Tourism in sub-global assessments of ecosystem services

Published in 2005, the United Nations Millennium Ecosystem Assessment (MA) stressed that influencing governments, businesses and communities to address the supra-national challenge of limiting biodiversity loss and ecosystem degradation requires a fuller understanding of the range of values and benefits people derive from ecosystems, including tourism. The MA was informed by, and has shaped, several conceptually and methodologically distinctive sub-global assessments (SGAs) of ecosystem services. Through content analysis, this paper is the first detailed examination of how tourism features in 14 extant SGAs identified in a database held by a major supra-national environmental organization. Although the SGAs should have incorporated the widest range of specialist subject expertise, tourism scholars played only peripheral roles in producing them even for territories where tourism is a significant land use. The SGAs examined did not benefit from the extensive body of knowledge relating to sustainable tourism. Limited portrayals of tourism restrict the capacity of SGAs in their current format as management solutions. It is also contradictory to the ethos, principles and purpose of ecosystem assessments. With the ecosystem services perspective set to become more important to policy and decision making, the paper argues for greater incorporation of recent progress in sustainable tourism in ecosystem assessment

The feasibility of determining the effectiveness and cost-effectiveness of medication organisation devices compared with usual care for older people in a community setting: systematic review, stakeholder focus groups and feasibility randomised controlled trial

Background: Medication organisation devices (MODs) provide compartments for a patient’s medication to be organised into the days of the week and the recommended times the medication should be taken. Aim: To define the optimal trial design for testing the clinical effectiveness and cost-effectiveness of MODs. Design: The feasibility study comprised a systematic review and focus groups to inform a randomised controlled trial (RCT) design. The resulting features were tested on a small scale, using a 2 × 2 factorial design to compare MODs with usual packaging and to compare weekly with monthly supply. The study design was then evaluated. Setting: Potential participants were identified by medical practices. Participants: Aged over 75 years, prescribed at least three solid oral dosage form medications, unintentionally non-adherent and self-medicating. Participants were excluded if deemed by their health-care team to be unsuitable. Interventions: One of three MODs widely used in routine clinical practice supplied either weekly or monthly. Objectives: To identify the most effective method of participant recruitment, to estimate the prevalence of intentional and unintentional non-adherence in an older population, to provide a point estimate of the effect size of MODs relative to usual care and to determine the feasibility and acceptability of trial participation. Methods: The systematic review included MOD studies of any design reporting medication adherence, health and social outcomes, resource utilisation or dispensing or administration errors. Focus groups with patients, carers and health-care professionals supplemented the systematic review to inform the RCT design. The resulting design was implemented and then evaluated through questionnaires and group discussions with participants and health-care professionals involved in trial delivery. Results: Studies on MODs are largely of poor quality. The relationship between adherence and health outcomes is unclear. Of the limited studies reporting health outcomes, some reported a positive relationship while some reported increased hospitalisations associated with MODs. The pre-trial focus groups endorsed the planned study design, but suggested a minimum recruitment age of 50–60 years. A total of 35.4% of patients completing the baseline questionnaire were excluded because they already used a MOD. Active recruitment yielded a higher consent rate, but passive recruitment was more cost-effective. The prevalence of intentional non-adherence was 24.7% [n = 71, 95% confidence interval (CI) 19.7% to 29.6%] of participants. Of the remaining 76 participants, 46.1% (95% CI 34.8% to 57.3%) were unintentionally non-adherent. There was no indication of a difference in adherence between the study arms. Participants reported a high level of satisfaction with the design. Five adverse/serious adverse events were identified in the MOD study arms and none was identified in the control arms. There was no discernible difference in health economic outcomes between the four study arms; the mean intervention cost was £20 per month greater for MOD monthly relative to usual supply monthly. Conclusions: MOD provision to unintentionally non-adherent older people may cause medication-related adverse events. The primary outcome for a definitive MOD trial should be health outcomes. Such a trial should recruit patients by postal invitation and recruit younger patients

Home-based health promotion for older people with mild frailty: the HomeHealth intervention development and feasibility RCT.

BACKGROUND: Mild frailty or pre-frailty is common and yet is potentially reversible. Preventing progression to worsening frailty may benefit individuals and lower health/social care costs. However, we know little about effective approaches to preventing frailty progression. OBJECTIVES: (1) To develop an evidence- and theory-based home-based health promotion intervention for older people with mild frailty. (2) To assess feasibility, costs and acceptability of (i) the intervention and (ii) a full-scale clinical effectiveness and cost-effectiveness randomised controlled trial (RCT). DESIGN: Evidence reviews, qualitative studies, intervention development and a feasibility RCT with process evaluation. INTERVENTION DEVELOPMENT: Two systematic reviews (including systematic searches of 14 databases and registries, 1990-2016 and 1980-2014), a state-of-the-art review (from inception to 2015) and policy review identified effective components for our intervention. We collected data on health priorities and potential intervention components from semistructured interviews and focus groups with older people (aged 65-94 years) (n = 44), carers (n = 12) and health/social care professionals (n = 27). These data, and our evidence reviews, fed into development of the 'HomeHealth' intervention in collaboration with older people and multidisciplinary stakeholders. 'HomeHealth' comprised 3-6 sessions with a support worker trained in behaviour change techniques, communication skills, exercise, nutrition and mood. Participants addressed self-directed independence and well-being goals, supported through education, skills training, enabling individuals to overcome barriers, providing feedback, maximising motivation and promoting habit formation. FEASIBILITY RCT: Single-blind RCT, individually randomised to 'HomeHealth' or treatment as usual (TAU). SETTING: Community settings in London and Hertfordshire, UK. PARTICIPANTS: A total of 51 community-dwelling adults aged ≥ 65 years with mild frailty. MAIN OUTCOME MEASURES: Feasibility - recruitment, retention, acceptability and intervention costs. Clinical and health economic outcome data at 6 months included functioning, frailty status, well-being, psychological distress, quality of life, capability and NHS and societal service utilisation/costs. RESULTS: We successfully recruited to target, with good 6-month retention (94%). Trial procedures were acceptable with minimal missing data. Individual randomisation was feasible. The intervention was acceptable, with good fidelity and modest delivery costs (£307 per patient). A total of 96% of participants identified at least one goal, which were mostly exercise related (73%). We found significantly better functioning (Barthel Index +1.68; p = 0.004), better grip strength (+6.48 kg; p = 0.02), reduced psychological distress (12-item General Health Questionnaire -3.92; p = 0.01) and increased capability-adjusted life-years [+0.017; 95% confidence interval (CI) 0.001 to 0.031] at 6 months in the intervention arm than the TAU arm, with no differences in other outcomes. NHS and carer support costs were variable but, overall, were lower in the intervention arm than the TAU arm. The main limitation was difficulty maintaining outcome assessor blinding. CONCLUSIONS: Evidence is lacking to inform frailty prevention service design, with no large-scale trials of multidomain interventions. From stakeholder/public perspectives, new frailty prevention services should be personalised and encompass multiple domains, particularly socialising and mobility, and can be delivered by trained non-specialists. Our multicomponent health promotion intervention was acceptable and delivered at modest cost. Our small study shows promise for improving clinical outcomes, including functioning and independence. A full-scale individually RCT is feasible. FUTURE WORK: A large, definitive RCT of the HomeHealth service is warranted. STUDY REGISTRATION: This study is registered as PROSPERO CRD42014010370 and Current Controlled Trials ISRCTN11986672. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 73. See the NIHR Journals Library website for further project information

Tourism in sub-global assessments of ecosystem services

This is the author accepted manuscript. The final version is available from Taylor & Francis via the DOI in this record.Published in 2005, the United Nations Millennium Ecosystem Assessment (MA) stressed that influencing governments, businesses and communities to address the supra-national challenge of limiting biodiversity loss and ecosystem degradation requires a fuller understanding of the range of values and benefits people derive from ecosystems, including tourism. The MA was informed by, and has shaped, several conceptually- and methodologically-distinctive sub-global assessments (SGAs) of ecosystem services. Through content analysis, this paper is the first detailed examination of how tourism features in 14 extant SGAs identified in a database held by a major supra-national environmental organization. Although the SGAs should have incorporated the widest range of specialist subject expertise, expert tourism scholars played only peripheral roles in producing them even for territories where tourism is a significant land use. The SGAs examined did not benefit from the extensive body of knowledge relating to sustainable tourism. Limited portrayals of tourism restrict the capacity of SGAs in their current format as management solutions. It is also contradictory to the ethos, principles and purpose of ecosystem assessments. With the ecosystem services perspective set to become more important to policy and decision making, the paper argues for greater incorporation of recent progress in sustainable tourism in ecosystem assessment

Variations in mortality across the week following emergency admission to hospital: linked retrospective observational analyses of hospital episode data in England, 2004/05 to 2013/14

Background: Patients admitted to hospital outside normal working hours suffer higher complication and mortality rates than patients admitted at times when the hospital is fully operational. This ‘weekend effect’ is well described but poorly understood. It is not clear whether or not the effect extends to other out-of-hours periods, or how far excess mortality for out-of-hours admissions reflects a different presenting population with higher severity of illness and how much is explained by poorer availability and quality of services. Objectives: We aimed to assess (1) the costs and benefits of introducing 7-day services, (2) whether or not mortality rates are elevated during all out-of-hours periods, (3) whether or not selection of more severely ill patients for admission out of hours explains elevated mortality rates and (4) whether or not mortality rates out of hours are related to staffing levels. Methods: We conducted a series of retrospective observational analyses of hospital episode data in England, using both national data and data from a single, large acute NHS trust. For the national studies, we analysed emergency admissions to all 140 non-specialist acute hospital trusts in England between April 2013 and February 2014 (over 12 million accident and emergency attendances and 4.5 million emergency admissions). For the single trust, we analysed emergency admissions between April 2004 and March 2014 (240,000 admissions). Deaths within 30 days of attendance or admission were compared for normal working hours and out-of-hours periods. Results: We found that, in addition to elevated mortality for weekend admissions, mortality rates are also elevated for patients admitted during night-time periods. Elevated mortality was reduced for stroke patients in a large acute trust when more – and more experienced – nursing staff were present during the first hour of admission. Nationally, we found that excess mortality out of hours was largely explained by a sicker population of patients being selected for admission. However, mortality rates were still elevated on Sunday daytimes when we accounted for severity of patient illness. We also found that the estimated cost of implementing 7-day services exceeds the maximum amount that the National Institute for Health and Care Excellence would recommend the NHS should spend on eradicating excess mortality at weekends. Limitations: Our results depend on the accuracy and completeness of data recording by hospital staff. If accuracy of recording is related to time of patient admission, our results may be biased. Results based on data from a single trust should be treated as indicative. Conclusions: In addressing variations in patient outcomes across the week, a more nuanced approach, extending services for key specialties over critical periods – rather than implementing whole-system changes – is likely to be the most cost-effective. Future work: Future research should aim to develop and use appropriate measures of severity of illness to facilitate meaningful analysis of variations in patient outcomes, and to identify candidate specialties and critical periods for which extending services is likely to be cost-effective

The influence of the IKEA effect on a value of good

In 4 experiments in which students assembled IKEA boxes, built LEGO-like construction sets and folded origami I demonstrate and examine the IKEA effect, which is defined as consumers' willingness to pay more for self-created products than for identical products made by others. I show that their increased valuation is led by the feelings of competence associated with self-created products and that affirming consumers sense of self decreases the value one derives from his creations. I found that students value more their labor only when labor results in successful completion of task regardless of whether they are "do-it-yourselfers" or not. I did not observe the IKEA effect in particular case of origami