Professionalisation and Social Attitudes: a Protocol for Measuring Changes in Hiv/aids-related Stigm

Abstract

Introduction HIV/AIDS-related stigma affects the access and utilisation of health services. Although HIV/AIDS-related stigma in the health services has been studied, little work has attended to the relationship between professional development and stigmatising attitudes. Hence, in this study, we will extend earlier research by examining the relationship between the stage of professional development and the kinds of stigmatising attitudes held about people living with HIV/AIDS.

Methods and analysis A serial cross-sectional design will be combined with a two-point in time longitudinal design to measure the levels of stigma among healthcare students from each year of undergraduate and graduate courses in Malaysia and Australia. In the absence of suitable measures, we will carry out a sequential mixed methods design to develop such a tool. The questionnaire data will be analysed using mixed effects linear models to manage the repeated measures.

Ethics and dissemination We have received ethical approval from the Monash MBBS executive committee as well as the Monash University Human Research Ethics Committee. We will keep the data in a locked filing cabinet in the Monash University (Sunway campus) premises for 5 years, after which the information will be shredded and disposed of in secure bins, and digital recordings will be erased in accordance with Monash University's regulations. Only the principal investigator and the researcher will have access to the filing cabinet. We aim to present and publish the results of this study in national and international conferences and peer-reviewed journals, respectively.

Introduction HIV/AIDS-related stigma affects the access and utilisation of health services. Although HIV/AIDS-related stigma in the health services has been studied, little work has attended to the relationship between professional development and stigmatising attitudes. Hence, in this study, we will extend earlier research by examining the relationship between the stage of professional development and the kinds of stigmatising attitudes held about people living with HIV/AIDS.

Methods and analysis A serial cross-sectional design will be combined with a two-point in time longitudinal design to measure the levels of stigma among healthcare students from each year of undergraduate and graduate courses in Malaysia and Australia. In the absence of suitable measures, we will carry out a sequential mixed methods design to develop such a tool. The questionnaire data will be analysed using mixed effects linear models to manage the repeated measures.

Ethics and dissemination We have received ethical approval from the Monash MBBS executive committee as well as the Monash University Human Research Ethics Committee. We will keep the data in a locked filing cabinet in the Monash University (Sunway campus) premises for 5 years, after which the information will be shredded and disposed of in secure bins, and digital recordings will be erased in accordance with Monash University's regulations. Only the principal investigator and the researcher will have access to the filing cabinet. We aim to present and publish the results of this study in national and international conferences and peer-reviewed journals, respectively.

Article focus

The primary objective of this research is to examine the relationship between professionalisation and stigmatising attitude towards people living with HIV/AIDS among healthcare students.

The secondary aim of this study is to investigate the availability of suitable measurement tool(s)-otherwise to create a scale to measure the transformation of HIV/AIDS-related stigma in the context of the health professionals' work environment.

Key messages

A fair and responsive health system requires a healthcare workforce that is blind to the 'undeserving' and the 'morally reprehensible'; hence, studying the professional development in relation to the stigmatising attitude development is of great importance in addressing the inequalities in the delivery of care.

Strengths and limitations of this study

The major strength of this protocol is its design which will allow us to study the professional development and possible change(s) in attitudes over a time period.

The limitation of this study is the uncertainties pertaining to the sample size calculation as well as the fact that we may measure a self-reported attitude rather than an actual attitude. The sampling limitations imposed by ethical requirements also raise issues about a selection bias. While the possibility of the bias needs to be acknowledged, the nature of the research question probably limits the bias.

Introduction

A healthcare workforce that is responsive and fair in its treatment of patients is one of the central pillars of a modern health system.1 It is for this reason, among others, that healthcare workers are bound by ethical codes of practice to treat patients according to their need, and not according to their gender, religious beliefs, sexual orientation, skin colour or other socially (de)valued attributes.2 Possible exceptions to this rule of social blindness arise when those otherwise ignorable social attributes may affect the diagnosis, prognosis or choice of the most effective treatment.

What should happen, however, when the patient is perceived as a complete reprobate-a repugnant individual whose very presence challenges the healthcare worker's moral foundation? In theory, the answer is simple-treat the patient in front of you according to their healthcare need.

The challenge for the health system is that practice does not necessarily mirror professional intent, and personal prejudices and fear of contagion interfere in decisions for care.3-5 The literature is replete with examples of patients who are accorded different (worse) treatment because of some perceived moral taints.6 The HIV epidemic provides a classic case in point. Healthcare workers have reported not wanting to treat people living with HIV/AIDS (PLWHA) for a range of reasons, including: because the patient was undeserving, or because treating PLWHA would devalue the healthcare worker in the eyes of others.7 This situation has, in many instances, created a tiered health system in which 'deserving' patients have received treatment and the 'undeserving' have not.6 High levels of stigma and discrimination are associated with a reduction in access to treatment and care for those with undesirable attributes.8

To overcome the dangers of discrimination associated with the social valuation of HIV/AIDS patients, many teaching programmes now contain explicit or integrated learning objectives that relate to professionalisation.9 The process of professionalisation fosters the inculcation of acceptable practice of healthcare workers in line with societal expectations, and the social contract between the client and the healthcare worker.10-12 In this context, increasing the professionalism of the healthcare workforce is as much about improved technical competency as it is about ethics of practice. Increasing professionalisation is thus expected to result in less stigma and discrimination in healthcare settings.13

Whether professionalisation does protect patients against the creation of tiered healthcare is an empirical question, but there is reason to believe that it would work by reducing negative attitudes and discriminatory behaviour towards patients-particularly those from socially marginalised groups, such as HIV/AIDS patients. There is already some evidence in the literature to support this idea.14 ,15 For instance, it is known that targeted learning focused on attitudes to specific marginalised groups can result in a positive attitudinal change.16 What is less clear is whether a generic focus on professionalisation not focused specifically on one disease or another is sufficient to improve attitudes towards all socially marginalised groups regardless of the socially devalued attribute.

In posing the idea that professionalisation may reduce stigmatising attitudes, two refinements need to be introduced. The first is a distinction between generic professionalisation and targeted learning, because it goes to the heart of ensuring a responsive and fair health system. For instance, in targeted learning, if programmes need to be developed to address stigmatising attitudes of a healthcare workforce to every marginalised group or disease, the cost will be too high and the educational process will always be reactive. By contrast, a generically professional healthcare workforce that understands and follows a holistic approach to the ethical codes of conduct is a more flexible workforce, which is less likely to create a tiered healthcare system.

The second refinement is to draw a distinction between an individual as a healthcare professional and that same individual within a private, non-professional domain. There is no reason to assume that the equanimity possessed in the professional domain towards socially marginalised people will translate into the private life of health professionals. Furthermore, there is no overwhelming reason to believe that it would be appropriate for professional attitudes to be always concordant with private attitudes, and earlier investigations of social attitudes among (future) healthcare professionals have clearly depicted discordant attitudes in personal and professional domains17 For example, I may be 'blind' to the fact that a person is a paedophile for the purposes of treating their myocardial infarction, but my vision might be restored if there is some indication that they are joining my social circle.

One might anticipate, therefore, that with increasing professionalisation there will arise a degree of bifurcation in the social attitudes of healthcare workers towards marginalised people. Specifically, while negative attitudes towards the socially marginalised may decrease with increasing professionalisation, for the purposes of providing treatment and care, the same change in attitude may not be observed towards the socially marginalised in the personal domain.

Rationale

Although HIV/AIDS-related stigma in the health services has been studied, little work has attended to the relationship between professional development and changes in stigmatising attitudes. Indeed, most research has relied on cross-sectional data to assess generic levels of stigma,18-28 without attempting to understand how attitudes may develop and change over time, or differences between stigma associated with the professional and private domains of life. This question is particularly crucial in the context of health service provision, because of the hypothesised link between the trajectory of stigmatising attitudes and the trajectory of professional development.

The primary main objective of this study is to investigate the relationship between the stage of professional development of healthcare students and the kinds of stigmatising attitudes held about PLWHA. More specifically, we aim to measure the attitudes of students towards PLWHA to assess (1) the level of stigmatising attitudes, (2) differences between attitudes in professional and private domains and (3) changes in the differences between attitudes in professional and private domains as the students become increasingly professionalised.

Although there are a number of measures of stigma, there are few separate measures of stigmatising attitudes in professional and private domains and none validated for use in our research setting. The conditional secondary objective, therefore, is to develop a suitable tool to measure the stigmatising attitudes in professional and private domains. This secondary objective, however is described in less detail and the protocol assumes that such a measure is identifiable.

Rationale

Although HIV/AIDS-related stigma in the health services has been studied, little work has attended to the relationship between professional development and changes in stigmatising attitudes. Indeed, most research has relied on cross-sectional data to assess generic levels of stigma,18-28 without attempting to understand how attitudes may develop and change over time, or differences between stigma associated with the professional and private domains of life. This question is particularly crucial in the context of health service provision, because of the hypothesised link between the trajectory of stigmatising attitudes and the trajectory of professional development.

The primary main objective of this study is to investigate the relationship between the stage of professional development of healthcare students and the kinds of stigmatising attitudes held about PLWHA. More specifically, we aim to measure the attitudes of students towards PLWHA to assess (1) the level of stigmatising attitudes, (2) differences between attitudes in professional and private domains and (3) changes in the differences between attitudes in professional and private domains as the students become increasingly professionalised.

Although there are a number of measures of stigma, there are few separate measures of stigmatising attitudes in professional and private domains and none validated for use in our research setting. The conditional secondary objective, therefore, is to develop a suitable tool to measure the stigmatising attitudes in professional and private domains. This secondary objective, however is described in less detail and the protocol assumes that such a measure is identifiable.

Method and analysis

Study design

The ideal design for this research would be a 4-year to 5-year longitudinal study of healthcare students measuring changes in attitude over their professional course; however, an alternative approach is proposed which limits the resource expenditure while providing a good indication of the idea's merit. Instead of a longitudinal design, a serial cross-sectional design (to examine differences between cohorts in different years of study) will be combined with a two-point in time longitudinal design (to examine differences between the beginning and the end of a single year of study; figure 1). Levels of stigma will be measured once at the beginning of a single year of study and once at the end of the same year, and this will be conducted across year cohorts.

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Figure1 Study design for MBBS programme.

Study population

Monash University is an Australian university that has multiple campuses in Australia as well as in Malaysia and South Africa. In this study, we will recruit Monash University healthcare students from three campuses (two campuses in Australia and one campus in Malaysia). Students over the age of 17, studying a 4-year plus, professional, healthcare qualification, degree course will be eligible.

Students with a previous healthcare qualification will be excluded; for example, a nurse returning to university to pursue medicine. Also, students below the age of 17 will be excluded. There are no other exclusion criteria.

Sample size calculation

Usually the number of predictor variables, the variability in the outcome variable, the correlation between the repeated measures, and the type of statistical test planned are used to calculate the minimum number of respondents needed to achieve a significant result with known probability.29 The variability in the outcome measures is unknown, as is the correlation between the repeated measure of personal and professional stigma, making a realistic sample size calculation almost impossible.30 However, a recent study of HIV knowledge and stigma in a Malaysian healthcare cohort provides a crude guide.31 In that study without repeated measures, a sample size of 340 was calculated. Inflating this estimate to account for the repeated measurement, in what amounts to a conservative design effect of 2.5, leads to an estimated sample size of 850. However, the ethical mechanisms operating within the University for the use of students as participants prevent random sampling and one must, in reality, attempt to contact all students.

Data analysis plan

If the assumptions hold, we anticipate the use of mixed effects linear models to examine differences between the level of stigmatising attitudes between year-group cohorts, controlling for appropriate covariates, such as age, sex, ethnographic backgrounds and course.

The approach to the analysis of the data assumes a serial cross-sectional design. It is conceptually simple to think of the data analysis in terms of repeated measures analysis of covariance (ANCOVA) where stigmatising attitudes are the outcome measures measured twice within a person (ie, a measure of personal and professional stigma). The level of professionalism is treated as an ordered factor based on years of study; and sex, level of HIV knowledge, and the type of degree programme are treated as nominal, interval and nominal covariates, respectively.

In the preliminary stages, exploratory data analysis will be used to check and describe the data. However, rather than repeated measures of ANCOVA, which was described for its conceptual simplicity, a mixed effects linear model will be fitted to the data to control for repeated measures of stigma within a person. The great advantages of the mixed effects linear model for repeated measures designs is that if one of the outcome measures is missing (eg, if a participant fails to complete the personal stigma scale but does complete the professional stigma scale), the remaining data from the individual can still be retained. The data will be analysed using the R statistical environment.32

Measurement tool

There is currently no measurement tool designed to measure stigmatising attitudes in a professional and private domain separately, and this is the secondary objective of the research. We will carry out a sequential mixed methods design to develop a measurement tool (ie, a questionnaire). We will form a group of healthcare specialist(s), health academics and healthcare team members, that is, nurses, medical doctors, pharmacists, etc with at least 5 years of clinical experience, and together we will implement a four-step approach to create the new measurement tool

We will define the main facets and domains of the measurement tool based on 'personal domains of stigma' versus 'professional domain of stigma in the context of a health professional's work environment'. We anticipate that this could be achieved by creating brief hypothetical scenarios about HIV positive individuals and HIV negative individuals in health settings. These hypothetical scenarios-vignettes-could be themed to reflect fear of contagion, etc. For example, a scenario in which 'a physician refuses to operate on a patient with HIV/AIDS to protect themselves from contracting HIV/AIDS'.

We will decide on the items for 'personal domain of stigma' and 'professional domain of stigma' either by adopting the available items from the available validated measurement tools or by developing new items. For instance, we will search the relevant sources of information, that is, published articles, book chapters, organisational documents like international and national codes of professional conduct and ethics in the health field to develop new items for 'professional domain of stigma'.2 ,13 ,33-38 We anticipate that common themes reflecting the traits of professionalism could be extracted from the above said sources of information. For example, fear of contagion, risks of infectivity, confidentiality and resource allocation could be the themes that might surface.

We will design the new items as such to capture the interplay between a social, either professional or personal, responsibility and a potentially stigmatised (HIV positive) or non-stigmatised (HIV negative) characteristic.

We will draft the finalised items to create a scale-a questionnaire-and will validate it.

We will administer the measurement tool in a series of time points to capture any change(s) in attitude.

Data collection

We will collect the data using the newly developed questionnaire by administering paper-based and/or online surveys. The online version of the survey will be available via the 'Blackboard' class management system, with a link in the announcements as the student's login (Australia). The paper-based version will be distributed in classrooms at the end of the taught session (Malaysia). There is no risk of students receiving the online version also receiving the paper-based version.

The questionnaire will contain demographic questions and the initial item pool of questions on HIV/AIDS-related stigma. We will also provide each participant with the questionnaire and explanatory statement-describing the purpose of the research, methods, etc.

Participating sites

We anticipate that healthcare students from each year will be invited to participate in the study over a 1-year period. This will allow us to examine differences between the level of stigmatising attitudes between year-group cohorts, controlling for appropriate covariates, such as age, sex, ethnographic backgrounds, cultural backgrounds and course.

Study design

The ideal design for this research would be a 4-year to 5-year longitudinal study of healthcare students measuring changes in attitude over their professional course; however, an alternative approach is proposed which limits the resource expenditure while providing a good indication of the idea's merit. Instead of a longitudinal design, a serial cross-sectional design (to examine differences between cohorts in different years of study) will be combined with a two-point in time longitudinal design (to examine differences between the beginning and the end of a single year of study; figure 1). Levels of stigma will be measured once at the beginning of a single year of study and once at the end of the same year, and this will be conducted across year cohorts.

Download figure

Open in new tab

Download powerpoint

Figure1 Study design for MBBS programme.

Study population

Monash University is an Australian university that has multiple campuses in Australia as well as in Malaysia and South Africa. In this study, we will recruit Monash University healthcare students from three campuses (two campuses in Australia and one campus in Malaysia). Students over the age of 17, studying a 4-year plus, professional, healthcare qualification, degree course will be eligible.

Students with a previous healthcare qualification will be excluded; for example, a nurse returning to university to pursue medicine. Also, students below the age of 17 will be excluded. There are no other exclusion criteria.

Sample size calculation

Usually the number of predictor variables, the variability in the outcome variable, the correlation between the repeated measures, and the type of statistical test planned are used to calculate the minimum number of respondents needed to achieve a significant result with known probability.29 The variability in the outcome measures is unknown, as is the correlation between the repeated measure of personal and professional stigma, making a realistic sample size calculation almost impossible.30 However, a recent study of HIV knowledge and stigma in a Malaysian healthcare cohort provides a crude guide.31 In that study without repeated measures, a sample size of 340 was calculated. Inflating this estimate to account for the repeated measurement, in what amounts to a conservative design effect of 2.5, leads to an estimated sample size of 850. However, the ethical mechanisms operating within the University for the use of students as participants prevent random sampling and one must, in reality, attempt to contact all students.

Data analysis plan

If the assumptions hold, we anticipate the use of mixed effects linear models to examine differences between the level of stigmatising attitudes between year-group cohorts, controlling for appropriate covariates, such as age, sex, ethnographic backgrounds and course.

The approach to the analysis of the data assumes a serial cross-sectional design. It is conceptually simple to think of the data analysis in terms of repeated measures analysis of covariance (ANCOVA) where stigmatising attitudes are the outcome measures measured twice within a person (ie, a measure of personal and professional stigma). The level of professionalism is treated as an ordered factor based on years of study; and sex, level of HIV knowledge, and the type of degree programme are treated as nominal, interval and nominal covariates, respectively.

In the preliminary stages, exploratory data analysis will be used to check and describe the data. However, rather than repeated measures of ANCOVA, which was described for its conceptual simplicity, a mixed effects linear model will be fitted to the data to control for repeated measures of stigma within a person. The great advantages of the mixed effects linear model for repeated measures designs is that if one of the outcome measures is missing (eg, if a participant fails to complete the personal stigma scale but does complete the professional stigma scale), the remaining data from the individual can still be retained. The data will be analysed using the R statistical environment.32

Measurement tool

There is currently no measurement tool designed to measure stigmatising attitudes in a professional and private domain separately, and this is the secondary objective of the research. We will carry out a sequential mixed methods design to develop a measurement tool (ie, a questionnaire). We will form a group of healthcare specialist(s), health academics and healthcare team members, that is, nurses, medical doctors, pharmacists, etc with at least 5 years of clinical experience, and together we will implement a four-step approach to create the new measurement tool

We will define the main facets and domains of the measurement tool based on 'personal domains of stigma' versus 'professional domain of stigma in the context of a health professional's work environment'. We anticipate that this could be achieved by creating brief hypothetical scenarios about HIV positive individuals and HIV negative individuals in health settings. These hypothetical scenarios-vignettes-could be themed to reflect fear of contagion, etc. For example, a scenario in which 'a physician refuses to operate on a patient with HIV/AIDS to protect themselves from contracting HIV/AIDS'.

We will decide on the items for 'personal domain of stigma' and 'professional domain of stigma' either by adopting the available items from the available validated measurement tools or by developing new items. For instance, we will search the relevant sources of information, that is, published articles, book chapters, organisational documents like international and national codes of professional conduct and ethics in the health field to develop new items for 'professional domain of stigma'.2 ,13 ,33-38 We anticipate that common themes reflecting the traits of professionalism could be extracted from the above said sources of information. For example, fear of contagion, risks of infectivity, confidentiality and resource allocation could be the themes that might surface.

We will design the new items as such to capture the interplay between a social, either professional or personal, responsibility and a potentially stigmatised (HIV positive) or non-stigmatised (HIV negative) characteristic.

We will draft the finalised items to create a scale-a questionnaire-and will validate it.

We will administer the measurement tool in a series of time points to capture any change(s) in attitude.

Data collection

We will collect the data using the newly developed questionnaire by administering paper-based and/or online surveys. The online version of the survey will be available via the 'Blackboard' class management system, with a link in the announcements as the student's login (Australia). The paper-based version will be distributed in classrooms at the end of the taught session (Malaysia). There is no risk of students receiving the online version also receiving the paper-based version.

The questionnaire will contain demographic questions and the initial item pool of questions on HIV/AIDS-related stigma. We will also provide each participant with the questionnaire and explanatory statement-describing the purpose of the research, methods, etc.

Participating sites

We anticipate that healthcare students from each year will be invited to participate in the study over a 1-year period. This will allow us to examine differences between the level of stigmatising attitudes between year-group cohorts, controlling for appropriate covariates, such as age, sex, ethnographic backgrounds, cultural backgrounds and course.

Discussion

Definitions

In the context of future healthcare professionals, the years towards the professional development could be considered as one indicator of professionalisation. Clinical knowledge, as well as knowledge of contagion and transmission, will increase with years in a healthcare programme. Within a modern healthcare programme, however, there is also a focus on professional ethics and professional practice-often implicit rather than explicit-probably increasing with the shift from preclinical to clinical years in a programme. Under these circumstances, the years of training becomes a reasonable indicator of professionalisation. Unfortunately, professionalism then becomes confounded by knowledge of transmission.

Strengths and weaknesses

The strength of the study is the two-point in time longitudinal design that will enable us to investigate the relationship between stigmatising attitude towards PLWHA and professionalisation by looking at change(s) in attitudes over a time period.

The approach to sampling, which is not an ideal but a constraint placed by ethical requirements, raises the possibility of a selection bias. In a more general invitation to participate given to all students, those with particular attitudinal dispositions (or dispositions to change attitudes with professional exposure) may self-select. This needs to be noted as a limitation, and may warrant further study. However, the nature of the hypothesis that participants will change on one dimension of stigma attitudes but not another seems to provide some protection against the plausibility of the selection bias as an explanation for any observed difference.

The lack of a universally accepted measure of 'professionalism'39-41 in healthcare students or the healthcare workforce is an issue. However, within the context of this study, years of study is a reasonable indicator in the first instance.

Moreover, the bifurcation of social attitude into the private and professional domains might be less distinctive than anticipated, and requires large samples to detect the differences. We also anticipate collecting the self-reported attitude rather than the actual attitude and this, of course, would also raise questions about the practical importance of the issue, which could be a finding in its own right.

Conclusion

A fair and responsive health system requires a healthcare workforce that is blind to the 'undeserving' and the 'morally reprehensible'. If we do not gain a better understanding of the relationship between professionalisation and negative social attitudes and behaviour towards the socially marginalised, we are in danger of recreating a tiered healthcare system each time a new disease or a new social group is devalued. Notwithstanding the measurement challenges outlined here, the implications for professional education and the health systems agenda are sufficiently important to warrant further investigation.

Ethics and dissemination

Participation in this study will be completely voluntary, where the completion and return of the questionnaire will be taken as consent. This protocol has been approved by the Monash University Human Research Ethics Committee (approval number: CF12/0829-201200368) and categorised as low risk.

Data deposition

We will keep the data in a locked filing cabinet in the Monash University (Sunway campus) premises for 5 years, after which the information will be shredded and disposed of in secure bins, and digital recordings will be erased in accordance with Monash University's regulations. Only the principal investigator and the researcher will have access to the filing cabinet.

Dissemination plan

We aim to present and publish the results of this study in national and international conferences and peer-reviewed journals, respectively.

Definitions

In the context of future healthcare professionals, the years towards the professional development could be considered as one indicator of professionalisation. Clinical knowledge, as well as knowledge of contagion and transmission, will increase with years in a healthcare programme. Within a modern healthcare programme, however, there is also a focus on professional ethics and professional practice-often implicit rather than explicit-probably increasing with the shift from preclinical to clinical years in a programme. Under these circumstances, the years of training becomes a reasonable indicator of professionalisation. Unfortunately, professionalism then becomes confounded by knowledge of transmission.

Strengths and weaknesses

The strength of the study is the two-point in time longitudinal design that will enable us to investigate the relationship between stigmatising attitude towards PLWHA and professionalisation by looking at change(s) in attitudes over a time period.

The approach to sampling, which is not an ideal but a constraint placed by ethical requirements, raises the possibility of a selection bias. In a more general invitation to participate given to all students, those with particular attitudinal dispositions (or dispositions to change attitudes with professional exposure) may self-select. This needs to be noted as a limitation, and may warrant further study. However, the nature of the hypothesis that participants will change on one dimension of stigma attitudes but not another seems to provide some protection against the plausibility of the selection bias as an explanation for any observed difference.

The lack of a universally accepted measure of 'professionalism'39-41 in healthcare students or the healthcare workforce is an issue. However, within the context of this study, years of study is a reasonable indicator in the first instance.

Moreover, the bifurcation of social attitude into the private and professional domains might be less distinctive than anticipated, and requires large samples to detect the differences. We also anticipate collecting the self-reported attitude rather than the actual attitude and this, of course, would also raise questions about the practical importance of the issue, which could be a finding in its own right.

Conclusion

A fair and responsive health system requires a healthcare workforce that is blind to the 'undeserving' and the 'morally reprehensible'. If we do not gain a better understanding of the relationship between professionalisation and negative social attitudes and behaviour towards the socially marginalised, we are in danger of recreating a tiered healthcare system each time a new disease or a new social group is devalued. Notwithstanding the measurement challenges outlined here, the implications for professional education and the health systems agenda are sufficiently important to warrant further investigation.

Ethics and dissemination

Participation in this study will be completely voluntary, where the completion and return of the questionnaire will be taken as consent. This protocol has been approved by the Monash University Human Research Ethics Committee (approval number: CF12/0829-201200368) and categorised as low risk.

Data deposition

We will keep the data in a locked filing cabinet in the Monash University (Sunway campus) premises for 5 years, after which the information will be shredded and disposed of in secure bins, and digital recordings will be erased in accordance with Monash University's regulations. Only the principal investigator and the researcher will have access to the filing cabinet.

Dissemination plan

We aim to present and publish the results of this study in national and international conferences and peer-reviewed journals, respectively.

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Footnotes

Contributors KA developed the concept and DDR reshaped it. KA and DDR have made substantive intellectual contributions to the manuscript. PA and MAAH have revised the manuscript critically and have improved the presentation of the ideas. All four authors have given final approval the publication of the manuscript.

Funding This work was supported by an internal grant from global public health (GPH) research strength, School of Medicine and Health Sciences, Monash University Sunway Campus. The grant number was 5140056.

Competing interests None.

Ethics approval MBBS executive committee and Monash University Human Research Ethics Committee.

Provenance and peer review Not commissioned; externally peer reviewed.

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A Filing Cabinet, Some Contracts, and Kate Duffy | Huffpost
I was surprised and saddened to see in the Times this A.M. that Kate Duffy had died.I had put my toe in publishing waters by agreeing to become Ron Busch's West Coast scout for his new publishing venture, Tudor Publishing, a new mass-market paperback house. One day, out of the blue, Ron told us he was going into the hospital for bypass surgery. He died the next day. Stan Corwin and I were partnered on various ventures then, and I suggested we buy Tudor and become the publishers ourselves. We put together a deal, and bought the company.Within a few weeks we were in New York inspecting our new property, which consisted, in its entirety, as follows: First we had an office, a dingy fluorescent-illuminated lower Park Avenue cell, with a steel desk and a two-drawer beige filing cabinet that Ron must have found in a vacant lot somewhere. In the cabinet was a distribution contract with our mass-market distributors, Kable News, ten contracts for paperback books in various stages of development, and some manuscripts. And there was also a chair, and a person in that chair. Our sole employee. Kate Duffy, our Editor in Chief.Kate held all the knowledge of Ron Busch's vision for Tudor. Our job was to get out of her way, to let her fill the pipeline of our first list. I busied myself with finding our new office/apartment. I found a beautiful spot down the street from our distributors, at the corner of 49th and 2nd, on the 25th floor with 90 feet of glass. Views of the U.N. and up and down the entire length of 2nd Ave. I discovered a fantastic cache of antiques for rent on Roosevelt Island, and had the place furnished in a day. Kate's desk was the pièce de résistance: an ornate French inlaid number with brass trimmings. When Kate first perched at it in her new corner with its spectacular view, She thought I was nuts, that it was too good for her. But she confided to us, "Now I really am Queen of Romances."Within a few days an author came by with a crazy Elvis book, and before long, we had purchased it. With Kate's coaching I reserved enough press time to get more than a million copies, and a million cassette tapes shrunk to it, into print. Soon we had our first paperback bestseller together: Is Elvis Alive? made the N.Y. Times list.Kate was my mentor in those early days at Tudor. Beloved by her authors, unflappable, funny and without pretence.If I still had that original filing cabinet, I'd have it bronzed in her honor. Kate Duffy had mass-market ink running in her veins. She was a book editor, through and through.
On the Trail of Bankrupt's Treasure
Police have seized a fortune in gold and silver from secret compartments in the suburban home of a retired psychiatrist. Now, the case has pulled in one of the country's most successful and reclusive businessmen. For a psychiatrist, Dr Alan Geraint Simpson had one of the best addresses in the world. In the medical world, Harley St in London has gold-plated credibility. But Simpson has seen it all swept away. His professional practice, the prestige that went with it and a small fortune got caught in the greatest financial scandal of the 1990s. The 68-year-old ended up half a world away in the Waikato - along with $2.3 million in hidden gold, silver and foreign currency. On their first visit to Simpson's Hamilton home, a specialist police team found $1 million in gold, silver and foreign currency. But soon, a builder led them to secret compartments he had constructed for the recently discharged English bankrupt. There, they found another $1 million in gold and silver. Simpson had said he was preparing for the end of the world, police were told. Eventually, Simpson surrendered another $300,000 in silver - but it is alleged another $1.8 million also exists. The house was like a Chinese puzzle. And wrapped inside that puzzle is the mystery of Simpson's relationship to one of New Zealand's most successful businessmen, the reclusive Carrick John Clough. The extraordinary story of the gold and silver is playing out in Hamilton's High Court. Simpson was bankrupted in England last year over a 12-year-old debt. The lawyer attempting to recoup money for those owed by Simpson has drawn New Zealand authorities into a world-first - using new international agreements to get our authorities to seize property that could be subject to another country's bankruptcy order. The case has yet to reach the stage of deciding who the gold and silver belongs to - and whether the court will order its confiscation to cover Simpson's debts. The case has drawn in builder Mike Holloway, who told the Herald on Sunday he had been sworn to silence by New Zealand's bankruptcy administrator, the Official Assignee. But court papers show it was his evidence about work he did for Simpson in December last year that prompted the second police search. Holloway told officials he was hired to replace flooring at the house Simpson was living in - and while there was asked to build new structures described in court as "bizarre". Holloway's staff created a compartment under the dining room floor. Examination found that part of the floor could be lifted up if screws holding it in place were removed. Unlike the remainder of the floor, this section was not glued. According to Holloway, Simpson had said he wanted the cavity because "the world was going to end". A second compartment was created under the house in the basement furnace room. A concrete block was laid and surrounded by small concrete walls. 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Collaboration Tools Are the New Filing Cabinet
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Australia Spy Agency Takes Possession of Secret Files Left ...
SYDNEY (Reuters) - Australia's domestic spy agency on Thursday took possession of thousands of classified documents that were left at a second-hand furniture shop as the government struggles to contain an embarrassing security lapse. The documents, which revealed top-secret details of five previous governments that under Australian law should remain secured for at least 20 years, were left inside a filing cabinet that was then sold at a store in Canberra that was stocked with ex-government furniture. The documents were then passed onto the Australian Broadcasting Corporation (ABC) that ran a string of stories, embarrassing former prime ministers and several lawmakers who still occupy prominent positions inside Australia's centre-right government. The ABC said the Australian Security and Intelligence Organisation took the files after talks with the spy agency in recent days, though as part of negotiations the national broadcaster said it will still have access to the files. The documents showed: Australia's now treasurer Scott Morrison sought to slow down security checks on refugees in order to restrict their chances of resettlement; former Prime Minister Tony Abbott considered abolishing financial aid to unemployed young Australians; the country's police lost hundreds of sensitive files. Australia's Deputy Prime Minister Barnaby Joyce said there had been a serious breach of security. "Obviously someone's had a shocker and the investigation will find out exactly how this happened," Joyce told ABC radio on Thursday. "In the process of running a country, there are things which go awry. This is one of them." Seeking to minimise the fallout of the security lapse, prominent conservative lawmakers have sought to focus attention on the decision of the ABC to publish details found within the top secret files. The ABC defended the publication, insisting it was in the national interest, though former Prime Minister Kevin Rudd said on Twitter on Thursday that he had launched legal action against the national broadcaster. Rudd was this week left embarrassed after the ABC ran a story that said the former leader had ignored advice around the dangers of a home insulation package in 2008. Rudd was later cleared on any wrongdoing by an independent investigation with sweeping powers, which he said the ABC ignored in its reporting. "The report by the ABC alleging I ignored warnings on the risks to the safety of installers of home insulation is a lie," Rudd said in the statement. "Legal proceedings against the ABC has now commenced."
Sandwich Superheroes Philadelphia's Cheese-steak Kings Have Fought for More Than 30 Years. now They
(FORTUNE Small Business) - Phone rings in Frank Olivieri's office (a desk, a couch, a filing cabinet, and a door opening onto a concrete stoop in South Philadelphia), and Olivieri picks up. "Tell me where you are, and I'll tell you how to get to where I'm at." Olivieri waits. "Take Broad Street northbound. Come to the 1200 block south, which is Wharton Street. You'll see a Mobil gas station on your right and a mural of Frank Sinatra. Make a right. Come five blocks down to Ninth. And get the hell out of the car." Welcome to ground zero in the Philly cheese-steak wars. For the better part of a half-century (24 hours a day, seven days a week), Pat's King of Steaks, in business since 1930, and Geno's Steaks, the challenger since 1967, have stared each other down across this barren patch of South Philly pavement like Apollo Creed and Rocky Balboa. It's the twin-shrine mecca of greasy meat, drawing visiting rock stars, college students with a severe case of the munchies, and politicos on the trail. (To Olivieri, Al Gore is just "Al" and John McCain is an "awesome guy.") You want diamonds, go to 47th Street in Manhattan. You want a honkin' drippin' cheese steak, right here. Both restaurants stake a claim to inventing the beloved sandwich. Pat, the original king of steaks, was Olivieri's great-uncle, a former street vendor who, the story goes, tossed some sliced beef on the grill because he was tired of eating hot dogs and so invented the steak sandwich. Geno's owner, Joe Vento, claims that he was the first to add cheese atop that sandwich, thereby inventing the classic Philly cheese steak. (Pat's later one-upped by introducing Cheese Whiz, which has since become the topping of choice.) Pat's is the dowdier-looking joint of the two--wrapped in aluminum siding, festooned with Pepsi signs, accessorized with a sheet-metal awning. Geno's is the same idea but a little brighter. The menus are nearly identical, and the prices might well be fixed ($5 for a steak, $5.50 with cheese). Order like a rookie on either side of the street, and the guy behind the window will make loud fun of you. And together they sell an awful, awful lot of meat--about $10 million worth if you accept Olivieri's hard estimate ($5.5 million) and Vento's boast ("He's trying to catch up with me now"). While both Vento, 64, and Olivieri, 38, eat steaks often (though not as often as they used to; Vento's cholesterol topped off at 252 before he discovered chelation therapy), neither will touch the other's product, which is one reason they've never shared a meal. The other reason: They hate each other. Vento uses words like "arrogant" and "idiot" to describe his opponent, and dismisses Pat's steaks. (So why do so many people eat them? "You can acquire a taste for bad food," he says.) Olivieri, who went to a Quaker high school, refuses to be drawn into a shouting match. "I don't even call him a competitor," he sniffs. Whatever. But Olivieri can't deny there's a rivalry. It's addictive, even. I ask him what he'd do if he woke up one day and Geno's was gone. "I'd feel a void--that'd be hard," Olivieri admits, then quickly adds, "I'd buy the place and open it up again. And call it Geno's. And fight with myself."
Home Office Interior Design Tips: Redesign Your Home ...
So, you work from home and are loving every minute of it, right? Then, it's time for some redecorating. No, not your living room, your home office.You'd probably be surprised to know that interior decorating your home-office space can be just as important as designing the rest of your house, maybe even more important. A well laid out office space can improve your productivity and your happiness.Location, Location, LocationNow, to start off, let's think about location. Your home office should be some place where you will have privacy. A spare bedroom or an out of the way alcove will work great. You still want to be part of the house, but you also need your privacy for those phone calls and business client visits.LightingNatural lighting also should be a significant part of your design plan. A window gives you something to look at when you get stressed out and some fresh air when you feel cramped. Speaking of lighting, try to avoid glaring overhead lights like you find in a regular office. Go for more diffused lighting. A good lamp may be all you need.Have extra closet space? Well, you can turn that into a home office. For more information, read Convert Your Closet into a Complete Home Office Space by MiAGon.Color and ConsolidationDecoratingNext up is color. You shouldn't paint your office in drab gray or black nor should it be too gaudy. You want to be comfortable, but not too agitated or depressed. Neutral colors work best. But, if you really want to add some personality to your walls, add artwork. Buy that artist that you admire so much. Just think of it as a business expense.Plants also are wonderful additions to home offices. They, too, will add color and personality to your space. When they bloom, it's like adding a whole different element to the room.StorageWhile you may not think of storage as an "design element", it's actually a very critical part of your home-office interior design plan. Now, when I refer to storage, I don't mean the metal filing cabinet with the key hanging from it. No. Storage can be anything: a built-in wall unit, unique shelving or even your own creation. Be artistic. It's your space. Really make it your own. Just do account for storage. A cluttered desk and work area is very distracting and will affect your work output. Another item that can greatly reduce clutter is a multifunction printer. As a home office worker, you have necessities: printer, fax and copier. Yet, these can come in one neat package. And, nowadays, these printers can be some really striking machines.For more information on what should be in a home office, read 10 Essential Items in a Telecommuting Home Office by S.A. Coggins.Functional FurnitureFinally, let's talk furniture. Forget the particle board desk that's already starting to chip. Try a roll top desk. They're great conversation pieces and fit in with any decor. Go for more decorative pieces for your desk organizers and even your trash can.Your home office is your home office. Don't try to copy the company pattern of function over style. Be your own home-office designer.
Keeping the Colonel's Secret Safe at KFC
Pssst. The secret's out at KFC. Well, sort of.Colonel Harland Sanders' handwritten recipe of 11 herbs and spices was removed Tuesday from safekeeping at KFC's corporate offices for the first time in decades. The temporary relocation is allowing KFC to revamp security around a yellowing sheet of paper that contains one of the country's most famous corporate secrets. The brand's top executive admitted his nerves were aflutter despite the tight security he lined up for the operation."I don't want to be the president who loses the recipe," KFC President Roger Eaton said. "Imagine how terrifying that would be." Trending News Couple arrested after spending mistaken $120,000 deposit Amazon to hire 30,000 workers at job fairs in 6 cities 48 states launch antitrust investigation into Google Kim Kardashian changes name of shapewear line FDA shoots down Juul claims that vaping is safer than smoking The recipe that launched the chicken chain was placed in a lock box that was handcuffed to security expert Bo Dietl, who climbed aboard an armored car that whisked away with an escort from off-duty police officers.Eaton's parting words to Dietl: "Keep it safe."So important is the 68-year-old concoction that coats the chain's Original Recipe chicken that only two company executives at any time have access to it. The company refuses to release their names or titles, and it uses multiple suppliers who produce and blend the ingredients but know only a part of the entire contents.KFC executives said they decided to upgrade security after retrieving the recipe amid preparations to add a new line of Original Recipe chicken strips.The recipe has been stashed at the company headquarters for decades, and for more than 20 years has been tucked away in a filing cabinet equipped with two combination locks. To reach the cabinet, the keepers of the recipe would first open up a vault and unlock three locks on a door that stood in front of the cabinet.Vials of the herbs and spices are also stored in the secret filing cabinet.Others have tried to replicate the recipe, and occasionally someone claims to have found a copy of Sanders' creation. The executive said none have come close, adding the actual recipe would include some surprises. Sanders developed the formula in 1940 at his tiny restaurant in southeastern Kentucky and used it to launch the KFC chain in the early 1950s.Larry Miller, a restaurant analyst with RBC Capital Markets, said the recipe's value is "almost an immeasurable thing. It's part of that important brand image that helps differentiate the KFC product."KFC had a total of 14,892 locations worldwide at the end of 2007. The chain has had strong sales overseas, especially in its fast-growing China market, but has struggled in the U.S. amid a more health-conscious public. KFC posted U.S. sales of $5.3 billion at company-owned and franchised stores in 2007.