Department of Emergency Medicine (UCSF)

Manuscript peer review is considered crucial to the selection and publication of quality scientific research, however, the practice is being increasingly challenged as a non-standardized process of unknown scientific validity with substantial weaknesses. Scientific disciplines appear to be confronted by a process of limited efficacy, resistant to rational maneuvers for its improvement, which yet continues to receive strong support from its practitioners. When a practice’s efficacy in achieving its goals is questionable and yet the practice persists, questions of its social functions arise which can only be addressed by qualitative research. This paper describes a normative model of peer review based on a qualitative profile of the attitudes of 72 peer reviewers towards the practice of manuscript peer review (obtained from extensive structured interviews). Masked by consensus amongst respondents about methods and goals were concerns centering on a series of contradictions inherent in the process. While at a practical level peer review was seen by respondents as a triage exercise, it was, at the same time, on a social level, valued as a mode of disciplinary discourse, important not only in the production of disciplinary knowledge, but also in the construction of the disciplinary identities of those who labor to bring that knowledge into being, i.e., the peers.

Objective: Peer review is considered crucial to the selection and publication of quality research, yet little is known of the values, beliefs and attitudes of peer reviewers towards the process of peer review. This study elicits reviewer beliefs about the process in order to produce a normative model of peer review. Methods and Findings: The 72 subjects were experienced reviewers at Annals of Emergency Medicine and had completed at least 5 reviews in the past 2 years. Subjects participated in 40 minute structured telephone interviews focusing on reviewer attitudes, beliefs and values towards the process of peer review. Subject responses were coded and categorized using grounded theory to produce a qualitative profile of reviewers' attitudes towards peer review and generate a normative model of the peer review process. This model was found to closely adhere to conventionally held beliefs 2 about the process of peer review. However, within it were revealed a number of areas where reviewers, aware of tensions within the process, questioned those conventional beliefs, expressing concern about methods, operations and outcomes. As researchers producing research and receiving reviews and as reviewers judging others’ research and producing reviews, the reviewer’s status as “peer” was seen as both essential to the operation of the system and problematic. In their perception of the role of the peer reviewer, though respondents identified evaluation of the manuscript (selecting submissions for publication by filtering out incorrect or inadequate work) as the primary goal of the formal process, instruction of the researcher (improving the accuracy, clarity and utility of published research) was considered by the majority of reviewers as the more important practice. Likewise, though there was recognition that the review process aims to prevent poor research from being published, there was more concern over the danger that it results in good research being “strangled in its cradle”. Though respondents believed that the quality of the review is determined primarily by the skills of the individual reviewer, they maintain that the validity of the process is determined by the corporate nature of the review panel acting as a system of checks and balances. Though perceiving this system of checks and balances as requiring a degree of separation of authorial, review and editorial functions, reviewers, at the same time, express the desire for a more open system of feedback leading towards a more consensual research outcome. Two issues of concern arose repeatedly in the interviews: frustration at a perceived lack of feedback from editors to reviewers and repeated condemnations of “mean-spirited” feedback from reviewers to authors. Defects in feedback were cited by respondents as a major barrier to optimizing research quality and editorial judgment. Conclusions: The tensions found in the peer review process, sometimes seen as barriers to its effective operation, are less defects in the process than definitive of the concept of peer review itself and thus necessary to its operation. While at a practical level peer review operates as a triage exercise, it is, at the same time, on a social level, a mode of disciplinary dialogue between peers: important not only to the maintenance of an effective knowledge base and thus disciplinary validity, but also, through its effect on researchers and reviewers, important in the construction of disciplinary identity. Peer review's practical and social operations are not antithetical to each other but rather are inherent in the hybrid concept of the peer reviewer, where one's status as a peer makes possible one's activity as reviewer.

Despite population-wide efforts to reduce tobacco use, low-income populations in the USA have much higher rates of tobacco use compared with the general population. The principal components of tobacco control policies in the USA include cigarette taxes, clean indoor air laws and comprehensive interventions to increase access to tobacco cessation services. In this review, we describe the effectiveness of these policies and interventions in reducing tobacco use among vulnerable populations, focusing on persons with mental health disorders and substance use disorders, persons who have experienced incarceration or homelessness, and low-income tenants of public housing. We discuss the challenges that evolving tobacco and nicotine products pose to tobacco control efforts. We conclude by highlighting the clinical implications of treating tobacco dependence in healthcare settings that serve vulnerable populations.

Difficulty performing activities of daily living ("functional impairment") is common in homeless adults aged 50 and older. However, little is known about the trajectory of these impairments, nor the extent to which these trajectories are similar to those of older adults in the general population. We identified trajectories of functional impairment in homeless adults aged 50 and older, and risk factors for differing trajectories. We conducted a prospective cohort study of 350 homeless adults, aged 50 and older, recruited via population-based sampling in Oakland, California and interviewed at 6-month intervals for up to 3 years. We assessed functional trajectories based on self-reported difficulty performing 5 activities of daily living. We used multivariable multinomial logistic regression to identify baseline risk factors for each trajectory. At baseline, participants' mean age was 58 years (SD, 5.3), 24.1% were women, 80.9% were African American, and 38.6% had difficulty performing 1 or more activities of daily living. We identified 4 distinct functional trajectories: minimal impairment in 136 participants (41.1%); persistent impairment in 81 (25.4%); partial improvement in 74 (23.5%); and decline in 28 (10.0%). Risk factors for persistent impairment included falls in the 6 months before baseline, depressive symptoms, and low physical performance. Although functional impairment improved in some homeless adults, it persisted or worsened in many others. These findings suggest that, similar to older adults in the general population, functional impairment among older homeless persons is not a transient phenomenon, but instead a chronic issue requiring long-term solutions.

Depression and food insecurity are prevalent among people with HIV (PLHIV) and contribute to poor HIV outcomes. Longitudinal data can help clarify the effect of food insecurity on depression among PLHIV in the United States. We assessed the longitudinal association of food insecurity with symptoms of depression using validated measures among participants living with HIV from the Research on Access to Care in the Homeless cohort in San Francisco. We followed 346 participants for a median of 28 months. Over half of participants (55.0 %) were food insecure and 35.8 % had symptoms of depression. In adjusted models, severe food insecurity in the previous period was associated with increased depressive symptom severity (b = 1.22; p < 0.001). The association remained statistically significant in models including participant fixed effects. Severe food insecurity was also longitudinally associated with a binary variable indicating probable depression. Efforts to increase access to and participation in food security safety net programs for PLHIV could improve depression.