Health Promotion: Evaluation, discourse and practice

This dissertation for the Degree of Doctor of Psychology (Health) presents three pieces of work: 1) A Re-analysis of a Systematic Review of Psychological Interventions Used to Aid Smoking Cessation; 2) Evaluation and Discourse Analysis of the EC's Health Promotion Programme; 3) A consultancy case study: Evaluation of Educational Needs Assessment Methods Used in General Practices in Barking and Havering and Redbridge and Waltham Forest. The theme that ties these three pieces of work together is evaluation. The re-analysis of the systematic review of psychological methods for smoking cessation shows how errors can be made in evaluation and how different researchers can obtain different results in what is considered to be a method that reduces bias and produces an accurate picture of `evidence' to inform health policy and practice. The evaluation of the EC's Health Promotion Programme gives insight into a case study of an evaluation to inform health promotion policy at an European level. This piece of work presents the results of an independent evaluation. It highlights unexpected difficulties of drawing conclusions from data such as the practical problems of obtaining data and also the pressures that may come from the commissioners of evaluations. The discourse analysis of the Health Promotion Programme reveals how current discourses in health promotion may compel health promotion practitioners to carry out a certain type of evaluation in which in truth they may have little understanding or commitment. As a result, the practice of evaluation becomes a formality or ritual which is a burden to carry out. A panel of health promotion expert assessors found a lack of acceptable evaluation of projects that were funded by the European Commission. This suggests that if evaluation can be avoided, it will be. The same themes of lack of understanding, commitment and time for evaluation were unveiled in the case study. The consultancy case study evaluated educational needs assessment methods used in general practices. The use of evidence-based practice requires that practitioners understand how to evaluate research and incorporate it into their practice. This needs more emphasis in the education and training of health professionals. However there has been a move away from the more didactic approach to education in primary care to one of listening to people's needs and preferred methods of learning. At the same time the ubiquitous need to evaluate to find the best method prevails. This is regardless of obvious limitations to the interpretation of findings. In this case study, it seemed as though the evaluation was an after-thought, rushed to satisfy some other group higher up the hierarchy in the health authority. Similarly, the discourse analysis pointed to a situation in which the Commission's services are constructed as superior, thus leaving no mechanism to question their knowledge or ways of working. While there may be efforts on one level to encourage a two-way flow of information and knowledge, on another level, a construction of decision-makers as being superior means that information and knowledge only flow one way, top down. All three pieces of work have shown that practical limitations restrict the interpretation of evaluations. Lack of time, incomplete data, commitment and knowledge of evaluation revealed here lead to questions about the possibility and desirability of evidence-based health promotion. For evaluation to advance, there is a need for a better understanding of its purpose and for it to have more meaning for all of the stakeholders involved. This requires a rethink concerning evaluation methods in health promotion that recognise the restraints of evaluation and start inquiry from this premise

Mapping Vesta: First Results from Dawn’s Survey Orbit

The geologic objectives of the Dawn Mission [1] are to derive Vesta’s shape, map the surface geology, understand the geological context and contribute to the determination of the asteroids’ origin and evolution.Geomorphology and distribution of surface features will provide evidence for impact cratering, tectonic activity, volcanism, and regolith processes. Spectral measurements of the surface will provide evidence of the compositional characteristics of geological units. Age information, as derived from crater sizefrequency distributions, provides the stratigraphic context for the structural and compositional mapping results, thus revealing the geologic history of Vesta. We present here the first results of the Dawn mission from data collected during the approach to Vesta, and its first discrete orbit phase – the Survey Orbit, which lasts 21 days after the spacecraft had established a circular polar orbit at a radius of ~3000 km with a beta angle of 10°-15°

Exploring the shell-based taxonomy of the Sri Lankan land snail Corilla H. and A. Adams, 1855 (Pulmonata: Corillidae) using mitochondrial DNA

The land-snail genus Corilla is endemic to Sri Lanka and India’s Western Ghats. The ten extant Sri Lankan species belong to two distinct shell forms that are associated respectively with lowland and montane rainforest. We here present the first molecular phylogenetic analysis for Corilla. Our dataset includes nine nominal Sri Lankan species and is based on three mitochondrial genes (CO1, ND1 and 16S). Although the deeper nodes in the trees are not fully resolved, the results do suggest speciation in Corilla has involved repeated, ecologically-driven convergence in shell form. The mtDNA data agree with the current shell-based taxonomy for C. adamsi, C. beddomeae, C. carabinata, C. humberti and C. colletti, consistently supporting the first four as monophyletic, and supporting the last also as monophyletic in nearly all analyses. Corilla adamsi, C. beddomeae and C. colletti may each contain at least one additional, previously undescribed species. The relationship between northern and eastern C. odontophora couldn’t be reliably resolved, but our results suggest that they are distinct species and that there is further species-level or intraspecific (geographical) differentiation within eastern C. odontophora. The current, morphologically-defined species limits of the three remaining nominal species, C. gudei, C. erronea and C. fryae, are inconsistent with the mtDNA sequence data. Northern and southern C. gudei appear to be distinct species: the sister taxon of southern C. gudei is C. humberti, and most analyses showed that the sister taxon of northern C. gudei is the lowland C. carabinata. Corilla erronea and C. fryae constitute a well supported clade in which both nominal species are paraphyletic. While most intra-clade CO1 p-distances are moderate to relatively large, the phylogenetic structuring within the clade does not seem to correspond to any obvious morphological, elevational or geographical patterns. These results are difficult to interpret, and further detailed study is needed before the taxonomic status of C. erronea and C. fryae can be resolved

The Kuiper Belt and Other Debris Disks

We discuss the current knowledge of the Solar system, focusing on bodies in the outer regions, on the information they provide concerning Solar system formation, and on the possible relationships that may exist between our system and the debris disks of other stars. Beyond the domains of the Terrestrial and giant planets, the comets in the Kuiper belt and the Oort cloud preserve some of our most pristine materials. The Kuiper belt, in particular, is a collisional dust source and a scientific bridge to the dusty "debris disks" observed around many nearby main-sequence stars. Study of the Solar system provides a level of detail that we cannot discern in the distant disks while observations of the disks may help to set the Solar system in proper context.Comment: 50 pages, 25 Figures. To appear in conference proceedings book "Astrophysics in the Next Decade

Developing a predictive modelling capacity for a climate change-vulnerable blanket bog habitat: Assessing 1961-1990 baseline relationships

Aim: Understanding the spatial distribution of high priority habitats and developing predictive models using climate and environmental variables to replicate these distributions are desirable conservation goals. The aim of this study was to model and elucidate the contributions of climate and topography to the distribution of a priority blanket bog habitat in Ireland, and to examine how this might inform the development of a climate change predictive capacity for peat-lands in Ireland. Methods: Ten climatic and two topographic variables were recorded for grid cells with a spatial resolution of 1010 km, covering 87% of the mainland land surface of Ireland. Presence-absence data were matched to these variables and generalised linear models (GLMs) fitted to identify the main climatic and terrain predictor variables for occurrence of the habitat. Candidate predictor variables were screened for collinearity, and the accuracy of the final fitted GLM was evaluated using fourfold cross-validation based on the area under the curve (AUC) derived from a receiver operating characteristic (ROC) plot. The GLM predicted habitat occurrence probability maps were mapped against the actual distributions using GIS techniques. Results: Despite the apparent parsimony of the initial GLM using only climatic variables, further testing indicated collinearity among temperature and precipitation variables for example. Subsequent elimination of the collinear variables and inclusion of elevation data produced an excellent performance based on the AUC scores of the final GLM. Mean annual temperature and total mean annual precipitation in combination with elevation range were the most powerful explanatory variable group among those explored for the presence of blanket bog habitat. Main conclusions: The results confirm that this habitat distribution in general can be modelled well using the non-collinear climatic and terrain variables tested at the grid resolution used. Mapping the GLM-predicted distribution to the observed distribution produced useful results in replicating the projected occurrence of the habitat distribution over an extensive area. The methods developed will usefully inform future climate change predictive modelling for Irelan

A novel formulation of inhaled sodium cromoglicate (PA101) in idiopathic pulmonary fibrosis and chronic cough: a randomised, double-blind, proof-of-concept, phase 2 trial

Background Cough can be a debilitating symptom of idiopathic pulmonary fibrosis (IPF) and is difficult to treat. PA101 is a novel formulation of sodium cromoglicate delivered via a high-efficiency eFlow nebuliser that achieves significantly higher drug deposition in the lung compared with the existing formulations. We aimed to test the efficacy and safety of inhaled PA101 in patients with IPF and chronic cough and, to explore the antitussive mechanism of PA101, patients with chronic idiopathic cough (CIC) were also studied. Methods This pilot, proof-of-concept study consisted of a randomised, double-blind, placebo-controlled trial in patients with IPF and chronic cough and a parallel study of similar design in patients with CIC. Participants with IPF and chronic cough recruited from seven centres in the UK and the Netherlands were randomly assigned (1:1, using a computer-generated randomisation schedule) by site staff to receive PA101 (40 mg) or matching placebo three times a day via oral inhalation for 2 weeks, followed by a 2 week washout, and then crossed over to the other arm. Study participants, investigators, study staff, and the sponsor were masked to group assignment until all participants had completed the study. The primary efficacy endpoint was change from baseline in objective daytime cough frequency (from 24 h acoustic recording, Leicester Cough Monitor). The primary efficacy analysis included all participants who received at least one dose of study drug and had at least one post-baseline efficacy measurement. Safety analysis included all those who took at least one dose of study drug. In the second cohort, participants with CIC were randomly assigned in a study across four centres with similar design and endpoints. The study was registered with ClinicalTrials.gov (NCT02412020) and the EU Clinical Trials Register (EudraCT Number 2014-004025-40) and both cohorts are closed to new participants. Findings Between Feb 13, 2015, and Feb 2, 2016, 24 participants with IPF were randomly assigned to treatment groups. 28 participants with CIC were enrolled during the same period and 27 received study treatment. In patients with IPF, PA101 reduced daytime cough frequency by 31·1% at day 14 compared with placebo; daytime cough frequency decreased from a mean 55 (SD 55) coughs per h at baseline to 39 (29) coughs per h at day 14 following treatment with PA101, versus 51 (37) coughs per h at baseline to 52 (40) cough per h following placebo treatment (ratio of least-squares [LS] means 0·67, 95% CI 0·48–0·94, p=0·0241). By contrast, no treatment benefit for PA101 was observed in the CIC cohort; mean reduction of daytime cough frequency at day 14 for PA101 adjusted for placebo was 6·2% (ratio of LS means 1·27, 0·78–2·06, p=0·31). PA101 was well tolerated in both cohorts. The incidence of adverse events was similar between PA101 and placebo treatments, most adverse events were mild in severity, and no severe adverse events or serious adverse events were reported. Interpretation This study suggests that the mechanism of cough in IPF might be disease specific. Inhaled PA101 could be a treatment option for chronic cough in patients with IPF and warrants further investigation

Mapping geographical inequalities in childhood diarrhoeal morbidity and mortality in low-income and middle-income countries, 2000–17 : analysis for the Global Burden of Disease Study 2017

Background Across low-income and middle-income countries (LMICs), one in ten deaths in children younger than 5 years is attributable to diarrhoea. The substantial between-country variation in both diarrhoea incidence and mortality is attributable to interventions that protect children, prevent infection, and treat disease. Identifying subnational regions with the highest burden and mapping associated risk factors can aid in reducing preventable childhood diarrhoea. Methods We used Bayesian model-based geostatistics and a geolocated dataset comprising 15 072 746 children younger than 5 years from 466 surveys in 94 LMICs, in combination with findings of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2017, to estimate posterior distributions of diarrhoea prevalence, incidence, and mortality from 2000 to 2017. From these data, we estimated the burden of diarrhoea at varying subnational levels (termed units) by spatially aggregating draws, and we investigated the drivers of subnational patterns by creating aggregated risk factor estimates. Findings The greatest declines in diarrhoeal mortality were seen in south and southeast Asia and South America, where 54·0% (95% uncertainty interval [UI] 38·1–65·8), 17·4% (7·7–28·4), and 59·5% (34·2–86·9) of units, respectively, recorded decreases in deaths from diarrhoea greater than 10%. Although children in much of Africa remain at high risk of death due to diarrhoea, regions with the most deaths were outside Africa, with the highest mortality units located in Pakistan. Indonesia showed the greatest within-country geographical inequality; some regions had mortality rates nearly four times the average country rate. Reductions in mortality were correlated to improvements in water, sanitation, and hygiene (WASH) or reductions in child growth failure (CGF). Similarly, most high-risk areas had poor WASH, high CGF, or low oral rehydration therapy coverage. Interpretation By co-analysing geospatial trends in diarrhoeal burden and its key risk factors, we could assess candidate drivers of subnational death reduction. Further, by doing a counterfactual analysis of the remaining disease burden using key risk factors, we identified potential intervention strategies for vulnerable populations. In view of the demands for limited resources in LMICs, accurately quantifying the burden of diarrhoea and its drivers is important for precision public health

Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990-2015: A systematic analysis for the Global Burden of Disease Study 2015

Background: The Global Burden of Diseases, Injuries, and Risk Factors Study 2015 provides an up-to-date synthesis of the evidence for risk factor exposure and the attributable burden of disease. By providing national and subnational assessments spanning the past 25 years, this study can inform debates on the importance of addressing risks in context. Methods: We used the comparative risk assessment framework developed for previous iterations of the Global Burden of Disease Study to estimate attributable deaths, disability-adjusted life-years (DALYs), and trends in exposure by age group, sex, year, and geography for 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks from 1990 to 2015. This study included 388 risk-outcome pairs that met World Cancer Research Fund-defined criteria for convincing or probable evidence. We extracted relative risk and exposure estimates from randomised controlled trials, cohorts, pooled cohorts, household surveys, census data, satellite data, and other sources. We used statistical models to pool data, adjust for bias, and incorporate covariates. We developed a metric that allows comparisons of exposure across risk factors—the summary exposure value. Using the counterfactual scenario of theoretical minimum risk level, we estimated the portion of deaths and DALYs that could be attributed to a given risk. We decomposed trends in attributable burden into contributions from population growth, population age structure, risk exposure, and risk-deleted cause-specific DALY rates. We characterised risk exposure in relation to a Socio-demographic Index (SDI). Findings: Between 1990 and 2015, global exposure to unsafe sanitation, household air pollution, childhood underweight, childhood stunting, and smoking each decreased by more than 25%. Global exposure for several occupational risks, high body-mass index (BMI), and drug use increased by more than 25% over the same period. All risks jointly evaluated in 2015 accounted for 57·8% (95% CI 56·6–58·8) of global deaths and 41·2% (39·8–42·8) of DALYs. In 2015, the ten largest contributors to global DALYs among Level 3 risks were high systolic blood pressure (211·8 million [192·7 million to 231·1 million] global DALYs), smoking (148·6 million [134·2 million to 163·1 million]), high fasting plasma glucose (143·1 million [125·1 million to 163·5 million]), high BMI (120·1 million [83·8 million to 158·4 million]), childhood undernutrition (113·3 million [103·9 million to 123·4 million]), ambient particulate matter (103·1 million [90·8 million to 115·1 million]), high total cholesterol (88·7 million [74·6 million to 105·7 million]), household air pollution (85·6 million [66·7 million to 106·1 million]), alcohol use (85·0 million [77·2 million to 93·0 million]), and diets high in sodium (83·0 million [49·3 million to 127·5 million]). From 1990 to 2015, attributable DALYs declined for micronutrient deficiencies, childhood undernutrition, unsafe sanitation and water, and household air pollution; reductions in risk-deleted DALY rates rather than reductions in exposure drove these declines. Rising exposure contributed to notable increases in attributable DALYs from high BMI, high fasting plasma glucose, occupational carcinogens, and drug use. Environmental risks and childhood undernutrition declined steadily with SDI; low physical activity, high BMI, and high fasting plasma glucose increased with SDI. In 119 countries, metabolic risks, such as high BMI and fasting plasma glucose, contributed the most attributable DALYs in 2015. Regionally, smoking still ranked among the leading five risk factors for attributable DALYs in 109 countries; childhood underweight and unsafe sex remained primary drivers of early death and disability in much of sub-Saharan Africa. Interpretation: Declines in some key environmental risks have contributed to declines in critical infectious diseases. Some risks appear to be invariant to SDI. Increasing risks, including high BMI, high fasting plasma glucose, drug use, and some occupational exposures, contribute to rising burden from some conditions, but also provide opportunities for intervention. Some highly preventable risks, such as smoking, remain major causes of attributable DALYs, even as exposure is declining. Public policy makers need to pay attention to the risks that are increasingly major contributors to global burden. Funding: Bill & Melinda Gates Foundation