ida oct 2014
TRANSCRIPT
Dr Will Stahl-Timmins
IDA talk Oct 2014
A PICTURE OF HEALTH Visualising medical research data
POTENTIAL MECHANISMS OF CHANGE / PROCESS OUTCOMES
SPIRITUALITYCHANGE IN PERSONAL / SOCIAL IDENTITY
SOCIAL CONTACT
BEING AWAY FROM STRESSORSRESTORATION / RECUPERATION
ACHIEVEMENT / CONTRIBUTION
KNOWLEDGE ACQUISITION
SELF-CONFIDENCE
ENJOYMENT/PLEASUREGOING INTO NATUREPHYSICAL ACTIVITY
WELLBEING AND THE ENVIRONMENT:POSSIBLE LINKS BETWEEN CONSERVATION ACTIVITIES AND HEALTH
ENVIRONMENTAL MODERATORS
ACTIVITY MODERATORS
MECHANISM MODERATORS
PERSONAL MEDIATORS
CHANGE IN SOCIAL / GROUP
COHESION
TYPE OF ENVIRONMENTAL
CHANGE
ENJOYMENT
ACHIEVEMENT(S)
DEVELOPMENTOF SOCIAL
CAPITAL
ACTIVITY TYPE /INTENSITY
TYPE
DEGREE OF ENVIRONMENTAL
CHANGE
QUIETNESS
FEATURES
CONTEXT(AWAY / NEAR)
TYPE OFENGAGEMENT
OTHERPARTICIPANTS
TYPE OF PROGRAMME (AIMS, OBJECTIVES, ETC.)
ENGAGEMENTROUTE(S)
EXPECTATIONS
FULFILMENT
MOTIVATIONS
PERSONALIDENTIFICATION
PERCEPTIONSOF SELF
SOCIALIDENTITY
PHYSICALABILITY
EXPECTATIONS
MENTALHEALTH
SOCIALFUNCTION
PHYSICALHEALTH
QUALITYOF LIFE
OTHERACTIVITIES
Nature of programmeE.g. GG VS Branching out
ENVIRONEMTAL ENHANCEMENT ACTIVITY
...
OUTCOMES
Physical health
Mental Health
Social function/
health
MODERATORS (e.g. personal/physical/environmental
characteristics)
MEDIATORS(e.g. psychological factors)
Social Contact
Hope, well informed futility
Engagement route
INDIVIDUAL
Personal characteristics (e.g. age…)
Programme Specifics (inc type of engagement)
Expectations
Perceptions of self/personal id
Social id
Spirituality
Knowledge acquisition (skills, employability, env knowledge)
ENVIRONMENTAL MODERATORS
TypeQuietnessFeatures
Going into nature
Restoration / recuperation
Being away from stressors
Spirituality
Achievement / contribution Altruism, responsibility
Environmental imporvment/change
Getting out of bed
Change in personal/social id (‘my place in the world’)
Physical Activity
Enjoyment/pleasure
MECHANISM MODERATORS
Type of env change
Achievement
Tranquillity
Social cohesion
Social capital
Enjoyment
Activity type/intensity
Fulfillment
MOTIVATIONS
PERSONALMEDIATORSFULFILMENT
SOCIALIDENTITYPHYSICALABILITY
EXPECTATIONSPERSONAL
IDENTIFICATIONPERCEPTIONS
OF SELF MOTIVATIONS
WELLBEING AND THE ENVIRONMENT: POSSIBLE LINKS BETWEEN CONSERVATION ACTIVITIES AND HEALTH
FROM:Husk K, Lovell R, Cooper C, Stahl-Timmins W, Garside R. Participation in environmental enhancement and conservation activities for health and well-being in adults. Cochrane Database of Systematic Reviews 2013.
PHYSICAL ACTIVITY
SELF-CONFIDENCE
GOING INTO NATURE
ENJOYMENT/PLEASURE
RESTORATION / RECUPERATION
BEING AWAY FROM STRESSORS
SOCIAL CONTACT
KNOWLEDGE ACQUISITION
ACHIEVEMENT / CONTRIBUTION
CHANGE IN PERSONAL / SOCIAL IDENTITY
SPIRITUALITY
MENTAL HEALTH
HEALTH-RELATED
OUTCOMES
SOCIAL FUNCTION
PHYSICAL HEALTH
POTENTIAL
MECHANISMS OF
CHANGE / PROCESS
OUTCOMES
MECHANISM MODERATORS
ENJOYMENT
ACTIVITY TYPE /
INTENSITY
CHANGE IN SOCIAL /
GROUP COHESIONDEVELOPMENT OF
SOCIAL CAPITAL
TYPE OF ENVIRON-
MENTAL CHANGE
ACHIEVEMENT(S)
ENVIRONMENTAL MODERATORSCONTEXT
(AWAY / NEAR)
DEGREE OF
ENVIRONMENTAL
CHANGE
FEATURES
TYPE
QUIETNESS
ACTIVITY MODERATORS
EXPECTATIONS
DEVELOPMENT OF
SOCIAL CAPITAL
OTHER
PARTICIPANTS
TYPE OF
PROGRAMME
(AIMS, OBJECTIVES
ETC.)
TYPE OF
ENGAGEMENT
ENGAGEMENT
ROUTE +QUALITY OF LIFE
MOTIVATIONS
PERSONALMEDIATORSFULFILMENT
SOCIALIDENTITYPHYSICALABILITY
EXPECTATIONSPERSONAL
IDENTIFICATIONPERCEPTIONS
OF SELF MOTIVATIONS
WELLBEING AND THE ENVIRONMENT: POSSIBLE LINKS BETWEEN CONSERVATION ACTIVITIES AND HEALTH
FROM:Husk K, Lovell R, Cooper C, Stahl-Timmins W, Garside R. Participation in environmental enhancement and conservation activities for health and well-being in adults. Cochrane Database of Systematic Reviews 2013.
PHYSICAL ACTIVITY
SELF-CONFIDENCE
GOING INTO NATURE
ENJOYMENT/PLEASURE
RESTORATION / RECUPERATION
BEING AWAY FROM STRESSORS
SOCIAL CONTACT
KNOWLEDGE ACQUISITION
ACHIEVEMENT / CONTRIBUTION
CHANGE IN PERSONAL / SOCIAL IDENTITY
SPIRITUALITY
MENTAL HEALTH
HEALTH-RELATED
OUTCOMES
SOCIAL FUNCTION
PHYSICAL HEALTH
POTENTIAL
MECHANISMS OF
CHANGE / PROCESS
OUTCOMES
MECHANISM MODERATORS
ENJOYMENT
ACTIVITY TYPE /
INTENSITY
CHANGE IN SOCIAL /
GROUP COHESIONDEVELOPMENT OF
SOCIAL CAPITAL
TYPE OF ENVIRON-
MENTAL CHANGE
ACHIEVEMENT(S)
ENVIRONMENTAL MODERATORSCONTEXT
(AWAY / NEAR)
DEGREE OF
ENVIRONMENTAL
CHANGE
FEATURES
TYPE
QUIETNESS
ACTIVITY MODERATORS
EXPECTATIONS
DEVELOPMENT OF
SOCIAL CAPITAL
OTHER
PARTICIPANTS
TYPE OF
PROGRAMME
(AIMS, OBJECTIVES
ETC.)
TYPE OF
ENGAGEMENT
ENGAGEMENT
ROUTE +QUALITY OF LIFE
PERSONALMEDIATORS
FULFILMENT
EXPECTATIONS
PERSONAL
IDENTIFICATION
PERCEPTIONSOF SELF
MOTIVATIONS
WELLBEING AND THE ENVIRONMENT: POSSIBLE LINKS BETWEEN CONSERVATION ACTIVITIES AND HEALTH
FROM:Husk K, Lovell R, Cooper C, Stahl-Timmins W, Garside R. Participation in environmental enhancement and conservation activities for health and well-being in adults. Cochrane Database of Systematic Reviews 2013.
SOCIALIDENTITYPHYSICALABILITY
PHYSICAL ACTIVITY
SELF-CONFIDENCE
GOING INTO NATURE
ENJOYMENT/PLEASURE
RESTORATION / RECUPERATION
BEING AWAY FROM STRESSORS
SOCIAL CONTACT
KNOWLEDGE ACQUISITION
ACHIEVEMENT / CONTRIBUTION
CHANGE IN PERSONAL / SOCIAL IDENTITY
SPIRITUALITY
MENTAL HEALTH
HEALTH-RELATED
OUTCOMES
SOCIAL FUNCTION
PHYSICAL HEALTH
POTENTIAL
MECHANISMS OF
CHANGE / PROCESS
OUTCOMES
MECHANISM MODERATORS
ENJOYMENT
ACTIVITY TYPE /
INTENSITY
CHANGE IN SOCIAL /
GROUP COHESIONDEVELOPMENT OF
SOCIAL CAPITAL
TYPE OF ENVIRON-
MENTAL CHANGE
ACHIEVEMENT(S)
ENVIRONMENTAL MODERATORSCONTEXT
(AWAY / NEAR)
DEGREE OF
ENVIRONMENTAL
CHANGE
FEATURES
TYPE
QUIETNESS
ACTIVITY MODERATORS
EXPECTATIONS
DEVELOPMENT OF
SOCIAL CAPITAL
OTHER
PARTICIPANTS
TYPE OF
PROGRAMME
(AIMS, OBJECTIVES
ETC.)
TYPE OF
ENGAGEMENT
ENGAGEMENT
ROUTE +QUALITY OF LIFE
POTENTIAL MECHANISMS OF CHANGE / PROCESS OUTCOMES
SPIRITUALITYCHANGE IN PERSONAL / SOCIAL IDENTITY
SOCIAL CONTACT
BEING AWAY FROM STRESSORSRESTORATION / RECUPERATION
ACHIEVEMENT / CONTRIBUTION
KNOWLEDGE ACQUISITION
SELF-CONFIDENCE
ENJOYMENT/PLEASUREGOING INTO NATUREPHYSICAL ACTIVITY
WELLBEING AND THE ENVIRONMENT:POSSIBLE LINKS BETWEEN CONSERVATION ACTIVITIES AND HEALTH
ENVIRONMENTAL MODERATORS
ACTIVITY MODERATORS
MECHANISM MODERATORS
PERSONAL MEDIATORS
CHANGE IN SOCIAL / GROUP
COHESION
TYPE OF ENVIRONMENTAL
CHANGE
ENJOYMENT
ACHIEVEMENT(S)
DEVELOPMENTOF SOCIAL
CAPITAL
ACTIVITY TYPE /INTENSITY
TYPE
DEGREE OF ENVIRONMENTAL
CHANGE
QUIETNESS
FEATURES
CONTEXT(AWAY / NEAR)
TYPE OFENGAGEMENT
OTHERPARTICIPANTS
TYPE OF PROGRAMME (AIMS, OBJECTIVES, ETC.)
ENGAGEMENTROUTE(S)
EXPECTATIONS
FULFILMENT
MOTIVATIONS
PERSONALIDENTIFICATION
PERCEPTIONSOF SELF
SOCIALIDENTITY
PHYSICALABILITY
EXPECTATIONS
MENTALHEALTH
SOCIALFUNCTION
PHYSICALHEALTH
QUALITYOF LIFE
OTHERACTIVITIES
Stahl-Timmins, W.; Redshaw, C.; White, M.P.; Fleming, L.; Depledge, M.H. 2013. The Pharma Transport Town: Understanding the Routes to Sustainable Pharmaceutical Use. Science, 339(6119) pp 514-515.
VETERINARY USE
PHARMACEUTICAL
COMPANIES,
MANUFACTURERS
& DISTRIBUTERS
PHARMACY
SPILLS
PROMOTION
HEALTHPROFESSIONALS
MEDICALLITERATURE
EDUCATION
PEOPLEAT HOME
DEMAND
USE
PRESCRIPTIONS
BODY
NON-USE SINK
TOILET
FISH
MEAT
CROPS
HOUSEHOLDWASTE
DISPOSAL
RETURN TOPHARMACY
WASTE WATER TREATMENT
METABOLISM
BIOSOLIDS
SPREAD ON LAND
RUN-OFF
LANDFILL
LEACHATELEACHATE
WATERABSTRACTION
& TREATMENT
SURFACE WATER
EXFILTRATION EXFILTRATION
LEACHATEEXTRACTION
RETURNED ITEMS
INCINERATED
MANUFACTURINGWASTE
LEAKS
LEACHATE
INCINERATION
FARMANIMALSRUN-OFF
IRRIGATION
GROUND WATER
LEAKS
FATE 2 – INCINERATION
INFLUENCE
PHARMACEUTICAL TRANSPORTINTO ENVIRONMENT
High temperature incineration (above 1200°C) is viewed as the safest disposal route for unwanted pharmaceuticals (particularly those with high halogen content). Unfortunately, high temperature incineration is expensive and in some situations only medium temperature incinerators (above 850°C) are available.
AIR POLLUTION
PROMOTIONAL INFLUENCESThe pharmaceutical industry spends billions of dollars annually promoting its products9. This plays an important role in raising medical professionals’ awareness and potentially improving clinical outcomes. However, the pathways of promotional influences are not always recognised. Direct-to-consumer advertising and promotional gifts to physicians, neither of which should influence clinical decision making, have been shown to influence prescription rates and thus, indirectly, the amount of chemicals entering the environment.10
REFERENCE LITERATUREThere are many different sources that health professionals use for reference when prescribing, including national formularies, pub-lished guidance, mobile phone apps, and others. However, the published scientific evidence on which such resources are based are sometimes funded by the pharmaceutical industry.11 Those who receive such funding are more likely to report favorable re-sults in the academic press than independent researchers.12,13
TRAINING AND EDUCATIONEducation can be an important way of encouraging responsible and effective prescibing practice. Health professionals’ attitudes towards the pharmaceutical industry and their products are formed during training.14 Restricting contact with pharmaceutical industry representatives during this time can attenuate positive attitudes towards the industry15 and may subsequently reduce promotional influence on prescription rates.16
NON-USEMany individuals do not take all, or even any, of their prescribed medication. Reasons include forgetting, reluctance, thinking them no longer necessary, side-effects and being ‘out of date’.17,18 Forgetting can be tackled using simple psychological techniques.19 In the UK it is estimated that 63% of unused medication is disposed of via household waste, 12% via the sink or toilet and only 22% are returned to pharmacies for safe disposal.20 Similarly low rates of safe disposal are reported in the US.21
KEY
BIOAVAILABILITY?We have an understanding of pharmaceutical transport around our environment, from our homes to waterways, aquatic organisms, fields and therefore potentially crops and/or animals. However, we lack knowledge about whether these compounds could be transferred to the consumer and if they have the same effect as taking medication.
This graphic illustrates the complex movement of pharmaceuticals around our social and physical environments, cycling endlessly.
Legislative pyramids24 provide a hierarchy of management strategies for waste reduction (reducing in sustainability down the pyramid). This concept could be used to limit environmental contamination by pharmaceuticals.
ROUTES TO SUSTAINABILITY
FATE 4 – DOWNSTREAMOnce pharmaceuticals have entered the environment they can continue to be transported via our waterways to other towns and eventually the sea. Some pharmaceuticals have even been found as far away as the arctic!
FATE 1 – METABOLISMWhen drugs are consumed, a proportion of the drug interacts or binds with a receptor in the body, which causes a biological response. The body transforms the remaining compound into a more water soluble form, allowing it to be excreted. Pharmaceuticals can be excreted as parent compounds (the drug consumed) or metabolites, in urine or faeces. In some cases an excreted metabolite can be as bioactive as the parent compound, such as Norfluoxetine, the metabolite of Fluoxetine HCl (Prozac®).
DRINKING WATERWater treatment processes vary across the world; with water for processing sourced from groundwater, surface water or from waste water treatment plants. As pharmaceuticals are present in all these compartments, the presence of drugs in our drinking water is of little surprise.22,23
FATE 3 – LOSSES
BIODEGRADATION
SORPTION
Degradation is the term used to describe the breakdown of a chemical into smaller component compounds or elements. Usually only partial degradation occurs (where specific chemical sub-structures are lost). Total degradation of a pharmaceutical to its elements, also termed complete mineralisation, is uncommon.
or biotic degradation, involves metabolism of pharmaceuticals by a biological organism, such as bacteria - and does occur in almost all parts of this transport system. However many pharmaceuticals are stable com-pounds, that are resistant to biodegradation and therefore persist in the environment.
is the process by which compounds become associated with another substance via absorption (permeation of a substance by another) or adsorption (surface assimila-tion of one substance upon another). This is a process often seen in high organic content materials such as soil and sewage sludge.
ROUTES BACK TO PEOPLE
BACKGROUNDThere are growing concerns about the ubiquitous presence of pharmaceuticals in the environment1, especially when coupled with knowledge of the dramatic impacts individual drugs and mixtures can have upon biota2,3 - such as antibiotic resistance4,5 and endocrine disruption6.
As future pharmaceutical usage is predicted to rise, due to a number of reasons including the aging demographic, availability of generics and global epidemics, such as obesity and bird-flu7, it is essential that we begin to take steps towards limiting environmental contamination.
This information graphic poster shows the complex system of pharmaceutical transport around the areas in which we live (adapted from PetroviDž et al.8). It also shows influence routes, suggesting possible points of intervention to begin to address the problems associated with environmental pharmaceutical pollution.
The quantities of waste that can be incinerated are limited by the amount of air pollution that is considered safe - and depends on other sources of air pollution in the area.
REFERENCES1 Kallenborn, R. et al. in Pharmaceuticals in the Environment: Sources, Fate, Effects and Risks (ed K. Kummerer) 61–74 (Springer, 2008)2 Gilbert, N. Drug waste harms fish. Nature 476, 265 (2011).3 Taggart, M. A. et al. Diclofenac residues in carcasses of domestic ungulates available to vultures in India. Environ. Int. 33, 759-765
(2007).4 MALIK, A. & AHMAD, M. 1994. Incidence of drug and metal resistance in E. coli strains from sewage water and soil. Chem Environ Res,
3, 3-11. And RADTKE, T., M. & GIST, G., L. 1989. Wastewater sludge disposal - antibiotic resistant bacteria may pose health hazard. journal of Environmental Health, 52, 102-105
5 Plano et al. BMC Microbiology 2011, 11:5 http://www.biomedcentral.com/1471-2180/11/56 PORTER, W. P., JAEGER, J. W. & CARLSON, I. H. 1999. Endocrine, immune, and behavioral effects of aldicarb (carbamate), atrazine
(triazine) and nitrate (fertilizer) mixtures at groundwater concentrations. Toxicology and Industrial Health, 15, 133-150.
7 Depledge, M. 2011. Pharmaceuticals: Reduce drug waste in the environment. Nature 478:7367, 36.8 Petrovic, M., Gonzales, S., Barcelo, D. 2003. Analysis and removal of emerging contaminants in wastewater and drinking water. Trends
in Analytical Chemistry, v 22, n 10, p685-6969 Mintzes, B. (2002). Direct to consumer advertising is medicalising normal human experience. BMJ. 2002 April 13; 324(7342): 908–911.
10 Moynihan R & Henry D (2006) The fight against disease mongering: Generating knowledge for action. PLoS Med 3(4): e191.11 Wazana A. Physicians and the pharmaceutical industry, is a gift ever just a gift? JAMA 2000;283:373-80.12 Bodenheimer, T. et al. (2000). Uneasy Alliance — Clinical Investigators and the Pharmaceutical Industry. N Engl J Med; 342:1539-1544. 13 Stelfox, H.T., Chua, G., O’Rourke, K. & Detsky, A.S. (1998). Conflict of Interest in the Debate over Calcium-channel antagonists. N Engl J
Med 1998; 338:101-106114 Friedberg M, et al (1999). Evaluation of conflict of interest in economic analyses of new drugs used in oncology. JAMA; 282:1453-7.15 Monaghan, M.S. et al. (2003): Student Understanding of the Relationship Between the Health Professions and the Pharmaceutical
Industry. Teach & Learning in Medicine, 15:1, 14-20
16 McCormick BB, et al. (2001). Effect of restricting contact between pharmaceutical company representatives and internal medicine residents on posttraining attitudes and behavior. JAMA;286:1994–9
17 Benson, J. & Britten, N (2002). Patients' decisions about whether or not to take antihypertensive drugs: qualitative study. BMJ, 2002;325:873.1
18 Cooper et al. (2007). Why people do not take their psychotropic drugs as prescribed: results of the 2000 National Psychiatric Morbidity Survey. Acta Psychiatrica Scandinavica, 16(1), 47–53.
19 Gollwitzer, P. M., & Sheeran, P. (2006). Implementation intentions and goal achievement: A meta-analysis of effects and processes. Advances in Experimental Social Psychology, 38, 69-119.
20 Bound, J.P. & Voulvoulis, N. (2005). Household disposal of pharmaceuticals as a pathway for aquatic contamination in the United Kingdom. Environmental Health Perspectives, 113, 1705-1711.
21 Glassmeyer, S.T., Hinchey, E.K., Boehme, S.E. et al (2009). Disposal practices for unwanted residential medications in the United States. Environmental International, 35, 566-572.
22 World Health Organisation. Pharmaceuticals in drinking water. (2011). 23 Official Journal of the European Union. DIRECTIVE 2008/98/EC OF THE EUROPEAN PARLIAMENT AND OF THE COUNCIL of 19 Novem-
ber 2008 on waste and repealing certain Directives 22.11.2008. L 312/3
24 Mark J. Benotti et al.Pharmaceuticals and Endocrine Disrupting Compounds in U.S. Drinking Water Environ. Sci. Technol., 2009, 43 (3), pp 597–603
25 Kümmerer, K, and Hempel, M (Eds) 2010 Green and Sustainable Pharmacy Springer, pp 313.26 Brother’s Brother Foundation, http://www.brothersbrother.org/medical.htm [accessed 28 sep 2012].27 Gospel Medical Mission International, http://gospelmedical.org/ [accessed 28 sep 2012].28 Owen, R, and Jobling, S, 2012 Environmental science: The hidden costs of flexible fertility. Nature, 485 (7399) 441-441.29 Kim, I, and Tanaka, H, 2010 Use of Ozone-Based Processes for the Removal of Pharmaceuticals Detected in a Wastewater Treatment
Plant. Water Environment Research, 82 (4) 294-301.
PHOTODEGRADATIONis a form of abiotic degradation, which can be important for the breakdown of pharmaceuti-cals, particularly in surface waters and during some waste water treatment processes. Absorption of radiant energy (photons), such as those in sunlight, by a compound results in photochemical transformation of the compound into smaller fragments.
BIOACCUMULATIONof pharmaceuticals can occur in organisms in the environment. Where a drug has a higher affinity for the chemical properties of particular tissues (e.g. fat) than it does the surrounding environment, it can become concentrated in an organism.
REDUCE
REUSE
RECYCLE
RECLAIM
REMOVE
Widespread acceptance of medical donation programmes26,27 would result in greater reuse of drugs and could be facilitated by use of smaller packaging.
The challenge of finding ways in which drugs could be recycled (processing of unwanted drugs, recovery of ‘usable’ compounds and subsequent product manu-facture) lies with the chemical industry.
Reclamation of pharmaceuticals (most likely at the waste water treatment works), followed by purification and reuse of drugs expensive to produce, could in theory be implemented alongside removal programmes.
Removal programmes could incorporate capture and destroy approaches (e.g. granular activated carbon28),
chemical transformation processes (e.g. ozone processing29), or could seek to maximise natural degradation processes by optimisation of treatment e.g. identifying, isolating and seeding with drug-degrading bacterial strains.
Upstream interventions should be the highest priority. Green pharmacy, which seeks to develop specific targeted drugs and/or more effective delivery mechanisms, has the potential to reduce the
dosages required.25 Also, education of consumers and
prescribers could result in more appropriate disposal and reduce
unnecessary prescribing.
THE PHARMA TRANSPORT TOWN:Dr Will Stahl-Timmins | Dr Mathew White | Prof Michael Depledge | Prof Lora Fleming | Dr Clare Redshaw
UNDERSTANDING THE ROUTES TO SUSTAINABLE PHARMACEUTICAL USE Funded by:EUROPEAN UNIONInvesting in Your Future
European Regional
Development Fund 2007-13
WINNERPEOPLE’S CHOICEPOSTERS & GRAPHICS
INTERNATIONAL SCIENCE AND ENGINEERING VISUALIZATION CHALLENGE 2012
AS PUBLISHEDIN 1 FEBRUARY 2013VOL 339, ISSUE 6119 PAGE 515
SCIENCE:
Title
Able Baker et al. 2010
Dogg's Hamlet 2009
Echo Bazaar 2006
Gender
M F
M F
M F
M F
Ages Sites
?
Features Outcomes
N=50
N=150
N=25
Design
Control N=28
500mg N=22
Health Technology Assessment 2009; Vol. 13: No. 44
Health Technology AssessmentNIHR HTA programmewww.hta.ac.uk
September 2009DOI: 10.3310/hta13440
The effectiveness and cost-effectiveness of cochlear implants for severe to profound deafness in children and adults: a systematic review and economic model
M Bond, S Mealing, R Anderson, J Elston, G Weiner, RS Taylor, M Hoyle, Z Liu, A Price and K Stein
33 studies
children and adults
multiple comparisons- 1 vs NT- 1 vs AHA- 1 vs 2- 1+AHA vs 2
broad range ofnon-randomisedstudy designs
62 outcome measures
Task-based cognitive interviewing
Speak-aloud protocol
9 expert users (HTA systematic reviewers)
Randomised, sequencial comparison to report
Quantitative results (time and accuracy)
Qualitative results (actions and words of participants - framework analysis)
GOfER test
TASK
1reportgivenfirst
graphicgivenfirst
TASK
2TASK
3TASK
4
TASK
5TASK
6TASK
7TASK
8TASK
1TASK
2TASK
3TASK
4
TASK
5TASK
6TASK
7TASK
8TASK
9TASK
10TASK
11TASK
12
Randomised, crossover design
12 tasks
COGSReport
Mean task time
(% of total task time)
20%
15%
10%
5%
0%
Error Bars: 95% CI
two-sample t(69) = 4.4p < 0.001
task accuracy !
COGS: 74.3%report: 46.4%
!
!
!c2 (1, N = 63) = 5.12, p = 0.024
Task 3: Which trials used the Lexical Neighbourhood Test (LNT)?
1 4 5 8 9 2 3 6 7
6.3% 6.4%
11.2%
8.0%
11.5%9.4%
14.8%
8.3% 9.1%
COGS display report section
Intervention N = 29
Control N = 20
cross-sectionaldesign (no follow-up)
Intervention N = 29
Control N = 205 year follow-up
Intervention N = 29
Control N = 2012 year follow-up
0 yrslength of follow-up
5 10 10
55 75 95
ADAS
-cog
MM
SE SIB
othe
rAD
CS-A
DL
DAD PDS
othe
rNPI
othe
rCI
BIC
GD
SCD
RAD
CS-C
GIC
QoLauthor ageslocation
design, size & follow-up
studyquality
cog
0yr 1 2
no. ofcentres
0 10 20 30
baselineMMSE sex
outcome measures usedfunc be glo
55 75 95
ADAS
-cog
MM
SESIB
othe
rAD
CS-A
DL
DAD
PDS
othe
rNPI
othe
rCI
BIC
GD
SCD
RAD
CS-C
GIC
QoL
0yr 1 2 0 10 20 30 cog func be glo
N = 161
Donepezil 1mg N = 42 M FRandCharBlindAnaly
N = 473
M F
M F
RandCharBlindAnaly
M F
M F
RandCharBlindAnaly
Rogers et al.
1998 (B)
Rogers &
1996? Donepezil 3mg N = 40
Donepezil 5mg N = 39Placebo N = 40
Donepezil 5mg N = 154
Placebo N = 162
N = 468
Donepezil 5mg N = 157
Placebo N = 153
M FM FM F
Rogers et al.
1998 (A)Donepezil 10mg N = 157
M F
Donepezil 10mg N = 158M F
M F
M F
RandCharBlindAnaly
M FM F
RandCharBlindAnaly
M F
M F
RandCharBlindAnaly
M F
M F
RandCharBlindAnaly
N = 818
Donepezil 5mg N = 271
Placebo N = 274
N = 60
Donepezil 5mg (D)
Placebo (p)
N = 268
Donepezil 5mg N = 134
Placebo N = 129
N = 431
Donepezil 10mg N = 214
Placebo N = 217
Burns et al.
1999
Greenberg et al.
2000
Homma et al.
2000
Mohs et al.
2001
Donepezil 10mg N = 273M F
group 1 (p-D-p-p) N=30group 2 (p-p-D-p) N=30
1mg3mg5mg
5mg
10mg
5mg10mg
5mg10mg
Seeing is BelievingRandomised, controlled study
Measuring impact of visualisation on knowledge and risk perception
Quota sample, using online market research panel (926 participants)
Working Group II Report impacts, Adaptation and Vulnerability !Chapter 8 Human Health
FLOODS AND STORMSGL
OBAL
TRE
NDS
FLOO
D CA
USES
HEAL
TH IM
PACT
S
CLIMATE CHANGE
STORMS
DEATH & INJURY
CASE STUDY 1: BANGLADESH
ASSUMPTIONS
Global temperature rise
Global Sea level rise
Increase in monsoon rains
Increase in monsoondischarge into rivers
People affected
Flooding depth
2°c
30cm
18%
5%
4.8%
30–90cm
4°c
100cm
33%
10%
57%
90–180cm
If human activity continues to warm global temperatures,countries like Bangladesh are likely to see more flooding.
CASE STUDY 2: USAStudies in industrialised countries indicate that densely populated urban areas are at risk from sea-level rise.
INFECTIOUSDISEASES
TOXIC CON-TAMINATION
MENTALHEALTH
RAINFALL EVAPORATIONSEA LEVEL SURFACERUN-OFF
LOCALTOPOGRAPHY
URBANISATION
190019502005
FUTU
RE C
HANG
ES
FLOODS
The majority of climate scientists agree that human activity is causing temperatures to rise around the world. As these higher temperatures free water that is usually frozen at the poles, sea levels are rising. Increased temeratures also lead to more evaporation of water from seas and lakes. This can lead to increased rainfall and greater numbers of storms, cyclones and extreme weather events.
Coastal regions are more vulnerable to flooding as sea levels rise.
Extreme rainfall can overwhelm rivers and lakes, causing them to flood.
Drowning by storm surge is the major killer in coastal storms.
Global warming and changes in land use (like urbanisation) affect how much water is carried in the air.
Urbanisation can affect how much excess water can be absorbed into the ground.
Sometimes, the shape of the land can make areas vulnerable to flooding.
The number of people living in cities is growing, particularly in low income countries.
= 100m people in towns or cities
Floods are low-probability, high-impact events that can overwhelm physical infrastructure, human resilience and social organisation.
Floods are the most frequent natural weather disaster. This informationgraphic shows some of the causes and health impacts of floods, and
shows how the number and severity of floods may increase in the future.
LATIN AMERICA
SOUTH ASIA
MICRONESIA
BAY OF BENGAL(particularly atrisk from stormsurges)
VULNERABLE PEOPLE
Those living in Low lying places(especially thosewith high density)
One-quarter of the world’s population resides within 100 km distance and 100 m elevation of the coastline.
In the USA, lower-income groups were most affected by Hurricane Katrina in 2005.
Such as children, theinfirm, or those livingin sub-standard housing.
Poorer communities
Those with limitedability to escape
VULNERABLE PLACES
THE NORTHSEA COAST
SEYCHELLES
THE GULFCOAST
THE NILEDELTA
GULF OFGUINEA
Deaths recorded in disaster databases are from drowning and severe injuries.
Improved warnings have decreased mortality from floods and storm surges in the last 30 years; however, the impact of weather disasters in terms of social and health effects is still considerable and is unequally distributed, particularly affecting women.
VENEZUELA
MOZAMBIQUE
CHINA
1999
2000/2001
2003
30,000 DEAD
1,813 DEAD
130m AFFECTED
Particularly inplaces withpoor sanitation:
From storage orfrom chemicalsalready in theenvironment:
Insufficientlyinvestigated,but may include:
Diarrhoealdiseases
Cholera
Cryptosporidiosis
Typhoid fever
Oil
Pesticides
Heavy metals
Hazardouswaste
Post-traumaticstress
Behaviouraldisorders inchildren
Anxiety?
Depression?
LIKELY EFFECTS
2.5–4m belowsea level by 2100
NEW ORLEANS (USA)
1.5–3m belowsea level now
This would mean that a storm surge from a Category 3 hurricane (estimated at 3 to 4 m without waves) could be 6 to 7 m above areas that were heavily populated in 2004.
Mid-range estimate of 48 cm sea level rise by 2100 plussubsidence
FLOODS AND STORMSGL
OBAL
TRE
NDS
FLOO
D CA
USES
HEAL
TH IM
PACT
S
CLIMATE CHANGE
STORMS
DEATH & INJURY
CASE STUDY 1: BANGLADESH
ASSUMPTIONS
Global temperature rise
Global Sea level rise
Increase in monsoon rains
Increase in monsoondischarge into rivers
People affected
Flooding depth
2°c
30cm
18%
5%
4.8%
30–90cm
4°c
100cm
33%
10%
57%
90–180cm
If human activity continues to warm global temperatures,countries like Bangladesh are likely to see more flooding.
CASE STUDY 2: USAStudies in industrialised countries indicate that densely populated urban areas are at risk from sea-level rise.
INFECTIOUSDISEASES
TOXIC CON-TAMINATION
MENTALHEALTH
RAINFALL EVAPORATIONSEA LEVEL SURFACERUN-OFF
LOCALTOPOGRAPHY
URBANISATION
190019502005
FUTU
RE C
HANG
ES
FLOODS
The majority of climate scientists agree that human activity is causing temperatures to rise around the world. As these higher temperatures free water that is usually frozen at the poles, sea levels are rising. Increased temeratures also lead to more evaporation of water from seas and lakes. This can lead to increased rainfall and greater numbers of storms, cyclones and extreme weather events.
Coastal regions are more vulnerable to flooding as sea levels rise.
Extreme rainfall can overwhelm rivers and lakes, causing them to flood.
Drowning by storm surge is the major killer in coastal storms.
Global warming and changes in land use (like urbanisation) affect how much water is carried in the air.
Urbanisation can affect how much excess water can be absorbed into the ground.
Sometimes, the shape of the land can make areas vulnerable to flooding.
The number of people living in cities is growing, particularly in low income countries.
= 100m people in towns or cities
Floods are low-probability, high-impact events that can overwhelm physical infrastructure, human resilience and social organisation.
Floods are the most frequent natural weather disaster. This informationgraphic shows some of the causes and health impacts of floods, and
shows how the number and severity of floods may increase in the future.
LATIN AMERICA
SOUTH ASIA
MICRONESIA
BAY OF BENGAL(particularly atrisk from stormsurges)
VULNERABLE PEOPLE
Those living in Low lying places(especially thosewith high density)
One-quarter of the world’s population resides within 100 km distance and 100 m elevation of the coastline.
In the USA, lower-income groups were most affected by Hurricane Katrina in 2005.
Such as children, theinfirm, or those livingin sub-standard housing.
Poorer communities
Those with limitedability to escape
VULNERABLE PLACES
THE NORTHSEA COAST
SEYCHELLES
THE GULFCOAST
THE NILEDELTA
GULF OFGUINEA
Deaths recorded in disaster databases are from drowning and severe injuries.
Improved warnings have decreased mortality from floods and storm surges in the last 30 years; however, the impact of weather disasters in terms of social and health effects is still considerable and is unequally distributed, particularly affecting women.
VENEZUELA
MOZAMBIQUE
CHINA
1999
2000/2001
2003
30,000 DEAD
1,813 DEAD
130m AFFECTED
Particularly inplaces withpoor sanitation:
From storage orfrom chemicalsalready in theenvironment:
Insufficientlyinvestigated,but may include:
Diarrhoealdiseases
Cholera
Cryptosporidiosis
Typhoid fever
Oil
Pesticides
Heavy metals
Hazardouswaste
Post-traumaticstress
Behaviouraldisorders inchildren
Anxiety?
Depression?
LIKELY EFFECTS
2.5–4m belowsea level by 2100
NEW ORLEANS (USA)
1.5–3m belowsea level now
This would mean that a storm surge from a Category 3 hurricane (estimated at 3 to 4 m without waves) could be 6 to 7 m above areas that were heavily populated in 2004.
Mid-range estimate of 48 cm sea level rise by 2100 plussubsidence
GLOB
AL T
REND
SFL
OOD
CAUS
ESHE
ALTH
IMPA
CTS
STORMS
DEATH & INJURY INFECTIOUSDISEASES
TOXIC CON-TAMINATION
RAINFALL EVAPORATIONSEA LEVEL SURFACERUN-OFF
190019502005
FLOODS
This can lead to increased rainfall and greater numbers of storms, cyclones and extreme weather events.
Coastal regions are more vulnerable to flooding as sea levels rise.
Extreme rainfall can overwhelm rivers and lakes, causing them to flood.
Drowning by storm surge is the major killer in coastal storms.
Global warming and changes in land use (like urbanisation) affect how much water is carried in the air.
Urbanisation can affect how much excess water can be absorbed into the ground.
LATIN AMERICA
SOUTH ASIA
MICRONESIA
BAY OF BENGAL(particularly atrisk from stormsurges)
VULNERABLE PEOPLE
Those living in Low lying places(especially thosewith high density)
One-quarter of the world’s population resides within 100 km distance and 100 m elevation of the coastline.
In the USA, lower-income groups were most affected by Hurricane Katrina in 2005.
Such as children, theinfirm, or those livingin sub-standard housing.
Poorer communities
Those with limitedability to escape
VULNERABLE PLACES
THE NORTHSEA COAST
SEYCHELLES
THE GULFCOAST
THE NILEDELTA
GULF OFGUINEA
Deaths recorded in disaster databases are from drowning and severe injuries.
VENEZUELA
MOZAMBIQUE
CHINA
1999
2000/2001
2003
30,000 DEAD
1,813 DEAD
130m AFFECTED
Particularly inplaces withpoor sanitation:
From storage orfrom chemicalsalready in theenvironment:Diarrhoeal
diseases
Cholera
Oil
Pesticides
KEY MEAN& 95% CI
ANOVASIGNIFICANT
(P < 0.05)
ANOVA NOTSIGNIFICANT
(P > 0.05)
CONTROLCONDITION
TEXTCONDITION
GRAPHICCONDITION
6
5
3
4
RISK GROUP 1:STORMS & FLOODS
RISK GROUP 2:AIR QUALITY
dmean
approval
KEY MEAN& 95% CI
ANOVASIGNIFICANT
(P < 0.05)
ANOVA NOTSIGNIFICANT
(P > 0.05)
CONTROLCONDITION
TEXTCONDITION
GRAPHICCONDITION
6 mins
3 mins
RISK GROUP 1:STORMS & FLOODS
RISK GROUP 2:AIR QUALITY
mean viewtime (log10)
a b
KEY MEAN& 95% CI
ANOVASIGNIFICANT
(P < 0.05)
ANOVA NOTSIGNIFICANT
(P > 0.05)
CONTROLCONDITION
TEXTCONDITION
GRAPHICCONDITION
80%
70%
60%
RISK GROUP 1:STORMS & FLOODS
RISK GROUP 2:AIR QUALITY
d
meanknowledge
KEY MEAN& 95% CI
ANOVASIGNIFICANT
(P < 0.05)
ANOVA NOTSIGNIFICANT
(P > 0.05)
CONTROLCONDITION
TEXTCONDITION
GRAPHICCONDITION
28
21
14
RISK GROUP 1:STORMS & FLOODS
RISK GROUP 2:AIR QUALITY
cmean risk
perception
KEY MEAN& 95% CI
ANOVASIGNIFICANT
(P < 0.05)
ANOVA NOTSIGNIFICANT
(P > 0.05)
CONTROLCONDITION
TEXTCONDITION
GRAPHICCONDITION
KEY MEAN& 95% CI
ANOVASIGNIFICANT
(P < 0.05)
ANOVA NOTSIGNIFICANT
(P > 0.05)
CONTROLCONDITION
TEXTCONDITION
GRAPHICCONDITION
meanknowledge
(baseline)
KEY MEAN& 95% CI
ANOVASIGNIFICANT
(P < 0.05)
ANOVA NOTSIGNIFICANT
(P > 0.05)
CONTROLCONDITION
TEXTCONDITION
GRAPHICCONDITION
(time 2)
meanknowledge
KEY MEAN& 95% CI
ANOVASIGNIFICANT
(P < 0.05)
ANOVA NOTSIGNIFICANT
(P > 0.05)
CONTROLCONDITION
TEXTCONDITION
GRAPHICCONDITION
meanrisk perception
(baseline)
KEY MEAN& 95% CI
ANOVASIGNIFICANT
(P < 0.05)
ANOVA NOTSIGNIFICANT
(P > 0.05)
CONTROLCONDITION
TEXTCONDITION
GRAPHICCONDITION
meanrisk perception
(time 2)
control graphictext
Mean knowledge
80%
70%
60%
50%
Error Bars: 95% CI
18-2
728
-37
38-4
748
-57
58-6
768
-77
18-2
728
-37
38-4
748
-57
58-6
768
-77
18-2
728
-37
38-4
748
-57
58-6
768
-77Age
group:
Conclusions
- This type of box / arrow diagram can be used to communicate information on climate change health impacts in less time and more effectively than using text, for this audience.
- The technique might be used to effectively present other non-linear narratives.
- Non-linear information graphics like this could be particularly useful for younger audiences
- The study suggests that understanding the mechanisms for climate change health impacts could increase risk awareness.
Limitations
-Questions asked only test limited knowledge.
-Captive audience - doesn’t investigate whether information graphics also attract attention.
-Higher drop-out in experimental conditions.
– More in high socio-economic status groups than national average
– Only surveys internet users
INTERACTIVE
Dr Will Stahl-Timmins
blog.willstahl.com
Twitter: @will_s_t
www.thebmj.com
Software:
Presentation software Illustrator InDesign !
Premiere Flash !
Processing / D3 PhP / HTML5 Other programming languages
Stills {Motion}
Interactive {
Stahl- Timmins, W.; Pitt, M. & Peters, J.
2010.
Graphical presentation of data for health policy decisions: An exploratory online decision task experiment to measure effectiveness.
Information Design Journal 18:3.