Extending and improving current frameworks for risk management and decision-making: A new approach for incorporating dynamic aspects of risk and uncertainty

In recent decades, there has been a growing recognition of the importance of risk-informed decision-making, and the use of risk assessments to support decisions is a core principle in current frameworks and standards for risk management and decision-making. While considerable efforts have been directed towards clarifying the role of risk assessment as input to decision-making, less attention has been paid to the follow-up of the risk assessment once a decision has been made. However, new knowledge, as well as changes in systems, phenomena or values, could alter the underlying premises of the initial risk assessment. Many of the current frameworks for risk management and decision-making lack suitable approaches for reflecting these issues, leaving important aspects of risk unaddressed. In this paper, we present an adjusted approach to risk management and decision-making in which the need for new risk assessments is evaluated, focusing on three main criteria: i) the introduction of new decision alternatives, ii) changes in risk, and iii) changes in context/values. Acknowledging the challenge of determining the appropriate timing for the evaluation, we emphasize that striking a balance between remaining responsive to challenging circumstances and avoiding the use of unnecessary resources on excessive evaluations, is a key task. By providing the basis for a more dynamic approach to risk assessment and risk management, the paper aims to strengthen the foundation for risk-informed decision-making.publishedVersio

The concept of plausibility in a risk analysis context: Review and clarifications of defining ideas and interpretations

The plausibility concept has gained increasing attention in recent years in risk analysis settings. A number of definitions exist, most of which interpret plausibility as an expression of uncertainty. The concept is frequently referred to in scenario analysis and emerging risk contexts, which are characterized by large uncertainties. The difficulty of assigning probabilities in such cases has led some to claim that, by offering a purely qualitative approach, plausibility is a more suitable tool for measuring uncertainty. However, a proper clarification of what the plausibility concept means in a risk analysis context is missing; current definitions of the concept do not provide a clear understanding of how plausibility is linked to fundamental aspects of risk and uncertainty. The present paper aims to rectify these issues, by i) reviewing and discussing how the plausibility concept is interpreted and used in the literature, ii) providing a suggested interpretation of the concept in a risk analysis context, and iii) giving our recommendations on how the practical application of the plausibility concept can be enhanced by drawing on contemporary risk science, specifically with regard to highlighting the likelihood and knowledge dimensions of risk. Based on the review, it is shown that the concept of plausibility should be seen as a measure of uncertainty capturing a combination of likelihood and judgments on the supporting knowledge. We conclude that a prudent use of the concept requires that each of these dimensions are addressed explicitly, using imprecise probabilities and strength of knowledge judgments.publishedVersio

A risk science perspective on vaccines

Vaccines can be seen as one of the greatest successes in modern medicine. Good examples are the vaccines against smallpox, polio, and measles. Unfortunately, vaccines can have side effects, but the risks are considered by the health authorities and experts to be small compared to their benefits. Nevertheless, there are many who are skeptical of vaccination, something which has been very clearly demonstrated in relation to the COVID-19 disease. Risk is the key concept when evaluating a vaccine, in relation to both its ability to protect against the disease and its side effects. However, risk is a challenging concept to measure, which makes communication about vaccines’ performance and side effects difficult. The present article aims at providing new insights into vaccine risks—the understanding, perception, communication, and handling of them—by adopting what is here referred to as a contemporary risk science perspective. This perspective clarifies the relationships between the risk concept and terms like uncertainty, knowledge, and probability. The skepticism toward vaccines is multifaceted, and influenced by concerns that extend beyond the effectiveness and safety of the vaccines. However, by clarifying the relationships between key concepts of risk, particularly how uncertainty affects risk and its characterization, we can improve our understanding of this issue.publishedVersio

Fitspiration: Association between Fitspiration on Instagram and young girls’ body image and exercise habits

Master i folkehelsevitenskap med vekt på endringer av livsstilsvaner, 2016Bakgrunn: Unge kvinner i dag blir utsatt for et stort kroppspress. Fremveksten av det sterke fitnessfokuset på Instagram, i andre sosiale medier og på treningssentre er urovekkende. I tillegg er Fitspiration en ny trend som gir grunn til bekymring. Formål: Å finne ut om det er noen sammenheng mellom eksponering for Fitspiration på Instagram og unge jenters kroppsbilde og treningsvaner. Samtidig undersøke om sosial sammenligning, om man bor i by eller bygd, og hvilken type trening man driver med har betydning for denne sammenhengen. Metode: Kvantitativ undersøkelse hvor 203 jenter i alderen 16-18 fra to videregående skoler svarte på et spørreskjema med 4 seksjoner. Deskriptive analyser, Spearmans korrelasjonskoeffisient og multippel hierarkisk regresjonsanalyse ble kjørt i SPSS. Resultat: Ingen signifikant sammenheng mellom eksponering for Fitspiration på Instagram og kroppsbilde ble funnet (rho BES-BV = -,035, p = ,631; rho BES-FF = ,102, p = ,163). En middels positiv sammenheng mellom eksponering for Fitspiration på Instagram og treningsvaner ble funnet (rho = ,368, p = ,001). Forskjellene i kroppsbilde og treningsvaner mellom jenter med høye og lave PACS-R-verdier som hadde blitt eksponert for Fitspiration på Instagram, var ikke signifikante (BES-BV: Zobs = 0,75, p = ,453; BES-FF: Zobs = 1,12, p = ,263; Treningsvaner Zobs = 1,31, p = ,190). Hvilken skole man gikk på, var ikke en signifikant predikator for kroppsbilde, men var en signifikant predikator for treningsvaner. Type trening var ikke en signifikant predikator for BES-BV, men var det for BES-FF og treningsvaner. Konklusjon: Funnene i denne undersøkelsen tyder på at eksponering for Fitspiration på Instagram ikke har sammenheng med kroppsbilde uten at andre faktorer, som sosial sammenligning, har en innvirkning. Denne undersøkelsen viser sammenhenger mellom unge jenters treningsvaner og Fitspiration på Instagram som ikke har blitt forsket på før. Funnene i denne undersøkelsen både bekrefter og utdyper fra tidligere forskning og gir ny kunnskap til fagfeltet.Engelsk sammendrag (abstract): Background: Young women today are exposed to massive body pressure. The emergence of the strong fitness focus on Instagram, in other social media and at fitness centres is a reason for concern. In addition there is Fitspiration, which is a new trend that causes concern. Purpose: To find out if there is any correlation between exposure to Fitspiration on Instagram and body image and exercise habits of young girls. To check whether social comparison, living in urban or rural areas, and the type of exercise you are doing are significant in this context. Method: Quantitative research comprising 203 girls aged 16-18 from two senior high schools answering a questionnaire with 4 sections. The data were statistically analysed using SPSS. Statistical techniques used were descriptive analyses, Spearman’s rank order correlation and hierarchical multiple regression. Results: No significant correlation between exposure to Fitspiration on Instagram and body image was found (rho BES-BV = -,035, p = ,631; rho BES-FF = ,102, p = ,163). A medium positive correlation was found between exposure to Fitspiration on Instagram and exercise habits (rho =,368, p = ,001). No significant differences were found as to body image and exercise habits between girls with high and low PACS-R values after exposure to Fitspiration in Instagram (BES-BV: Zobs = 0,75, p = ,453; BES-FF: Zobs = 1,12, p = ,263; Treningsvaner Zobs = 1,31, p = ,190). School was no significant predictor for body image. School was, however, a significant predictor for exercise habits. Type of exercise was no significant predictor for BES-BV, it was, however, for BES-FF and exercise habits. Conclusion: Findings of this survey indicate that exposure to Fitspiration on Instagram has no correlation with body image without other factors, such as social comparison, having an impact. However this study shows a correlation between exercise habits of young girls and Fitspiration on Instagram, which has not been revealed by previous research. The findings in this study thus confirm and widen the results of previous research, and provide new information to the field

Evaluating the cost-effectiveness of existing needle and syringe programmes in preventing hepatitis C transmission in people who inject drugs

AIM: To evaluate the cost-effectiveness of needle and syringe programmes (NSPs) compared with no NSPs on hepatitis C virus (HCV) transmission in the United Kingdom. DESIGN: Cost-effectiveness analysis from a National Health Service (NHS)/health-provider perspective, utilizing a dynamic transmission model of HCV infection and disease progression, calibrated using city-specific surveillance and survey data, and primary data collection on NSP costs. The effectiveness of NSPs preventing HCV acquisition was based on empirical evidence. SETTING AND PARTICIPANTS: UK settings with different chronic HCV prevalence among people who inject drugs (PWID): Dundee (26%), Walsall (18%) and Bristol (45%) INTERVENTIONS: Current NSP provision is compared with a counterfactual scenario where NSPs are removed for 10 years and then returned to existing levels with effects collected for 40 years. MEASUREMENTS: HCV infections and cost per quality-adjusted life year (QALY) gained through NSPs over 50 years. FINDINGS: Compared with a willingness-to-pay threshold of £20 000 per QALY gained, NSPs were highly cost-effective over a time-horizon of 50 years and decreased the number of HCV incident infections. The mean incremental cost-effectiveness ratio was cost-saving in Dundee and Bristol, and £596 per QALY gained in Walsall, with 78, 46 and 40% of simulations being cost-saving in each city, respectively, with differences driven by coverage of NSP and HCV prevalence (lowest in Walsall). More than 90% of simulations were cost-effective at the willingness-to-pay threshold. Results were robust to sensitivity analyses, including varying the time-horizon, HCV treatment cost and numbers of HCV treatments per year. CONCLUSIONS: Needle and syringe programmes are a highly effective low-cost intervention to reduce hepatitis C virus transmission, and in some settings they are cost-saving. Needle and syringe programmes are likely to remain cost-effective irrespective of changes in hepatitis C virus treatment cost and scale-up

Implementering av pasientbrev for nedtrapping og seponering av benzodiazepiner og benzodiazepinliknende preparater : ved Gågata legesenter

Benzodiazepiner og benzodiazepinliknende preparater (BoBLP) er de mest brukte legemidlene mot angst og søvnforstyrrelser, og medfører et betydelig misbrukspotensial samt risiko for toleranseutvikling. Avhengighet kan oppstå etter 2-4 ukers bruk innenfor terapeutiske doser. Seponering etter jevnlig bruk kan til tider gi alvorlige abstinenssymptomer. På tross av at nasjonale og internasjonale retningslinjer anbefaler korttidsbruk av BoBLP, er langtidsbruk fortsatt et utbredt fenomen. Vi ønsker i denne oppgaven å kartlegge effektive tiltak for å redusere langtidsbruk av BoBLP, og på bakgrunn av dette skissere et forbedringsprosjekt for en allmennpraksis. I eksisterende litteratur ble hovedsakelig to intervensjoner identifisert; (1) minimal intervensjon; for eksempel å gi enkle råd i form av brev, og (2) systematisk nedtrapping; behandlingsprogrammer ledet av lege eller psykolog. Det er evidens for effekt av begge de identifiserte intervensjonene. Vi valgte minimal intervensjon med utsending av brev som hovedtiltak i vårt forbedringsprosjekt. Forbedringsarbeidet går ut på å skissere et opplegg for å implementere bruk av informasjons- og motivasjonsbrev for å initiere nedtrapping og seponering av BOBLP, samt oppfordre til timebestilling for evalueringssamtale. Tiltaket skal implementeres ved hjelp av informasjonsskriv og kollegabasert terapiveiledning for de involverte allmennlegene. Vi ser for oss en prøveperiode på 6 måneder før vi, basert på våre indikatorer, evaluerer tiltaket. Vi konkluderer med at det er behov for et slikt tiltak, og at de foreslåtte intervensjonene er rimelige, lite arbeidskrevende og effektive

Health-related quality of life in young adults born small for gestational age : a prospective cohort study

Background Individuals born small for gestational age (SGA) have an increased risk of several adverse health outcomes, but their health-related quality of life (HRQoL) across young adulthood has yet to be studied. The main aim of this study was to investigate if being born SGA at term is associated with poor HRQoL at 32 years of age. A second aim was to explore longitudinal changes in HRQoL from age 20 to 32 years. Methods In the prospective NTNU Low Birth Weight in a Lifetime Perspective study, 56 participants born SGA and 68 non-SGA control participants completed the Short Form 36 Health Survey (SF-36) at age 32 years to assess HRQoL. The SF-36 was also administrated at age 20 and 28 years. Longitudinal changes in the eight SF-36 domains and the two component summaries from 20 to 32 years were analyzed by linear mixed models. In total, 82 adults born SGA and 98 controls participated at least once and were included in the longitudinal analyses. Results At age 32 years the participants born SGA scored 14.8 (95% CI 4.7 to 25.3) points lower in the SF-36 role-physical domain compared with the control group, i.e. more problems with work or other daily activities due to physical health problems. The longitudinal analyses showed significant group differences from 20 to 32 years in the role-emotional domain, and in the physical and mental component summaries. Among participants born SGA, the physical component summary decreased from age 20 to 28 years (-3.2, 95% CI -5.0 to -1.8), while the mental component summary (6.0, 95% CI 2.9 to 8.6) and role-emotional domain score (19.3, 95% CI 9.9 to 30.3) increased, but there were no further changes from 28 to 32 years. There were no longitudinal changes in the control group from 20 to 32 years. Conclusion Overall, individuals born SGA at term reported similar HRQoL at age 32 years compared with non-SGA controls. Self-perceived mental health improved during young adulthood among individuals born SGA, while self-perceived physical health deteriorated. The latter findings warrant further investigation.Peer reviewe

Transcranial direct current stimulation as a memory enhancer in patients with Alzheimer’s disease: a randomized, placebo-controlled trial

Background: The purpose of this study was to assess the efficacy of transcranial direct current stimulation (tDCS) on verbal memory function in patients with Alzheimer’s disease. Methods: We conducted a randomized, placebo-controlled clinical trial in which tDCS was applied in six 30-minute sessions for 10 days. tDCS was delivered to the left temporal cortex with 2-mA intensity. A total of 25 patients with Alzheimer’s disease were enrolled in the study. All of the patients were diagnosed according to National Institute of Neurological and Communicative Disorders and Stroke and Alzheimer’s Disease and Related Disorders Association criteria. Twelve patients received active stimulation, and thirteen patients received placebo stimulation. The primary outcome measure was the change in two parallel versions of the California Verbal Learning Test–Second Edition, a standardized neuropsychological memory test normalized by age and gender. The secondary outcome measures were the Mini Mental State Examination, clock-drawing test, and Trail Making Test A and B. Results: Changes in the California Verbal Learning Test–Second Edition scores were not significantly different between the active and placebo stimulation groups for immediate recall (p = 0.270), delayed recall (p = 0.052), or recognition (p = 0.089). There were nonsignificant differences in score changes on the Mini Mental State Examination (p = 0.799), clock-drawing test (p = 0.378), and Trail Making Test A (p = 0.288) and B (p = 0.093). Adverse effects were not observed. Conclusions: Compared with placebo stimulation, active tDCS stimulation in this clinical trial did not significantly improve verbal memory function in Alzheimer’s disease. This study differs from previous studies in terms of the stimulation protocol, trial design, and application of standardized neuropsychological memory assessment. Trial registration: ClinicalTrials.gov identifier NCT02518412. Registered on 10 August 2015

Health-related quality of life from 20 to 32 years of age in very low birth weight individuals : a longitudinal study

Background Preterm birth with very low birth weight (VLBW, birth weight < 1500 g) is associated with health problems later in life. How VLBW individuals perceive their physical and mental health-related quality of life (HRQoL) is important to understand their putative burden of disease. Previous studies have shown mixed results, and longitudinal studies into adulthood have been requested. This study aimed to investigate differences in HRQoL between preterm VLBW and term born individuals at 32 years of age, and to study changes in HRQoL from 20 to 32 years. Methods In a geographically based longitudinal study, 45 VLBW and 68 term born control participants completed the Short Form 36 Health Survey (SF-36) at 32 years of age. Data from three previous timepoints was also available (20, 23 and 28 years of age). The SF-36 yields eight domain scores as well as a physical and a mental component summary. Between-group differences in these variables were investigated. We also performed subgroup analyses excluding individuals with disabilities, i.e., cerebral palsy and/or low estimated intelligence quotient. Results At 32 years of age, the physical component summary was 5.1 points lower (95% confidence interval (CI): 8.6 to 1.6), and the mental component summary 4.1 points lower (95% CI: 8.4 to - 0.3) in the VLBW group compared with the control group. For both physical and mental component summaries there was an overall decline in HRQoL from 20 to 32 years of age in the VLBW group. When we excluded individuals with disabilities (n = 10), group differences in domain scores at 32 years were reduced, but physical functioning, bodily pain, general health, and role-emotional scores remained lower in the VLBW subgroup without disabilities compared with the control group. Conclusion We found that VLBW individuals reported lower HRQoL than term born controls at 32 years of age, and that HRQoL declined in the VLBW group from 20 to 32 years of age. This was in part, but not exclusively explained by VLBW individuals with disabilities.Peer reviewe