are used for all analyses in this paper rather than entity axis codes.A brief description of the entity and record axis coding is given here. The translation of causes of death listed on the death certificate . When we refer to a cause of death and do not want to distinguish if it is underlying or non-underlying we will refer to it as a "mentioned" cause of death.In addition to listing one underlying and up to 14 non-underlying causes of death, each death certificate also contains information about the demographics of the deceased, including age, gender, race, marital status, and educational attainment. Also, other conditions related to the death are recorded – place and time of death, who completed the death certificate, if autopsy has been performed and type of body disposal. Minnesota Laws and guidelines govern the process for who and how a death is certified under different circumstances in Minnesota. For example when an unattended death occurs (e.g. at a persons residence) a medical examiner's investigator must arrive at the scene. The medical examiner will contact the last attending physician asking about past medical history of the decedent and most likely cause of death. When an attending physician has seen the decedent within 90 days and the death is natural, jurisdiction is usually given to the physician to certify the death. Sudden or unexpected deaths due in part to any factor other than natural disease must be referred to the medical examiner's office. Autopsies are performed at the discretion of the medical examiner but can also be performed for any death at the request of the immediate family.th revision of International Classification of Disease (ICD). The specific ICD9 codes are grouped into standard reporting of cause of death categories resulting in a total of 107 different causes of death. In this study, individuals are dichotomized as having multiple causes of death (i.e. at least one non-underlying cause) or not having multiple causes of death (i.e. only having an underlying). In addition, because heart disease is the leading cause of death and diabetes is a good example of a disease which often shows up as a non-underlying cause of death, this research investigates two sub -populations: 1) Individuals that have ischemic heart disease (ICD-9: 410 – 414) mentioned as a cause of death (n = 79,833), and 2) Individuals that have diabetes mellitus (ICD-9: 250) mentioned as a cause of death (n = 27,181). For both sub-populations, a dichotomous variable is created to indicate whether the mentioned disease is coded as the underlying cause of death or not.The underlying and non-underlying causes of death derived from the death certificate, in this study, are coded according to the 9Descriptive statistics including total numbers and proportion of all deaths (n = 326,332) in each of the covariate categories are reported as well as proportions of people within each covariate category who have multiple causes of death. In order to examine the association between each covariate and the dichotomous outcome of multiple causes of death, logistic regression is used to mutually adjust each factor for the others. 95% confidence intervals of odds ratios are reported. Trends in multiple cause of death reporting across time are investigated graphically.Similarly, descriptive statistics including total numbers and proportions will be presented for the two sub-populations with ischemic heart disease (n = 79,833) or diabetes mellitus (n = 27,181) mentioned either as underlying or non-underlying cause of death. Logistic regression is used and 95% confidence intervals are reported to examine factors that are associated with each of these diseases being reported as underlying cause of death rather than non-underlying.Overall, 68.9% of the 326,332 deaths from 1990–1998 had at least one non-underlying cause of death in addition to the underlying cause (i.e. have multiple causes). There was a noticeable decreasing trend of reporting multiple causes of death over the 9 year period from 1990 to 1998 with 74.0% in 1990 consistently dropping down to 64.8% in 1996 and remaining around 66% until 1998. Table For places of death, hospital in-patient 73.4%) and nursing home (70.6%) had the highest probability of reporting multiple causes of death, and residence had the lowest percentage (58.7%) Table . Between.4% and nThe results presented so far explored how covariates may be correlated with multiple causes of death being reported. The following results pertain to the conditional probability that a particular cause of death (ischemic hear disease or diabetes) is selected as underlying given that it is mentioned. Results for the subpopulations with ischemic heart disease or diabetes mentioned are shown in Table Table Unlike Ischemic heart disease, only 29.3% of deaths with diabetes mentioned on the certificate had it selected as the underlying cause of death. While only 2.3% of deaths with diabetes mentioned occurred in the youngest age group 0–44 years), , followed by cerebrovascular disease (2.7% of the time underlying), then pneumonia (1.5% of the time underlying). When we focus on the population that has diabetes mentioned on the death certificate, as mentioned above 29.3% of the time diabetes is selected as the underlying, and the second most common underlying cause selected is ischemic hear disease at 25.4%, followed by cerebrovascular disease at 7.75% then followed by Other diseases of the heart 2.9%.Distinct differences in the frequency of multiple causes of death were found across time, age, race, disposal method and place of death. Definitive explanations for the differences cannot be given based on this study, but it is of interest to consider plausible explanations which may motivate further investigation. The increased reporting of non-underlying causes of death as the age of the decedent increases is likely due to actual increases in co-morbidity with age, hence would be explained by actual differences in the causes of death.th most commonly reported cause of death to be the only cause of death listed on the certificate. This reporting of it as the only cause of death pushes it up to be the overall 12th leading cause of death. If almost any other cause would be listed simultaneously on the death certificate, this code would not end up as underlying.The differences found in reporting of multiple causes of death for the other factors may be partly due to systematic reporting biases. According to the NCHS All Mortality Altas [, p. 3], The decreasing trend in reporting multiple causes over the decade may be reflective of a gradual change in the procedures of death certification. It would be of interest to consider this trend across different states and longer periods of time including shifts from one ICD coding system to the next.Previous literature offers various plausible explanations to what contributes to the inaccuracy of reporting causes of death. The cause of death reported on the death certificates depends on a person's disease history that leads to death . If a peGender and race can also play a role in the accuracy of reporting. Lloyd  showed tSimilar to the case of reporting multiple cause of death, the selection of ischemic heart disease and diabetes as underlying compared to non-underlying differs across the several factors considered. The implications of these differences across demographics are that mortality rates would be differentially affected when underlying cause of death is used compared to any mention cause of death. For example, for diabetes we might conclude that diabetes is being under-reported in Whites compared to Blacks, Native Americans and Hispanics if only underlying cause of death were considered since the proportion of diabetes as underlying to mentioned is substantially lower in Whites. This is not to say there is any inaccuracy in the way it is being coded but it points out where multiple cause of death reporting will provide a different perspective than underlying.Nevertheless, studies have shown the sensitivity and positive predictive value of the death certificate are particularly poor with regard to stroke and diabetes . FurtherAs mentioned in the introduction, one limitation of this research is the fact that there is no outside panel of experts who decide independently what the true causes of death are for each decedent, thus whether the associations we found are due to actual differences or reporting bias cannot be discerned. Therefore, this study cannot provide sensitivity or specificity per se, but it aims to identify factors that are associated with variability in reporting multiple cause of death and that perhaps contribute to inaccuracy in reporting underlying cause.There is much to be learned from multiple cause of death data. It provides ways of looking at mortality data that go well beyond the typical examination of underlying cause of death. Future research is needed to understand further what the greatest concerns are about the accuracy of reporting causes of death. Multiple cause of death data have the potential to help point out potential concerns in the accuracy as well as provide a more complete picture of mortality for causes which are frequently not recorded as the underlying cause of death.The author(s) declare that they have no competing interests.MW conceived of the study and wrote most of the manuscript. JH performed the statistical analysis and wrote part of the manuscript. JO provided access to the data and collaboration regarding processes underlying data collection. DD provided details about cause of death reporting and collaboration regarding processes underlying data collection. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:


Asthma and sickle cell disease are common conditions that both may result in pulmonary complications. We hypothesized that children with sickle cell disease with concomitant asthma have an increased incidence of vaso-occlusive crises that are complicated by episodes of acute chest syndrome.A 5-year retrospective chart analysis was performed investigating 48 children ages 3–18 years with asthma and sickle cell disease and 48 children with sickle cell disease alone. Children were matched for age, gender, and type of sickle cell defect. Hospital admissions were recorded for acute chest syndrome, cerebral vascular accident, vaso-occlusive pain crises, and blood transfusions . Mann-Whitney test and Chi square analysis were used to assess differences between the groups.Children with sickle cell disease and asthma had significantly more episodes of acute chest syndrome (p = 0.03) and cerebral vascular accidents (p = 0.05) compared to children with sickle cell disease without asthma. As expected, these children received more total blood transfusions (p = 0.01) and chronic transfusions (p = 0.04). Admissions for vasoocclusive pain crises and exchange transfusions were not statistically different between cases and controls. SS disease is more severe than SC disease.Children with concomitant asthma and sickle cell disease have increased episodes of acute chest syndrome, cerebral vascular accidents and the need for blood transfusions. Whether aggressive asthma therapy can reduce these complications in this subset of children is unknown and requires further studies. Lung disease is a major cause of cardiopulmonary disability and mortality . ProgresAsthma is the most common chronic disease of childhood occurring in 6% of the general population. Moreover, the African American population has the highest prevalence (8%), emergency department (ED) visits, hospitalizations and risk of mortality of any ethnic population in the United States [The African American population is at significant risk for the occurrence of both diseases simultaneously but little is known of the affect of asthma on individuals with sickle cell anemia. In this study, we examined hospitalized children with sickle cell disease with concomitant asthma establishing whether there was an increased rate of acute chest syndrome or other complications compared to patients with sickle cell disease without asthma in those presenting with vaso-occlusive pain crises.We performed a 5-year retrospective chart review of 48 children with asthma and sickle cell disease and compared them to a control group of 48 children with sickle cell disease alone. The 48 children with sickle cell and asthma represented all patients with complete medical records with both diseases that were cared for at our center. These children had no hospitalizations for sickle cell crises at other facilities. Children in the control group were matched for age, hemoglobinopathy and gender. Sickle cell disease was determined by high performance liquid chromatography and isoelectric focusing analysis and grouped into phenotypes of hemoglobin SS or hemoglobin SC.Children were included in the asthma group if they had medical record documentation of a discharge diagnosis of asthma (ICD-493) and had been prescribed asthma medications.Vaso-occlusive pain was defined as pain that could not be explained by injury or infection requiring hospital admission and treatment with intravenous pain medication. The criteria for a diagnosis of acute chest syndrome included respiratory distress, hypoxemia, and a new infiltrate on chest x-ray that required hospitalization and a transfusion of packed red blood cells. A cerebral vascular accident diagnosis was based on the new onset of an acute neurological syndrome with a focal neurological finding on examination associated with ischemic changes (images compatible with stroke) on a brain MRI or computed tomography scan.Inpatient admissions were recorded from March 1997 to March 2002 for episodes of acute chest syndrome, vasoocclusive pain crises, cerebral vascular accidents, total blood transfusions, exchange transfusions and chronic transfusions (monthly blood transfusions).Exclusion criteria included any child who had incomplete documentation of their hospital records or those who had moved into or out of the Milwaukee area during the 5-year study period. Six children were excluded because they moved from Milwaukee. The study was approved by the Investigational Review Board.The Mann-Whitney test was used to evaluate differences between the incidents of vasoocclusive pain crises, acute chest syndrome, total blood transfusions and cerebral vascular accidents. Chi-squared analysis was used to evaluate the number of exchange and chronic transfusions. Statistical significance was given to p values 0.05 or less.or hospital admissions for asthma. Of these children, 13 (76%) had been prescribed only albuterol. Twelve (25%) had at least 1 ED visit and at least 1 hospital admission for asthma. Twenty-six (54%) subjects had only hospital admissions for asthma, while 15 children had only been treated in the ED for acute asthma. Of 14 children with a severity category documented, 9 had mild intermittent asthma, 1 each with mild persistent and moderate persistent asthma, and 3 with severe persistent asthma. No patient had documented bronchoprovocation with methacholine and only 3 had documented spirometry with 1 consistent with airway obstruction, 1 with reversibility of airway obstruction, and one with poor technique and unreliable results. Two patients (age 3) were too young for spirometry. Four subjects had been seen in the Asthma and Allergy clinic for consultation and the diagnosis of asthma reaffirmed. Twenty-one (44%) subjects had a primary family member with asthma. Only 5 children were born preterm (27, 33, 34, 36, and 37 weeks gestation) and none were diagnosed with bronchopulmonary dysplasia.All subjects in the asthma group had asthma recorded in their medical record with symptoms consistent with asthma. All had been prescribed albuterol; while 28 (58%) had been prescribed controller medications . Most patients had been prescribed combination therapy with more than 1 controller medication or had been switched from 1 controller to another. There was no reliable means to confirm adherence to the prescribed asthma drug regimen. Seventeen (35%) subjects had not had prior ED The cases and controls were well-matched for age, gender and type of hemoglobinopathy Table . The casPatients with sickle cell disease and asthma had significantly more episodes of acute chest syndrome, cerebral vascular accidents, blood transfusions and chronic transfusions as compared to the control group Table . AdmissiNo patient with SC disease in either group had a history of a cerebral vascular accident. Only 1 patient with SC disease had acute chest syndrome, while 3 children in the asthma group had acute chest syndrome with one child experiencing 2 episodes.Despite the high prevalence of these two diseases that affect the African American population, there is paucity of research investigating patients with concomitant asthma and sickle cell disease.In this study, we discovered that children with both asthma and sickle cell disease are significantly more likely to develop severe complications of sickle cell disease including acute chest syndrome and cerebral vascular accidents compared to children with sickle cell disease alone. The significance of these findings relates to the hypothesis that appropriately aggressive treatment of asthma in children with sickle cell disease may diminish the frequency of pulmonary complications.Patients with reactive airway disease and sickle cell disease have a lower transcutaneous oxyhemoglobin saturation . The lowCerebral vascular accidents affect 10% of the children with sickle cell disease often with devastating long term implications. The Cooperative Study of Sickle Cell Disease reported that recent and recurrent episodes of acute chest syndrome are risk factors for cerebral vascular accidents . LikewisOur study demonstrates that pediatric patients with sickle cell disease and asthma are more likely to require acute and chronic blood transfusions. It is not surprising that these patients needed more frequent transfusions since treatment for cerebral vascular accidents and severe acute chest syndrome is blood transfusions. Although SS type of sickle cell anemia is more severe than SC type, the small numbers of patients with SC prevent us from making broad conclusions regarding the degree of risk based on hemaglobinopathy.Two studies have demonstrated increased airway hyperreactivity with reversibility in patients with sickle cell disease without known asthma ,13. ThirA randomized, placebo-controlled trial of 43 episodes of acute chest syndrome in 38 children revealed that intravenous dexamethasone prevented clinical deterioration in mild to moderately severe episodes of acute chest syndrome . Mild anLimitations of our study include those inherent in a retrospective analysis including selection bias, measurement bias and confounding factors. The children who received transfusions for acute chest syndrome likely represent the more severe form of disease. In contrast, those patients deemed to have asthma were primarily being treated as if they had mild to moderate asthma. Only 3 had been diagnosed with severe persistent asthma and none were on daily or every-other-day oral steroids. Importantly, even individuals with mild intermittent asthma can experience severe asthma exacerbations. Other sources of potential error that deserve recognition include the diagnosis of asthma (whether over-diagnosed or under-diagnosed), medication compliance and unknown admission to other hospitals. Although a strict definition of asthma was lacking, the history gleaned from the medical records supported an asthma diagnosis. Most patients with asthma are not cared for by asthma specialists and frequently the diagnosis is made on clinical grounds without formal pulmonary function testing. Additionally, spirometry was not routinely performed during ED and hospital admissions. Although other EDs and hospitals in the metropolitan area evaluate, treat, and admit pediatric patients with asthma exacerbations, the concomitant diagnosis of sickle cell disease likely prompted evaluation at the children's hospital.In this small series, children with a history of asthma and sickle cell disease developed acute chest syndrome and cerebral vascular accidents more frequently than children with sickle cell disease without asthma. The implications of this retrospective study are wide ranging and should lead to further prospective investigations. Whether aggressive asthma therapy in patients with sickle cell disease and asthma reduces the incidence of serious complications is unknown. The potential gains are far reaching and could make enormous impacts on the morbidity, quality of life and mortality of many patients.The author(s) declare that they have no competing interests.MEN conceived the study, participated in its design and coordination and drafted the manuscript. JL participated in data collection. MCZ participated in coordination and manuscript preparation. JPS participated in design, coordination and manuscript preparation. KJK participated in design and coordination.


Problem-based learning (PBL) is gaining popularity as a teaching method in UK medical schools, but statistics and research methods are not being included in this teaching. There are great disadvantages in omitting statistics and research methods from the main teaching. PBL is well established in Australian medical schools. The Australian experience in teaching statistics and research methods in curricula based on problem-based learning may provide guidance for other countries, such as the UK, where this method is being introduced.All Australian medical schools using PBL were visited, with two exceptions. Teachers of statistics and medical education specialists were interviewed. For schools which were not visited, information was obtained by email.No Australian medical school taught statistics and research methods in a totally integrated way, as part of general PBL teaching. In some schools, statistical material was integrated but taught separately, using different tutors. In one school, PBL was used only for 'public health' related subjects. In some, a parallel course using more traditional techniques was given alongside the PBL teaching of other material. This model was less successful than the others.There are several difficulties in implementing an integrated approach. However, not integrating is detrimental to statistics and research methods teaching, which is of particular concern in the age of evidence-based medicine. Some possible ways forward are suggested. Problem-based learning (PBL) is a method of teaching and learning which is widely used in the education of medical students ,2. In prThis project was conceived at a meeting of statisticians from UK medical schools, which is held every year at the Burwalls conference centre, University of Bristol. In 2002, one of the topics for discussion was problem-based learning (PBL). Several things became apparent during this discussion. First, most of the statisticians present had no idea what problem-based learning was. Second, in the few UK medical schools where PBL was in use, statistics and research methods were not being taught through this medium. Statisticians in some of these schools felt excluded. Third, the new medical schools which were starting up in the UK were adopting PBL as their method of teaching.As far as I know, only four of the older UK medical schools have adopted a PBL curriculum at the time of writing: Liverpool, Manchester, Glasgow, and St. George's. St. George's is a special case, as it has two medical courses. The five-year undergraduate entry course is taught in the traditional way, with a small 'case-based learning' element added on. The new four-year Graduate Entry Programme (GEP) is based on the McMaster model, a PBL course which takes graduates in any subject . In noneNew medical schools, such as Anglia, Peninsular, and Hull-York, are being set up as PBL courses . This isThe adoption of PBL in new medical schools may indicate the possibility that PBL will become more widely adopted in UK medical schools. If this were to happen, there would be a real danger of statistics and research methods being marginalised in the medical curriculum. It is difficult enough to persuade medical students of the importance of these topics and it would be even more so if it were taught outside the mainstream of the course. More importantly, in the era of evidence-based medicine these topics should be central to the medical curriculum, not on the sidelines.During a sabbatical visit to Australia, I spent one to three weeks each at most of the medical schools. I interviewed educationalists and statisticians at each of these to ask how statistics and research methods were taught to medical students in their problem-based learning curricula. I had no prior knowledge of how this might be done, so the interviews were open in nature, rather than structured. I enquired about statistics as a subject in its own right and the wider principles of research, critical reading of research, and evidence-based medicine. I then synthesised the information collected to provide a picture of the current situation.. I am particularly interested in how statistics is taught in problem-based learning programmes. I am presenting this material at the forthcoming International Biometrics Conference in Cairns and preparing a paper for possible publication. I would be very interested to learn how these matters are ordered in [your university] . . . Are you the right person to ask? If not, could you suggest someone who would be?' I obtained helpful replies from all three universities.I visited the following universities with medical schools: the University of Western Australia, Perth, Flinders University, Adelaide, Monash University, Melbourne, the University of Melbourne, the Australian National University, Canberra , the University of Sydney, the University of Newcastle, and the University of Queensland, Brisbane. I omitted the University of Adelaide, the University of New South Wales, and James Cook University, Townsville, but was able to get information from them by email. I identified potential informants from the university website and emailed them as follows: 'I am interested in the teaching of statistics to medical students. Last year I visited several medical schools in Australia, but unfortunately I did not manage to visit [your university] on this trip, a serious omission. I have written a report on my experiences, which is available on one of my websites at I went to Australia in search of the fully integrated teaching of statistics and research methods as part of the PBL tutorials. I did not find it anywhere. I did find three different models:• Material integrated but separately taught,• A parallel course,• PBL used only for 'public health' related subjects.In addition, one school  did not use problem-based learning and one (James Cook) taught virtually no statistics. More information about the individual medical schools is available see .This approach was used or planned at the University of Sydney, the University of Melbourne, and the Australian National University. However, of these only the University of Sydney had actually put this into practice. The University of Melbourne and the Australian National University were about to implement what was essentially the Sydney model.In this model, statistics and research methods are taught by PBL and the PBL triggers are integrated with the PBL problems for other parts of the course, but the material is not taught in the same tutorials or by the same tutors as anatomy, biochemistry and physiology. There will be a separate set of triggers for the statistics, etc., presented in a separate tutorial, and by separate tutors.I asked why the main PBL tutors could not do this. As I understood it, the function of a PBL tutor is to facilitate and guide the group, not to impart knowledge. I had no problem, at least that I was aware of, in acting as PBL tutor when students were working with triggers designed to elicit questions about anatomy, biochemistry, and physiology, subjects of which I know virtually nothing. Besides, many of these tutors must routinely read journals which bristle with P values, t tests, correlation coefficients, etc. They must be familiar with the terms, if nothing else. Answers to this included:• the tutors themselves refused to do it,• in the early years of the course we need expert tutors,• many tutors are still rooted in the old paradigm and are reluctant to embrace EBM and it was the view of my informants that experience round the world shows that it is difficult to teach EBM principles.The team at the University of Sydney were on the whole positive about their course.This approach was used at Monash University, the University of Queensland, Flinders University, the University of Newcastle, and the University of Adelaide.In this approach, a non-PBL course is given separately from the main PBL course. This may consist of any combination of lectures, seminars, practicals, web pages, or text handouts. Usually there is an attempt to link this to the PBL cases by using examples related to the case of the week. For example, the case of the week might be asthma and the parallel course could include a critique of a paper reporting a trial of a treatment for asthma.There are several problems with this approach to teaching statistics and research methods. As noted in the Background, the subject may seem peripheral to the main thrust of the medicine course. Student feedback tends to give a much lower approval to parallel courses than to the main PBL teaching. Finally, teaching is dependent on the cases chosen by the PBL teachers, who may change the cases or reorder them at little or no notice. This can make statistics teaching, which is much more dependent on the order of presentation than most subjects in the medical curriculum, extremely difficult.Most people involved in these courses were unhappy with them, the exception being a group project in the Flinders course.This approach was used at the University of Western Australia.This was an unusual model, found at only one university. PBL teaching had been initiated by an enthusiast, after a period spent at McMaster University. She was a member of the public health group and persuaded her colleagues to introduce PBL. However, only about one third of the course is taught this way, anatomy, biochemistry and physiology are taught traditionally. The consequence of this approach is that the tutors are drawn from the population medicine area and so are quite happy to teach statistics, research methods, and EBM. The triggers can be chosen as population-oriented problems, rather than being restricted to the patient case.People I spoke to were very positive about this course, not surprisingly as they saw themselves as the educational leaders in their institution.I did not to find anywhere in Australia a single instance of truly integrated teaching of statistics and research methods through PBL. I have to conclude from this that there are considerable difficulties. I did, however, find an instance of unintegrated PBL teaching, at the University of Western Australia, where anatomy, biochemistry and physiology have continued to be taught in a more traditional manner.What are these difficulties?• If tutors are drawn mainly from the laboratory disciplines, they may be unsympathetic to the population and clinical foci of EBM and its core subjects. We need strong advocates to persuade them of the importance of these topics.• If tutors are drawn from the clinical staff, they may be unsympathetic to the idea of EBM as a core activity. Converting the existing clinical teachers to the new paradigm of EBM may take a generation, but this will be a problem whatever teaching method we use.• Tutors may be ignorant of the principles and details of statistics. This may be true. My own experience as a PBL tutor has been that lack of knowledge has seldom been a problem. It is not the function of a PBL tutor either to impart knowledge or to explain concepts. Persuading tutors of this should be part of their general PBL training.• The changing patterns of cases as the course develops is a particular problem for statistics. This is undoubtedly true.• The nature of the subject does not lend itself to PBL. It would certainly be difficult to deduce the calculations required for a t test from a problem based on a patient with asthma. However, we must consider what we actually want to teach. I do not think there is much point in teaching undergraduate medical students to analyse data, even using computers. What we need to teach them is how to understand research publications, the evidence on which we hope their future evidence-based practice will be based. We can certainly do this using triggers such as published papers, as the University of Western Australia has demonstrated.• The patient case is not suited to teaching these subjects. This is true, though I do not think it is beyond us to devise cases which lead to research and evidence questions. However, we must persuade our colleagues that the patient vignette is not the only type of problem which we can use.We should not see only the difficulties, however, but also the opportunities. If we can integrate statistics and research methods into PBL, there may be great advantages. One consequence of integration would be that the subject would not be marginalised or seen as separate. It would be just one aspect of medicine. Indeed, one of the features of a PBL course is that the distinctions between the different subjects should blur.A second advantage would be that students would be learning statistics and research methods in the contexts in which we hope that they will apply them: the interpretation of clinical data and the assessment of research evidence. The relevance of the subject should be very clear and during their professional careers they would be more likely to be able to recall and use this material when needed.So how can we do it? There must be an advocate for statistics and research methods at the start of the preparations for PBL, who is able to argue convincingly for the inclusion of these subjects. They must form part of the matrix of topics and problems. This is not an easy task and I have been told of great difficulty experienced at this level, as other teachers sought to exclude these subjects so that their own discipline could have more time. This is a natural human reaction, of course. I think that statistics and research methods are central to medical education, and would argue for more of them, at the expense of some anatomy if necessary.We must get away from the idea that the problem must be a patient vignette. There are some statistical topics which can be covered quite conveniently in this way, such as measurement error, coefficients of variation, reference intervals, sensitivity and specificity, etc. After all, when my GP looks at my serum cholesterol on his practice computer, it has by the side of it a 95% reference interval. However, problems could equally be a published paper. We use these routinely in the teaching of statistics, research methods, and critical appraisal.We could use a paper as a trigger for non-research methods topics. For example, a paper on an asthma trial could trigger questions about asthma as well as about randomisation. This may lead to too many questions being raised by the trigger. Another possibility would be to have such a trigger immediately following a case vignette problem on the disease in question. The patient vignette would raise the questions on anatomy, biochemistry, pharmacology, etc., associated with the disease. The following problem using a research paper would then raise only the research methodological questions. The fixed resource sessions in this week would then be devoted to these.We may also, for variety, link research publications to the patient vignette by devices such as newspaper articles which the patient presents to the physician , or say that in a patient problem the clinician has already found a Cochrane review.Fixed resource sessions could include lectures, but I am very reluctant to suggest formal lectures in statistics and research methods for medical students. I would prefer to offer open question and answer sessions, where students can ask the statistician lecturer to explain anything they are unsure of. For example, if the PBL trigger is a randomised controlled clinical trial with results presented in terms of P values, we might be expecting this trigger to lead to questions such as 'why randomize?', 'what does P < 0.05 mean?', and 'should patients be told they are in a trial?'. Students should have made some attempt to answer these before the fixed resource session.There are several difficulties in implementing an integrated approach. However, not integrating is detrimental to statistics and research methods teaching, which is of particular concern in the age of evidence-based medicine. I remain optimistic that we can incorporate statistics and research methods into a fully problem-based curriculum. I think that if we do not, medicine will be the poorer for it.The author(s) declare that they have no competing interests.J M Bland is the sole author.The following is a typical example drawn from the teaching at St. George's Hospital Medical School. The students work in a small group with a tutor to act as facilitator. The students are given the following information:'You are a member of the on-duty Trauma Team in the Accident and Emergency department one Monday evening, when you are alerted to the imminent arrival of an "RTA (road traffic accident) patient". As she is being wheeled in to the Emergency Room, the paramedic accompanying her reports on the circumstances:'The patient is called Janet Phillips, she appears to be a medical student in her early 20s, and was on a Pelican crossing when she was struck by a car which had gone out of control. Janet had been thrown some distance from the car by the force of the impact. She is confused, in shock, has superficial lacerations to her face and severe pain in her pelvis and legs.'At the accident site her airway was cleared, oxygen administered, a traction splint applied to her right leg, and she was immobilised on a long spinal board.'The driver had only minor injuries but his breath smelled strongly of alcohol, and he was now in police custody.'In the Accident and Emergency Department Janet is given a pelvic clamp to arrest her internal bleeding.'The students are told that they should address four general themes in their discussion: basic and clinical sciences, patient and doctor, community and public health, and professional development. In the first tutorial, they are asked to work through the following steps:1. Clarify any terms and concepts in the scenario with which they are not familiar.2. Define the problem(s) and issue(s) raised by the scenario.3. Analyse the problems and issues, seeking explanations or hypotheses.4. Agree on specific questions (learning objectives) for each of the four general themes to which you need answers.They then work individually on tackling the questions agreed upon. In thesubsequent tutorial they discuss their findings and decide how the problems and issues raised by the scenario could be resolved. They may then be given further information about the patient, which might raise further topics for their research. When a problem has raised all the points required, a fresh problem is presented to the students.The pre-publication history for this paper can be accessed here:'The Australian Universities visited'. This provides a descriprtion of teaching at the universities visited as part of this project.Click here for file