ida oct 2014

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)


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


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



CHANGE IN PERSONAL / SOCIAL IDENTITY

SPIRITUALITY

MENTAL HEALTH

HEALTH-RELATED

OUTCOMES

SOCIAL FUNCTION

PHYSICAL HEALTH

POTENTIAL

MECHANISMS OF

CHANGE / PROCESS

OUTCOMES


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



CHANGE IN PERSONAL / SOCIAL IDENTITY

SPIRITUALITY

MENTAL HEALTH

HEALTH-RELATED

OUTCOMES

SOCIAL FUNCTION

PHYSICAL HEALTH

POTENTIAL

MECHANISMS OF

CHANGE / PROCESS

OUTCOMES


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



SELF-CONFIDENCE

ENJOYMENT/PLEASUREGOING INTO NATUREPHYSICAL ACTIVITY

WELLBEING AND THE ENVIRONMENT:POSSIBLE LINKS BETWEEN CONSERVATION ACTIVITIES AND HEALTH


ACTIVITY 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


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


Placebo N = 274

N = 60

Donepezil 5mg (D)

Placebo (p)

N = 268


Placebo N = 129

N = 431


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


MENTALHEALTH


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.






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


VULNERABLE PEOPLE





Poorer communities


VULNERABLE PLACES

THE NORTHSEA COAST

SEYCHELLES

THE GULFCOAST

THE NILEDELTA

GULF OFGUINEA


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


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



190019502005

FLOODS

This can lead to increased rainfall and greater numbers of storms, cyclones and extreme weather events.






LATIN AMERICA

SOUTH ASIA

MICRONESIA


VULNERABLE PEOPLE





Poorer communities


VULNERABLE PLACES

THE NORTHSEA COAST

SEYCHELLES

THE GULFCOAST

THE NILEDELTA

GULF OFGUINEA


VENEZUELA

MOZAMBIQUE

CHINA

1999

2000/2001

2003

30,000 DEAD

1,813 DEAD

130m AFFECTED


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)


(P > 0.05)

CONTROLCONDITION

TEXTCONDITION

GRAPHICCONDITION

6 mins

3 mins



mean viewtime (log10)

a b

KEY MEAN& 95% CI

ANOVASIGNIFICANT

(P < 0.05)


(P > 0.05)

CONTROLCONDITION

TEXTCONDITION

GRAPHICCONDITION

80%

70%

60%



d

meanknowledge

KEY MEAN& 95% CI

ANOVASIGNIFICANT

(P < 0.05)


(P > 0.05)

CONTROLCONDITION

TEXTCONDITION

GRAPHICCONDITION

28

21

14



cmean risk

perception

KEY MEAN& 95% CI

ANOVASIGNIFICANT

(P < 0.05)


(P > 0.05)

CONTROLCONDITION

TEXTCONDITION

GRAPHICCONDITION

KEY MEAN& 95% CI

ANOVASIGNIFICANT

(P < 0.05)


(P > 0.05)

CONTROLCONDITION

TEXTCONDITION

GRAPHICCONDITION

meanknowledge

(baseline)

KEY MEAN& 95% CI

ANOVASIGNIFICANT

(P < 0.05)


(P > 0.05)

CONTROLCONDITION

TEXTCONDITION

GRAPHICCONDITION

(time 2)

meanknowledge

KEY MEAN& 95% CI

ANOVASIGNIFICANT

(P < 0.05)


(P > 0.05)

CONTROLCONDITION

TEXTCONDITION

GRAPHICCONDITION

meanrisk perception

(baseline)

KEY MEAN& 95% CI

ANOVASIGNIFICANT

(P < 0.05)


(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

http://blog.willstahl.com

http://www.thebmj.com

Software:

Presentation software Illustrator InDesign !

Premiere Flash !

Processing / D3 PhP / HTML5 Other programming languages

Stills {Motion}

Interactive {

Processing

http://processing.org/

http://processing.org

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.

ida oct 2014

Design

conservation activities

environmental enhancement

possible links

stahltimmins w

ageprogramme specifics

cooper c

personalsocial id

lovell r