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Desires, Relations, Intimacy & Exploitation: An Introductory Mind Genomics Cartography

DOI: 10.31038/PSYJ.2020211

Abstract

We present two methods-oriented studies on sexuality, one dealing with the discussion of sexuality in the context of a relationship, the second with the societal protection of sex workers. Both studies used consumer respondents to evaluate systematically varied combinations of messages about the topic, the combinations created by experimental design, following the method of Mind Genomics. Study 1 on discussions of sexual intimacy presents Mind Genomics to understand the way people process information, their criteria for decision-making, and the nature of possibly easy-to-understand mind-sets, i.e., different criteria of importance assigned to the same pieces of information. Study 2 on the protection and recourse given to legal workers shows how to assess the interaction between person and situation as drivers of judgments and drivers of engagement. Both studies point to the emerging science of Mind Genomics as an easy, rapid, and cost-effective ways to create archival databases, to introduce new ways of thinking, and to democratize research world-wide, respectively.

Introduction

During the past three decades the focus of researchers has steadily increased on issues involving intimacy, specifically sexual intimacy between consenting partners (love, romance), as well as sexual intimacy as a business (sex workers.) Sexuality in its many manifestations has always attracted research because of its centrality in daily life, but as society has evolved, issues of sexuality have become intertwined with emotions, with public health (e.g., sexually transmitted disease), and finally with issues of the law (e.g., prostitution and the issues revolving around sex workers.)

The topics of love, sexuality, sexual exploitations, and societal reactions each have spawned enormous literatures. Table 1 shows the number of ‘hits’ for Google® and for Google Scholar®, for each of these topics, at the time of this writing, December 2019,

Table 1. Number of citations dealing with sex and its ramifications.

Topic

Citations–Google®

Citations–Google Scholar®

Love

18 billion

3.34 million

Sexuality

80 million

2.47 million

Sexual exploitation

72 million

1.03 million

Societal response to sexual exploitation

59 million

0.20 million

No set of studies can hope to be comprehensive, given the long history of the study of sexuality, the many manifestations in daily life, and the many cultures as well as stages of individual development that must be considered. Rather, we introduce here a new approach to the study of sexuality, the science of Mind Genomics, designed to take small snapshots of a topic, focus in depth on a specific, limited topic, and work with small, affordable samples of respondents.

The worldview of Mind Genomics involves a small, limited topic, investigating the patterns of decision making within that topic. Rather than emerging out of the history of the hypothetico-deductive method, isolating a variable and studying that variable in an experiment, Mind Genomics proceeds in the reverse direction. One might think of the Mind Genomics researcher as a cartographer faced with a new land. The cartographer measures the relevant variables of a topographical area, deduces the nature of the structure below, and maps the land. The cartographer creates maps, not theories. In the case of Mind Genomics, the ‘land’ is the world of sexuality. The cartography of this paper deals with the reactions to issues of sexual intimacy (one set of experiments), and reactions to issues of sex workers (another set of experiments.)

Exploring two topics of sex using Mind Genomics to generate insights and hypotheses

The topic of sexual behavior spans a wide range of topics, from the physical to the emotional to the legal, and to the societal. It is impossible to cover even a very small fraction of the topics with a set of experiments or surveys. The strategy of this paper is to demonstrate how the emerging science of Mind Genomics can generate an affordable, powerful database at the start of a research initiative, using simple ideas, simple thinking, consumer research, and powerful analyses, meaningful even with samples that are traditionally considered ‘small’.

The emerging science of Mind Genomics (Moskowitz & Gofman, 2007) [1], traces its intellectual heritage to the systematized thinking using experimental design to structure the test stimuli, as well as to sociology and consumer research for transforming the ideas into questions to be answered, and finally to the Socratic method to create the system as an inductive knowledge-development technique, easily applied in practice

Experimental design

Experimental design allows a researcher to understand the effects of a variable, either tested along in ‘splendid isolation’ or tested as part of a mixture (Box, Hunter & Hunter, 1978) [2]. Mind Genomics deals with the ordinary situation, wherein a person is presented with a combination of ideas, as the typical situation of daily life. The person responds to the combination, making a decision. But just what specific component of the combination or set of components ‘drive’ that decision? Experimental design sets up efficient combinations of independent variables, messages or elements in the language of Mind Genomics. It is the response to these systematically created mixtures, which, through regression reveals, quite directly the contribution of each Message or Element to the response. The response, in turn, is what the respondent answers.

Sociology and consumer research

These social science disciplines rely upon the responses of people to questions about behavior, or upon the measurement of the behavior of people in situations, i.e., upon attitude versus upon behavior, respectively. Where possible a meaningful behavioral measure may be better than an attitude, although the term ‘meaningful’ is important as a qualifier.

Over almost a century there has been a subtle current of belief that implicit measures are better than explicit ones, e.g., that EEG (brain waves) or GSR (activation) or pupil behavior (dilation, pupil motion) somehow are better than simple attitudinal ratings because the former are more objective, more biological (Boring, 1929) [3].

The foregoing use of ‘meaningful’ is not what is meant here. Rather, the term ‘meaningful’ is used in the sense that the measure to be meaningful must be a direct correlate of the mind of the person, whether person in society or an ordinary citizen faced with a choice. Mind Genomics uses the responses to combinations of messages, i.e., combinations of elements as the meaningful measure, since a great deal of behavior in everyday life is responses to mixtures. Mind Genomics goes the additional step by creating combinations of these messages, presenting them to respondents, measuring the reactions, and then estimating the contribution of each message.

The Socratic Method

The approach is grounded empiricism, not in the hypothetico-deductive method. There is no hypothesis to be tested. Rather, there is a topic to be studied. The topic of interest is presented to the researcher, who must create four questions which ‘tell a story’ about the topic. The questions are not necessarily final, but rather represent the way the topic is thought about, either those who are grounded in the topic, or even novices with no idea at all, so-called ‘newbies’. The four questions each motivate four answers, or a total of 16 answers, as shown in the next sections. The researcher then combines these answers into small vignettes, obtains responses to the vignettes, and shows how the different answers shed light on the topic.

The best way to show the Mind Genomics method is through a case history, dealing with a topic relevant to an individual, or even beyond the individual to a group, and to society. This paper focuses on two aspects of sexual behavior, the first dealing with discussions of sexual intimacy and disease protection between consenting partners, the second dealing with protection of the ‘sex’ worker. These are but two of the perhaps hundreds of topics in the rainbow of topics in sexuality. We show how a one-day experiment can produce data for each topic, making it feasible to explore hundreds of topics about sexuality in the time frame of a year, with affordable, rapid, insightful and archival data.

Study 1 – Discussinag disease prevention between two consenting & emotionally-involved partners

A great deal has been written about sexual relations between consenting partners, from issues to measurements (e.g., Fisher et. al., 2013; Montesi, et. al., 2013; Stephenson, et. al., 2010). [4, 5, 6] The topics range from the emotions felt by the participants to the behavior of adolescents versus older individuals, and on to the issues caused by the ravages of sexually transmitted disease (Harvey et al., 2016; Katz et al., 2000; Peplau et. al., 2007; Widman et. al., 2006). [7, 8, 9, 10] Our focus in this experiment is the couple’s discussion of issues around the prevention of sexually transmitted diseases using methods under their control. The study was motivated by author Ortiz’s plan to sponsor a campaign to reduce sexually transmitted disease.

Method

The Mind Genomics study begins with the creation of the four questions and the four answers to each question. These appear in Table 2 and were created by author Ortiz as part of a campaign against sexually transmitted diseases. The important thing to realize from Table 2 is that the study does not exhaust the topic. Indeed, Mind Genomics studies are not designed as single, exhaustive treatments of a subject, treatments which generate a large volume of disparate information. Rather, Table 2 shows a preliminary attempt to understand four aspects of the topic. The reality is that there may be 40 or 400 aspects of the topic. When one attempts to cover a topic thoroughly, the entire endeavor may collapse because, in common folk wisdom ‘the perfect is often the enemy of the good.’ The Mind Genomics strategy is to create a set of such small studies, accrete the results, and identify emergent patterns ‘from the bottom up.’ Mind Genomics represents the inductive way to learn, i.e., by discovering patterns, rather than by confirming or disconfirming ingoing hypotheses.

Table 2. Sexual Intimacy: Four questions and four answers to each question.

 

Question A: How do you communicate to your partner that you want to exchange STD results before sexual activity?

A1

Discussing STD precautions planning in a phone conversation

A2

Discussing STD precautions planning through texting

A3

Discussing STD precautions planning in an email

A4

Discussing STD precautions planning during lunch

 

Question B: How do you ensure your own safety before, during, and after sex?

B1

Using condoms during sex

B2

Getting tested regularly

B3

Both partners using birth controls

B4

Knowing partner’s prior sexual history

 

Question C: When is the best time to have a conversation with your partner about safe sex?

C1

Talking about safe sex when you first start dating

C2

Talking about safe sex before engaging in sexual activity

C3

Talking about safe sex during the first conversation about intimacy

C4

Talking about safe sex on the first date

 

Question D: What kind of answers do you think a partner can give your request for safe sex?

D1

Partner says: “Let’s get tested”

D2

Partner says: “There’s no need for safe sex”

D3

Partner says: “Let’s use protection”

D4

Partner says: “Safe sex is the best move”

The researcher combines these elements (the answers A1-D4) into small, easy to read combinations, so-called vignettes. The actual experimental design is created as ‘kernel,’ in which the 16 elements are statistically independent of each other, allowing for subsequent analysis by OLS (ordinary least-squares) regression. The kernel, or basic experimental design is permuted so that the design structure remains the same, but the individual combinations changes in a permutation pattern (Gofman & Moskowitz, 2010.) [11] Table 3 shows the experimental design for one respondent (independent variables in the subsequent analysis), and then the ratings, binary transformation (Bin) and Consideration or response Time (CT) (the dependent variables in the subsequent analysis.)

Table 3. Example of the data from one respondent, prepared for statistical analysis.

 

The 16 answers or elements in binary form.
1=present in the vignette, 0=absent from the vignette

Ratings & transformation
 Top3 = Comfortable

Vig

A1

A2

A3

A4

B1

B2

B3

B4

C1

C2

C3

C4

D1

D2

D3

D4

Rating

Top3

CT

1

0

1

0

0

0

1

0

0

1

0

0

0

0

0

0

1

9

100

9.0

2

0

1

0

0

0

0

1

0

0

1

0

0

1

0

0

0

9

100

6.9

3

1

0

0

0

0

0

0

1

0

0

0

0

1

0

0

0

5

1

9.0

4

0

0

0

0

0

0

1

0

0

1

0

0

0

1

0

0

3

1

9.0

5

0

0

0

0

0

1

0

0

0

0

0

1

0

0

0

0

3

1

0.7

6

0

0

0

1

0

0

1

0

0

0

0

0

0

0

0

1

5

0

0.4

7

0

0

1

0

0

0

0

1

0

0

0

0

0

0

0

0

8

100

0.3

8

1

0

0

0

0

0

0

0

0

1

0

0

0

0

0

1

4

1

0.7

The structure of the vignettes follows these conventions:

The experimental design, metaphorically a booklet of recipes of the same ingredients to create different dishes. The experimental design specifies the composition of vignettes comprising two elements, three elements, and four elements, respectively.

Each respondent is required to evaluate 24 vignettes, all different from each other. Across the 24 vignettes, each element appears five times and is absent 19 times. A vignette comprises at most one element or answer from any question (Table 3.) This strategy of testing both complete vignettes (one answer from each question) and incomplete vignettes (no answer from either one or two questions) ensures that the analysis of the data by OLS (ordinary least-squares) regression generates coefficients having absolute value, where ratios of coefficients are meaningful.

Each respondent evaluates 24 unique, different vignettes. The underlying experimental design ensures that the 24 vignettes for each respondent differ from the 24 vignettes for any other respondent. The benefit to this permutation scheme is that the Mind Genomics experiment covers a great deal of the so-called ‘design space’. The benefit to the researcher is one need not know ‘what works’ ahead of the study. In contrast, in other research methods using experimental design of messages (so-called conjoint analysis; Green & Srinivasan, 1990), [12] the researcher selects one set of combinations, and tests that set with many people in order to suppress the variation by averaging. Whether averaging out the variation in the typical approach or averaging out the variation by looking at a great deal of the design space ultimately proves to be better is still a matter of dispute.

Table 3 show the 24 vignettes as rows. The 16 elements are shown as A1-D4, corresponding to the four questions and the four answers in each question featured in Table 1.

The column labelled Rat is the 9-point rating assigned to the vignette by the respondent. Table 3 shows the respondent ratings of all 24 vignettes.

The column labelled Top3 is the ‘binary’ transformation of the 9-point ratings, with ratings of 1–6 transformed to 0, and a very small random number added to the transformed number For ratings 7–9 the rating is transformed to 100, and again a very small random number is added to the transformed number.

The addition of the random number is done so that the regression analysis will not ‘crash’ when the analysis creates individual-level models to generate mind-set segments. When a respondent rates all 24 vignettes between either 1–6 or between 7–9, respectively, then transformed ratings will all become either 0 or 100, respectively for the Top 3 measure, and the regression model using the Top3 measure as the dependent variable will ‘crash.’ Adding a small random number prevents that crash, ensuring that the statistical analysis proceeds without incident.

Finally, the column labelled CT is Consideration Time, or Response Time, defined as the number of seconds elapsing between the presentation of the vignette on the screen and the rating assigned by the respondent. The vignettes are short, so that any Consideration Time longer than 9 seconds is assumed to reflect the respondent’s multi-tasking and is brought to the value 9.0. The use of the term Consideration Time makes the number more meaningful to the reader, because the magnitude of the CT can be associated with the time it takes the respondent to consider the element.

The analysis of Mind Genomics data proceeds in a straightforward manner, enabled by the experimental design for the creation of the different vignettes. The experimental design created for a single individual ensures that the 16 elements or answers for that individual appear independently of each other among the 24 vignettes. Putting together a set of such experimental designs, each different from the others simply by a permutation scheme, maintain the statistical independence of the 16 elements.

An easy-to-interpret analysis (OLS Regression) relates the presence/absence of the 16 elements to the binary rating. OLS regression uses the 16 elements as independent variables, and the binary transformation, Top3, as the dependent variable. The regression incorporates the relevant cases, namely the 24 rows from each respondent who belongs to the subgroup. Thus, when it comes to the model or equation for ‘males,’ only the data from the male respondents are used. Each male respondent contributes 24 cases or observations.

The regression model estimates the parameters of this simple equation: Top3 = k0 + k1(A1) + k2(A2) … + k16(D4). Top3 is defined as ‘comfortable talking about the topic.

The parameters for the total panel and key subgroups appear in Table 4. The table shows total panel, gender, age groups, relationship status, and the response from all respondents, but broken out into the results from Vignettes 1–12 (Half1) and then from Vignettes 13–24 (Half2). This final comparison shows us whether the respondents ‘change their criteria’ as the study proceeds

Table 4. Parameters (additive constant, coefficients) for equations relating the presence/absence of the 16 elements for binary transformed rating ‘comfortable talking about the topic (prevention of sexually transmitted disease.)’. The table is sorted by the coefficients for the total panel.

 

Top 3 = Comfortable talking about the topic

Tot

Male

Fem

A25 Older

A24 Younger

Q3 Single

Q3 Relationship

Half1

Half2

 

Additive constant (k0)

61

55

65

73

43

60

62

62

61

D3

Partner says: “Let’s use protection”

6

5

8

6

6

6

6

5

6

A1

Discussing STD precautions planning in a phone conversation

4

2

6

3

6

6

1

5

3

D4

Partner says: “Safe sex is the best move”

4

3

4

5

3

7

0

9

-4

B2

Getting tested regularly

4

8

0

3

4

-1

9

5

3

A2

Discussing STD precautions planning through texting

3

-3

8

-1

6

1

4

-10

15

B3

Both partners using birth controls

3

8

-3

-3

10

-5

11

13

-11

C2

Talking about safe sex before engaging in sexual activity

3

4

3

-2

10

6

1

0

6

B4

Knowing partner’s prior sexual history

3

9

-2

3

3

-2

9

5

3

B1

Using condoms during sex

2

4

1

-1

6

-4

8

7

-4

C3

Talking about safe sex during the first conversation about intimacy

2

8

-4

-2

7

3

0

-2

5

C1

Talking about safe sex when you first start dating

-2

1

-3

-4

3

-3

0

-3

0

D1

Partner says: “Let’s get tested”

-2

-6

2

-2

-2

-4

0

-1

-6

A4

Discussing STD precautions planning during lunch

-2

-8

3

-1

-4

-3

-2

-6

2

A3

Discussing STD precautions planning in an email

-3

-2

-3

-5

0

-3

-3

-8

3

C4

Talking about safe sex on the first date

-8

-5

-10

-8

-7

-8

-8

-9

-6

D2

Partner says: “There’s no need for safe sex”

-28

-22

-33

-27

-29

-30

-26

-25

-33

The additive constant is a measure of basic comfort talking about the topic, but with no elements in the vignette. The basic comfort for the total panel is 61, meaning that in the absence of any elements, 61% of the responses will be 7–9. That is, about 3 in 5 times the response will be ‘comfortable.’ The only group showing less comfort is the younger respondents (additive constant = 43), whereas their complementary age group, the older respondents, age 25 and older, is more comfortable (additive constant = 73).

There are some elements which ‘stand out’ from the others, topics about which the respondents feel very comfortable discussing. The elements below list the strong performing elements. Although there are strong performing elements, as shown by the coefficient, an underlying theme or story does not appear.

Total – None

Males

Knowing partner’s prior sexual history
Getting tested regularly
Both partners using birth controls
Talking about safe sex during the first conversation about intimacy

Females

Partner says: “Let’s use protection”
Discussing STD precautions planning through texting

Age 25 or older – None

Age 24 or younger

Talking about safe sex before engaging in sexual activity
Both partners using birth controls

Single – None

In a relationship

Both partners using birth controls
Getting tested regularly
Knowing partner’s prior sexual history
Using condoms during sex

First half of the individual’s vignettes (vignette 01- vignette 12)

Both partners using birth controls
Partner says: “Safe sex is the best move”

Second half (vignette 13 – vignettes 24)

Discussing STD precautions planning through texting

An increasing focus of Mind Genomics is upon Consideration Time (CT). In experimental psychology the term Consideration Time may be replaced by either Reaction Time or Response Time. CT is defined as the number of seconds (to the nearest tenth of second) between the presentation of the test stimulus, the vignette, and the rating assigned by the respondent. The term Consideration Time’ is used to underscore that the response is not only the time to perceive and react, but to read and consider.

The computation of response time is straightforward. The Mind Genomics algorithm relates the response time to the presence/absence of the elements, using the same form of equation as done for the Top3 value (comfort, in Table 3). The only difference is that the equation for consideration time has no additive constant. That is, the ingoing assumption is that without any elements in the vignette, the consideration time should be 0.

Table 5 shows the six elements with long consideration times in at least one group of responses or in either the first half or the second half of the Mind Genomics experiment, respectively. In turn, Table 6 shows the Consideration Times for the full set of elements across the different subgroups.

Table 5. The six elements showing long (estimated) consideration times of 1.5 seconds or longer.

 

Elements showing long consideration times (1.5 seconds +)

Groups

C3

Talking about safe sex during the first conversation about intimacy

4

C2

Talking about safe sex before engaging in sexual activity

3

B3

Both partners using birth controls

2

A4

Discussing STD precautions planning during lunch

1

D4

Partner says: “Safe sex is the best move”

1

B4

Knowing partner’s prior sexual history

1

To give a perspective, the typical consideration time of a full vignette for less serious topics may be 1–2 seconds. People make up their mind quickly for topics considered to be of minor import, perhaps System 1 in the language of Nobel Laureate Daniel Kahneman in his book Thinking Fast, Thinking Slow (Kahneman, 2011) [13] In contrast, topics of sexual discussion may involve System 2, the slower, more deliberate thinking which is the hallmark of a serious topic.

Table 6. The full set of consideration times for the total panel and key subgroups.

 

Consideration Time

Total

Male

female

Age 25+

Age 24 Younger

Single

Relationship

First Half

Second Half

B3

Both partners using birth controls

1.4

1.4

1.4

1.5

1.4

1.6

1.2

1.5

1.0

C2

Talking about safe sex before engaging in sexual activity

1.4

0.8

1.9

1.3

1.5

1.0

1.7

1.6

1.2

C3

Talking about safe sex before engaging in sexual activity

1.4

1.4

1.5

1.3

1.7

1.6

1.3

1.6

1.4

A4

Discussing STD precautions planning during lunch

1.3

1.2

1.3

0.9

1.8

1.1

1.4

1.3

1.1

B1

Using condoms during sex

1.3

1.2

1.3

1.3

1.2

1.3

1.2

1.4

1.0

A2

Discussing STD precautions planning through texting

1.2

1.1

1.2

1.1

1.3

1.2

1.1

1.3

1.1

B4

Knowing partner’s prior sexual history

1.2

1.0

1.3

1.0

1.4

1.4

0.9

1.6

0.7

C1

Talking about safe sex when you first start dating

1.1

0.8

1.4

0.9

1.4

1.2

1.1

1.4

0.9

D4

Partner says: “Safe sex is the best move”

1.1

1.0

1.2

0.9

1.3

1.2

1.1

1.5

0.8

A1

Discussing STD precautions planning in a phone conversation

1.0

0.9

1.0

0.9

1.1

1.1

0.8

0.6

1.3

A3

Discussing STD precautions planning in an email

1.0

1.0

1.1

1.0

1.0

1.0

1.0

1.1

1.0

C4

Talking about safe sex on the first date

1.0

0.8

1.1

1.0

0.9

1.1

0.9

1.0

1.1

B2

Getting tested regularly

0.9

0.9

0.9

1.0

0.8

1.0

0.8

1.1

0.6

D3

Partner says: “Let’s use protection”

0.9

0.6

1.2

0.9

0.7

1.0

0.8

1.4

0.3

D2

Partner says: “There’s no need for safe sex”

0.8

0.8

0.8

0.7

1.0

0.7

1.0

1.0

0.6

D1

Partner says: “Let’s get tested”

0.7

0.8

0.7

0.6

0.9

0.8

0.7

1.4

0.2

Three emergent mind-sets

One of the ongoing tenets of Mind Genomics is that within any topic where human judgment plays a role, there are usually at least two different groups of people, having different criteria about the same topic. That is, for those topics involving judgment, people disagree. The disagreement may be minor, or major, depending upon the people, the topic, and the information presented.

Researchers have uncovered these differences as a matter of course when studying the criteria for human judgment. The differences themselves exist, but Mind Genomics goes one step further beyond noting the differences. Mind Genomics attempts to uncover, classify and then understand the nature of these differences, creating a set of mind-sets embodying the different criteria for judgment. Mind Genomics can go one step further, creating a tool, the PVI (personal viewpoint identifier), to predict the way new people will respond to the information, i.e., an assignment tool. The analogy is to color science and colorimetry. Mind Genomics creates the ‘color science’ for a topic, and then crafts the tool to identify these mind-sets in the population at large. In the interest of length, the PVI for these data are not presented in this paper.

Mind Genomics follows these steps to identify the emergent mind-sets, with all the information needed present in the data from the basics study:

  1. Create the data matrix, with the rows corresponding to the respondents, and the columns corresponding to the elements. For the data presented here, the data matrix comprises 16 columns, one for each element. (The additive constant is not used). The data matrix comprises 50 rows, one row for each respondent.
  2. Define the distance between rows (respondents) by a single number. The choice of the number can range from the simple Euclidean distance to a distance between patterns, defined as (1-Pearson correlation between two rows). Mind Genomics uses the latter (1 – Pearson Correlation, or 1-R).
  3. The distance metric (1-R) ranges from a low of 0 when two rows are perfectly correlated, to a high of 2 when two rows are perfectly but inversely correlated.
  4. The program, k-means clustering (Dubes & Jain, 1980), [14] creates complementary and exhaustive groups, called clusters or segments.
  5. Mind Genomics creates two clusters and assigns each respondent to one of the two clusters.
  6. Mind Genomics then creates three clusters, and assigns every respondent to one of the three clusters
  7. The data from respondents in each cluster are analyzed separately, first for the model for comfort (Top3) and then for the model for Consideration Time.
  8. The strongest performing elements for each set of clusters are used to determine whether there is a coherent story (interpretability), and whether the number of clusters is as few as necessary (parsimony). It is important to have as few clusters (mind-sets) as possible, provided that the clusters are interpretable, i.e., make sense.

Table 7 suggests three mind-sets, based upon the clustering using the coefficients for comfortable. Recall that the ingoing coefficients come from the data wherein the response (1–9 scale) was converted to 0 (ratings 1–6) or 100 (ratings 7–9.).

Table 7. Coefficients for ‘Comfortable with talking about the topic of preventing sexually transmitted disease,’ as well as Consideration Time, for three emergent mind-sets.

 

 

Top 3 = Comfortable talking about the topic

 

Consideration
Time

 

 

MS1

MS2

MS3

 

MS1

MS2

MS3

 

Additive constant (k0)

59

69

52

 

 NA

 NA

NA 

 

Mind-Set 1 – Actual conversation

 

 

 

 

 

 

 

D3

Partner says: “Let’s use protection”

17

2

-2

 

0.9

0.9

0.8

D4

Partner says: “Safe sex is the best move”

10

3

-9

 

1.3

1.0

1.1

B2

Getting tested regularly

9

0

-5

 

0.9

1.0

0.7

D1

Partner says: “Let’s get tested”

9

-6

-14

 

1.0

0.5

0.8

 

Mind-Set 2 – Discuss safe sex as prelude to intimacy

 

 

 

 

 

 

 

A1

Discussing STD precautions planning in a phone conversation

1

7

-4

 

0.5

1.9

-0.3

C2

Talking about safe sex before engaging in sexual activity

-1

7

-2

 

1.2

1.6

0.9

C3

Talking about safe sex during the first conversation about intimacy

-2

5

0

 

1.5

1.6

1.0

 

Mind-Set 3 – Safe sex the responsibility of both partners

 

 

 

 

 

 

 

B3

Both partners using birth controls

4

0

5

 

1.3

1.8

0.7

 

Not- comfortable for any segment

 

 

 

 

 

 

 

C1

Talking about safe sex when you first start dating

-6

-1

4

 

1.3

1.0

0.9

B4

Knowing partner’s prior sexual history

6

0

1

 

1.5

1.3

0.5

A2

Discussing STD precautions planning through texting

1

4

0

 

0.9

1.7

0.3

B1

Using condoms during sex

4

2

-1

 

1.4

1.4

0.6

A4

Discussing STD precautions planning during lunch

-11

1

-1

 

0.8

2.0

0.2

A3

Discussing STD precautions planning in an email

-1

-7

-4

 

0.3

2.0

0.0

C4

Talking about safe sex on the first date

-13

-6

-5

 

0.9

1.2

0.6

D2

Partner says: “There’s no need for safe sex”

-13

-50

-7

 

0.8

1.1

0.5

The three mind-sets can be really divided into one group which feels comfortable with actual conversation as shown by quotation marks (Mind-Set 1), and the remaining two groups, which are less responsive to the elements. We might be satisfied with two mind-sets, not three, one responsive to conversation (Mind-Set 1), and others. On the other hand, the differences between Mind-Set 2 (Discuss safe sex as a prelude to intimacy) and Mind-Set 3 (Safe sex as the responsibility of both partners) points to some key differences between these two groups. That difference between Mind-Sets 2 and 3 is underscored by the differences between the mind-sets in terms of Consideration Time. Mind-Set 2 (discuss safe sex) spends a lot longer than Mind-Set 3 (focuses on responsibility) when reading and rating the vignettes.

Study 2 – Recourse & Protection for the sex worker

The recent literature is replete with discussions of sex trafficking, and other offenses (Van der Meulen, et. al., 2018; Kempadoo & Doezema, 2018) [15, 16] Those stories talk about the system which creates and benefits from the sex worker, and not generally about the sex worker in terms of emotions and personal development (Bekteshi et. al., 2012; McClain & Garrity, 2011.) [17, 18].

This second study was inspired by the interests of marketing students in a graduate course in Bogota, Colombia. The students under the instruction of a8uthor Herrera, investigated the nature and magnitude of the interaction between the WHO (who is the sex worker), the DANGER (what is the danger facing a sex worker in Colombia), as they drive the response of ‘protection of’ and ‘legal recourse available to’ the sex worker. Over the past decades there has been a recognition that prostitution and allied activities constitute a profession with the workers deserving he benefits and protection due to any person who works in a job. The study approach was the same, in terms of creating the four questions, developing four answers to each question (Table 8), and then presenting the vignettes to the respondents. The 24 students themselves offered to be respondents, and so we present this second study as a methodological advancement within the emerging science of Mind Genomics.

Table 8. Sex worker – Four questions and four answers to each question.

 

Question A: Who is the person who is the sex worker?

A1

Worker: A young woman who is just starting out in life

A2

Worker: An older woman who has gone bankrupt

A3

Worker: A young, very handsome, male student who needs money

A4

Worker: A young, very beautiful, female student who needs money

 

Question B: What is a danger which confront a sex worker?

B1

Danger: Getting beaten up and robbed

B2

Danger: Not getting paid

B3

Danger: Shunned as undesirable person

B4

Danger: Shame and disgraceful feelings inside

 

Question C: How do we institute ongoing physical safety for the sex worker?

C1

Protection: Have officers assigned to red light districts

C2

Protection: Register them and give them safety electronic alarms

C3

Protection: Have the local newspaper write positive articles about sex workers

C4

Protection:  Have a special legal office to deal with those hurt sex workers

 

Question D: What legal recourse can we create for the sex worker?

D1

Legal Recourse: Special attorneys for sex workers

D2

Legal Recourse: Steep fines for those who cheat sex workers

D3

Recourse: Special “shaming” notices for those who hurt sex workers

D4

Legal Recourse: Union for sex workers, to increases rights

Creating scenarios to uncover interactions among answers

The first study presented in the previous sections treated all 16 answers as independent variables, which in fact they are. In this second study, we created the study specifically to comprise a WHO (the sex worker), the danger that the person would face (DANGER), and then two different types of protection (ongoing physical safety, legal recourse, respectively.) Thus, the first two answers are really ‘set-ups’ to frame the information, that information given by protection and recourse. The objective was to identify how different ‘set-ups,’ i.e., combinations of WHO and DANGER, drive the response to protections and to recourse, respectively. The analysis below explicates the approach to study interactions, using two sets of vignettes. The first set comprises a single sex worker exposed to four different dangers. The second set comprises four sex workers, each facing the same danger.

Set 1 – sex worker constant, danger varies

Select one person to study. It does not matter which one, since we are interested in the method. For the sake of simplicity, we study one specific sex worker; an older woman who has gone bankrupt. We create five different strata, varying by the danger to which the individual (older woman) can be exposed. Each stratum thus can be defined as having one type of worker (the older woman), and one type of danger. Each individual danger and ‘no danger’ jointly define the stratum. For each stratum we run a simple model using the eight elements as predictors, the four elements describing physical protection, and the four elements describing legal recourse. Our model has no additive constant, because the rating is ‘agree/disagree.’ The additive constant makes no intuitive sense. We create this model for the rating question, again converted to binary (Top2, for agree), and then for consideration time. Table 9 presents the coefficients for agree (coefficients of 60 or higher shown in shaded cells, bold type.) Table10 presents the coefficients for consideration time (5 seconds and higher shown in shaded cell, bold type.) Both tables also show the average coefficient across all eight elements.

Table 9. Interactions between Sex Worker, Danger as stratifying variables, and legal recourse and protection as variables to be considered when disagreeing or agreeing.

 

 Person constant, danger varies

Worker: An older woman who has gone bankrupt

 

Agree (Top2 on the 5-point rating scale)

Danger: Absent from vignette

Danger: Not getting paid

Danger: Shunned as undesirable person

Danger: Getting beaten up and robbed

Danger: Shame and disgraceful feelings inside

 

Average Agree Coefficient
across C1-D4

31

25

22

22

21

D1

Legal Recourse: Special attorneys for sex workers

64

35

66

20

101

C3

Protection: Have the local newspaper write positive articles about sex workers

61

40

45

14

-14

C1

Protection: Have officers assigned to red light districts

46

9

12

47

-114

C2

Protection: Register them and give them safety electronic alarms

40

51

12

26

8

C4

Protection:  Have a special legal office to deal with those hurt sex workers

21

4

-20

12

-59

D3

Recourse: Special “shaming” notices for those who hurt sex workers

16

41

37

25

114

D2

Legal Recourse: Steep fines for those who cheat sex workers

1

44

49

60

80

D4

Legal Recourse: Union for sex workers, to increases rights

0

-27

-23

-30

49

The coefficients are high because two of the variables are not considered in the model. Thus, the binary transformed rating, ‘agree’ (4–5), must be allocated across eight elements, not 16 elements, even though the vignettes still comprised 2–4 elements.

What is remarkable about the table is the dramatic interaction among the ingoing facts of the case, specifically WHO the sex worker is, and the DANGER the sex worker faces, and the specific protections and recourses selected.

  1. On average across the eight elements (four protection, four recourse), the level of agreement is similar close across all four Dangers for the single person (older woman)
  2. Yet, the specific interactions are dramatic. For example, when the Danger is shame and disgraceful feelings inside’ the sex worker, the strongest Recourse is: Special “shaming” notices for those who hurt sex workers. In contrast, when the Danger is getting beaten up and robbed, the strongest performing else is the legal Recourse: Steep fines for those who cheat sex workers.

When we move to Consideration Time (Table 10), we see that with an older woman who has gone bankrupt, we emerge with dramatically different Consideration Times. The longest Consideration Time comes from the combination of the older woman with ‘not getting paid’ and with ‘shunned as undesirable person’, both an average of 4.6 seconds.

Table 10. Interactions between Sex Worker, Danger as stratifying variables, and legal recourse and protection as variables driving ‘Consideration Time’ when rating disagree vs agree.

 

Person constant, danger varies

Worker: An older woman who has gone bankrupt

 

Consideration Time

Danger: Absent from vignette

Danger: Not getting paid

Danger: Shunned as undesirable person

Danger: Getting beaten up and robbed

Danger: Shame and disgraceful feelings inside

 

Average Consideration Time across C1-D4

3.5

4.6

4.6

3.6

2.0

C4

Protection:  Have a special legal office to deal with those hurt sex workers

7.1

3.6

4.9

2.3

0.5

C1

Protection: Have officers assigned to red light districts

5.8

6.0

7.4

-3.7

-6.4

C2

Protection: Register them and give them safety electronic alarms

5.5

5.4

4.2

-1.2

-2.1

C3

Protection: Have the local newspaper write positive articles about sex workers

4.6

7.3

3.9

1.1

-1.6

D1

Legal Recourse: Special attorneys for sex workers

3.8

3.5

3.3

6.1

0.6

D3

Recourse: Special “shaming” notices for those who hurt sex workers

0.8

2.3

6

7.8

7.7

D2

Legal Recourse: Steep fines for those who cheat sex workers

0.5

4.2

4.1

7.9

9.1

D4

Legal Recourse: Union for sex workers, to increases rights

0.2

4.5

3.2

8.2

8.1

There is also a noticeable interaction between the person (older woman who has gone bankrupt), the nature of the danger from the outside (not getting paid / shunned as undesirable), versus from the inside (‘’shame and disgraceful feelings.”). The outside actions / dangers generate longer Consideration Times.

The Consideration Times do not generate as clear a pattern as do the Agreement coefficients. So-called ‘objective measures’ in research may be attractive because of a belief that they are ‘tapping something real,’ but the interpretation of what they are tapping may be harder, and undoubtedly problematic.

Set 2 – danger constant, person varies

Select one danger to study. It does not matter which danger is held constant for purposes of explicating the approach. For simplicity, we focus on an emotional danger from the person’s self-image, ‘shame disgraceful feeling inside.’ As before, we create five different strata anew, varying by the sex worker. Thus, each of five strata has one danger (shame disgraceful feeling inside) and one of four sex workers, as well as the case of ‘no sex worker’.

For each of the five strata we run a simple model using the eight elements as predictors, as we did before, the four for physical protection, and the four for legal protection, respectively Our model has no additive constant. Table 11 presents the coefficients for agree (coefficients of 60 or higher shown in shaded cells, bold type.) Table 12 presents the coefficients for consideration time (5 seconds and higher shown in shaded cell, bold type.) Both tables also show the average coefficient across all eight elements.

  1. On average, for a given danger, the average coefficients vary, from a high achieved by vignettes featuring the young woman who is just starting out (average coefficient = 35), to a low achieved by vignettes featuring an older woman who has gone bankrupt (average = 21).
  2. When the danger is ‘shame and disgraceful feelings inside’), most of the strong performing elements are plausible, i.e., legal recourse, rather than protection. The shame and disgraceful feelings do not present danger.

Table 11. Interactions between Danger and Worker as stratifying variables, and legal recourse and protection as variables to be considered when disagreeing or agreeing.

 

Danger constant, person varies

Danger: Shame and disgraceful feelings inside

 

Agree: Needs social intervention below

Worker: Absent from vignette

Worker: A young woman who is just starting out in life

Worker: A young, very beautiful, female student who needs money

Worker: A young, very handsome, male student who needs…

Worker: An older woman who has gone bankrupt

 

Average coefficient C1-D4

40

35

31

30

21

D4

Legal Recourse: Union for sex workers, to increases rights

67

67

120

-28

49

D2

Legal Recourse: Steep fines for those who cheat sex workers

60

11

-8

70

80

D1

Legal Recourse: Special attorneys for sex workers

49

50

54

19

101

D3

Recourse: Special “shaming” notices for those who hurt sex workers

44

-21

33

41

114

C1

Protection: Have officers assigned to red light districts

36

49

37

33

-114

C3

Protection: Have the local newspaper write positive articles about sex workers

34

33

22

28

-14

C2

Protection: Register them and give them safety electronic alarms

34

47

-19

48

8

C4

Protection:  Have a special legal office to deal with those hurt sex workers

-3

42

9

29

-59

Finally, Table 12 shows the how Consideration Time for each of the protection and recourse elements vary with the single fixed danger (shame and disgrace inside), the four different types of sex workers, and the Consideration Time. All Consideration Times are high (4.2- 4.8) except for the older woman who has gone bankrupt (2.0). For the younger sex workers, the focus is protection. For the older sex worker, the focus is legal recourse.

Table 12. Interactions between Danger and Worker as stratifying variables, and legal recourse and protection as variables affecting Consideration Time when assigning a rating of disagree agree for legal recourse and protection.

 

Danger constant, person varies

Danger: Shame and disgraceful feelings inside

 

Consideration Time

Worker: Absent from vignette

Worker: A young woman who is just starting out in life

Worker: A young, very beautiful, female student who needs money

Worker: A young, very handsome, male student who needs

Worker: An older woman who has gone bankrupt

 

Average Consideration Time C1-D4

3.9

4.6

4.8

4.2

2.0

C1

Protection: Have officers assigned to red light districts

9.4

7.0

8.8

2.3

-6.4

C4

Protection:  Have a special legal office to deal with those hurt sex workers

9.2

6.7

9.1

2.9

0.5

C3

Protection: Have the local newspaper write positive articles about sex workers

7.9

5.0

5.7

4.5

-1.6

C2

Protection: Register them and give them safety electronic alarms

6.7

3.0

4.3

3.5

-2.1

D4

Legal Recourse: Union for sex workers, to increases rights

0.6

7.4

4.7

4.3

8.1

D3

Recourse: Special “shaming” notices for those who hurt sex workers

-0.4

0.1

5.3

5.6

7.7

D2

Legal Recourse: Steep fines for those who cheat sex workers

-1.0

1.9

-0.1

6.6

9.1

D1

Legal Recourse: Special attorneys for sex workers

-1.2

5.3

0.9

3.7

0.6

Discussion – Mind Genomics as a tool to map and to understand relationships

As suggested by the introduction, the field of sexuality, and especially the sexual behavior of intimate couples and the issues involved with sex workers have created in their wake an enormous literature. This paper does not address that literature, and especially does not attempt to answer questions raised by previous studies. Such an effort requires an encyclopedia of papers, not a single short research note. Rather, the objective here is to introduce a way to understand a topic from the inside-out, from the mind of the person, from a combination of psychological ‘thinking’ and consumer research methods.

The tradition of today’s science can be summarized by the term ‘hypothetico-deductive.’ The term means that we create a hypothesis about the nature of behavior, and then perform the requisite experiments either to falsify the hypothesis, or to not-falsify it. Not falsifying a hypothesis does not mean that the hypothesis is correct, but rather that for the time-being the hypothesis may be accepted. The focus of today’s research thus becomes increasingly narrow. The rigors of scientific research demand an almost superhuman concentration to focus the research on the specific problem. Little is left to the exploration of new ideas.

When it comes to the study of human behavior, the many aspects, the nuances, and the impossible-to-remove interactions among the variables make the hypothetico-deductive system interesting, but not particularly productive. One has pieces of information, some convincing than others. Yet, one is missing a narrative, not necessary spun from narratives and stories, but rather emerging from easy-to-do studies. The sheer difficulty of doing inexpensive, comprehensive, focused experiments with people force the researcher either to rely on questionnaires (self-reports), or to weave a story from interviews, or a limited number of experiments.

The approach presented here, Mind-Genomics, demonstrates the opportunity to create a new archival literature on people, personal relations, focusing either on specifics, on limited topics, or on a set of topics which bring into focus a bigger picture. What we see in these two studies is the relative ease of doing computer-aided experiment with messaging in order to identify how the person thinks about a topic. The experiments are short, iterative, yet generate information emerging from the structure of the experiment. The test stimuli are cognitively rich. The richness means that beyond the emergent patterns (what other studies discover) lies the responses to individually, meaningful, relevant, and possible important stimuli. The responses to the individual stimuli teach, rather than having value simply because they are part of an emergent pattern.

Acknowledgement

Attila Gere wishes to acknowledge and thank the Premium Postdoctoral Research Program of the Hungarian Academy of Sciences.

References

  1. Moskowitz HR, Gofman A, (2007) Selling blue elephants: How to make great products that people want before they even know they want them. Pearson Education.
  2. Box GE, Hunter WG, Hunter JS (1978) Statistics for experimenters, New York, John Wiley.
  3. Boring EG (1929) A History of experimental psychology. The Century Company, New York.
  4. Fisher TD, Davis CM, Yarber WL (2013) Handbook of sexuality-related measures. Routledge.
  5. Montesi JL, Conner BT, Gordon EA, Fauber RL, Ki KH, et al. (2013) On the relationship among social anxiety, intimacy, sexual communication, and sexual satisfaction in young couples. Archives of Sexual Behavior 42: 81–91. [Crossref]
  6. Stephenson KR, Meston CM (2010) When are sexual difficulties distressing for women? The selective protective value of intimate relationships. The Journal of Sexual Medicine 7: 3683–3694. [Crossref]
  7. Harvey SM, Washburn I, Oakley L, Warren J, Sanchez D (2017) Competing priorities: Partner-specific relationship characteristics and motives for condom use ang at-risk young adults. The Journal of Sex Research 54: 665–676. [Crossref]
  8. Katz BP, Fortenberry JD, Zimet GD, Blythe MJ, Orr DP (2000) Partner-specific relationship characteristics and condom use among young people with sexually transmitted diseases. Journal of Sex Research 37: 69–75.
  9. Peplau LA, Rubin Z, Hill CT (1977) Sexual intimacy in dating relationships. Journal of Social Issues 33: 86–109.
  10. Widman L, Welsh DP, McNulty JK, Little KC (2006) Sexual communication and contraceptive use in adolescent dating couples. Journal of Adolescent Health 39: 893–899. [Crossref]
  11. Gofman A, Moskowitz H (2010) Isomorphic permuted experimental designs and their application in conjoint analysis. Journal of Sensory Studies 25: 127–145.
  12. Green PE, Srinivasan V (1990) Conjoint analysis in marketing: New developments with implications for research and practice. The Journal of Marketing 54: 3–19.
  13. Kahneman D (2011) Thinking fast and slow. Macmillan.
  14. Dubes R, Jain AK (1980) Clustering methodologies in exploratory data analysis. Advances in Computers 19: 113–238.
  15. Van der Meulen E, Durisin EM, Love V (2013) Selling sex: Experience, advocacy, and research on sex workers in canada. (eds.). UBC Press.
  16. Kempadoo K, Doezema J (eds.), (2018) Global sex workers: Rights, resistance, and redefinition. Routledge.
  17. Bekteshi V, Gjermeni E, Van Hook M (2012) Modern day slavery: Sex trafficking in Albania. International Journal of Sociology and Social Policy 32: 480–494.
  18. McClain NM, Garrity SE (2011) Sex trafficking and the exploitation of adolescents. Journal of Obstetric, Gynecologic & Neonatal Nursing 40: 243–252. [Crossref]

Conferences Vs Candidates: Selling Intangibles to Ages, Genders & Mind-Sets

DOI: 10.31038/PSYJ.2019121

Abstract

Two studies were run to understand the driving factors for intangibles, the first study dealing with attendance at an academic/business conference, the second dealing with the likelihood of voting for a candidate promoting specific values. In each study, groups of US respondents, varying in age and gender, each evaluated unique sets of 24 vignettes, comprising 16 different messages with the vignettes created by experimental design, following the Mind Genomics paradigm.Noticeable and occasionally significant age and gender differences emerged in the set of elements driving positive responses, but the group differences did not tell a coherent story. Only when the respondents were divided into mind-sets, based upon the pattern of their responses did a coherent story emerge, both for the first experiment on conferences, and the second experiment on candidates. Focusing analysis on age and gender may hinder the search for more profound difference among people, one based upon mind-set. With mind-sets, inter-individual variation in thinking about a topic becomes to become more interpretable and meaningful.

Introduction

Convincing others to do something may occupy a great deal of time. Whether the convincing is to have a child eat or behave, convincing children to study, convincing another to become romantically involved, purchase, and so forth, the normal life of a person in society is grounded in the act of persuading.  A great deal of a nation’s literature, a great deal of psychology and sociology, not to mention economics, deals with the various aspects of attempts to convince.

Convincing individuals varies by the nature of the topic. Thousands of years ago the Greeks, masters of rhetoric, realized that it was both the substance of the argument and the form of the argument which were important.  Yet, to make the topic simple, we may summarize the process by first observing the problem, second by proposing solutions, third explaining how the solutions will work, and fourth, appealing to the individual interests of the audience.  Beyond that, the rest is method and content, respectively, for those wanting to do the convincing, and by the need states and susceptibilities of those who are to be convinced. The literature of decision making is vast and cannot be dealt in a simple ‘methods paper.’ Rather, the objective of this paper to present a new, alternative approach, Mind Genomics, which emerges from experimental psychology and disciplined behavioral science [1]. Mind Genomics at its heart comprises experiments which identify ‘causation’ when messages are used to convince a decision maker.

This paper introduces a relatively new approach to study the art of ‘convincing.’ Mind Genomicshas been used in the form of conjoint measurement to understand what messages one to use in order to convince. Mind Genomics focuses in the application of conjoint measurement to the decisions, and the decision rules, of the everyday experience [2, 3]. The paper use Mind Genomics to compare two types of ‘convincing,’ one to ‘sell a professional conference,’ the other to sell a ‘candidate’ for an election. Historically, conjoint measurement has been used to identify the relative importance of factors in a considered decision, such as insurance selection, or health benefits. The respondent is provided with pairs of stimuli, whose composition is known for each alternative in the pair. The respondent must select one of the two stimuli. The pattern of selections can be processed by an accepted computation scheme to generate the ‘utilities’ or ‘impact’ of each element of the set of elements.  The methods can be tedious, but have found use in large-scale, expensive, but critical decisions, such as the choice of medical and so forth [4].

Mind Genomics – foundations and processes

The scientific method teaches that variables should be separated and studied in ‘splendid isolation.’  For most variables the isolation works, but not necessarily in messages. Typically, messages come to people in combinations, with the different messages complementing each other, suppressing each other, or even synergizing with each other so that the whole, the combination, often is far more impactful than would be by the sum of individual impacts.   In normal life, we do not encounter single messages, except perhaps for those signaling ‘emergency’ or ‘danger.’  When we are exposed to single messages in a research context or in public opinion polling, we focus unduly on the topic, and give biased answers by trying to ‘guess’ the correct answer, or answer in the way that the researcher expects.

The Mind Genomics approach differs dramatically from the conventional one-at-a-time approach espoused by traditional research. The researcher presents the respondent with different combinations of messages, instructing the respondent to ‘vote’ for the combination.  The approach seems a bit odd, based upon the traditional method of ‘one at a time.’   When compared to conventional approaches, we can say that that the Mind Genomics approach is more Socratic, holistic, yet systematic, and oriented towards creating combinatorial models for persuasion and communication:

Holistic: The test stimuli are combinations of messages, not single messages alone. The holistic approach simulates what we see in real, daily life. For the most part, we deal with mixtures of stimuli coming at us all the time. When we talk, walk, drive, read, eat, and so forth, we do not pay attention to one variable, except perhaps for a very short time to examine it more closely. We live in the moment, the moment comprising a kaleidoscope of changing combinations.

Socratic: The Socratic method comprises a question and answer dialogue. Carried out effectively, the dialogue reveals the underlying structure of the topic. Socratic dialogue is not the pure science to which we are accustomed (nomothetic), for it is intensely individual rather than general (idiographic).  Yet, for topics studying the act of judgment itself, the Socratic method can generate the necessary test material by which the researcher uncovers some individual ‘rules’ of decision.  

Systematic: The abovementioned answers to questions are ‘elements,’ namely simple, easy to comprehend statements, almost factoids. These elements or answers to questions are combined by the discipline of experimental design into small, easy to read combinations. [2]. Mind Genomics is based upon the belief that when making a decision the respondent ‘grazes’ for information, rather than ingests, chews, and digests, respectively. The Mind Genomics research process recognizes grazing, and is designed to be fast and minimally intellectual, metaphorically similar to grazing at a superficial level. No effort is made to combine the different elements into a flowing paragraph.

Models:  Mind Genomics develops mathematical models showing how each element or answer ‘drives’ the response. The response may be a rating (would not attend to would attend, would vote for candidate to would vote for candidate), the selection of an emotion or feeling from a set of several alternatives (happy, sad, curious, excited, etc.), the selection of a price, the selection of an end use, etc.  The models show the linkage between the different elements and the rating.

Steps in the Process – Creation of raw materials through a Socratic process: The researcher selects a topic. The researcher then asks four questions which ‘tell a story.’ Asking the four questions can be hard, and forces creative and critical thinking. Most people are not educated to ask questions in a systematic way, in contrast to a reporter or writer who does so by habit when creating a coherent story. Once the four questions are asked, it become very easy to provide four simple answers to each question. The concern is often raised as to whether the questions are truly the ‘correct questions’ to ask, and in turn, whether the four answers to each question suffice, as well as whether or not they are the proper answer. It takes a while to disabuse the novice of the reality that there are no correct questions nor answers, but rather report ‘blocks’ at this stage, because they either cannot think of questions, and freeze up, or they take the instruction literally, and cannot ‘tell a story.’  With practice, however, they realize that the narrative can tell a story, but not the polished story to which they have been accustomed.

Steps in the Process –Creating the vignettes using experimental design to specify combinations: Mind Genomics traces back to the evaluation of combinations of messages, with the combinations prescribed by experimental design, or metaphorically by a set of recipes which combine the individual messages into known combinations. For the Mind Genomics studies run here, with the four questions and four answers per question, each respondent evaluated a unique set of 24 vignettes or combinations. Each vignette comprised 2, 3 or 4 answers, at most one answer from each question. The answers are coded 0 when absent from a vignette, and 1 when presented in a vignette. The experimental design ensures that each respondent evaluates the 16 answers in different combinations, and that the answers or elements are statistically independent of each other.  The statistical independence will allow the researcher to create individual-level equations, one for each respondent, relating the presence/absence of the 16 elements either to the binary transformed rating (0/100) or to the consideration time (CT).

Table 1 shows the schematic for eight vignettes from Respondent #1. The respondent evaluated the eight vignettes in sequence. The combination is defined by the experimental design. A ‘0’ represents the fact that the element was absent from the vignette. A ‘1’ represents the fact that the element was present in the vignette. The respondent rating on a 9-point scale was recorded, along with CT, consideration time, the number of seconds elapsing between the presentation of the vignette on the screen and the rating. The CT is recorded to the nearest tenth of a second.

Table 1. Eight vignettes from the conference study.

Order

A1

A2

A3

A4

B1

B2

B3

B4

C1

C2

C3

C4

D1

D2

D3

D4

Rating

CT

1

0

0

1

0

0

0

0

0

0

0

1

0

1

0

0

0

4

9.0

2

1

0

0

0

0

0

0

1

1

0

0

0

0

0

0

0

4

4.5

3

1

0

0

0

0

0

1

0

0

0

0

0

1

0

0

0

4

3.0

4

0

0

0

1

0

0

0

1

1

0

0

0

0

0

0

0

4

2.0

5

0

1

0

0

0

0

0

0

0

0

0

1

0

1

0

0

5

3.2

6

0

1

0

0

0

0

1

0

0

1

0

0

0

0

0

1

6

2.9

7

0

0

1

0

0

1

0

0

0

1

0

0

0

0

1

0

5

6.1

8

0

0

0

1

0

0

1

0

0

0

0

1

0

0

1

0

5

4.6

Study 1 – ‘Selling a conference’

Study 1 focused on how one ‘sells’ or at least advertises a conference about the evolving area of data analytics, when the audience comprises random people.

Conferences are important as a key venue for academics. It is important to market conferences, to communicate what the conference provides for the attendee [5]. Beyond the conference as an academic product to be marketed, the conference is a topic of interested in itself, The conference is a contained environment where relevant interpersonal behaviors are strongly demonstrated. Researchers have investigated conferences from the outside, from the benefits of the respondent [6].  One of the key benefits is making connections [7].

Conferences themselves are a venue for sociological and psychological research. The conference is a specific venue, offering the chance to observe a variety of different behaviors. For example, one research avenue is to study behavior at conferences in terms of the behaviors of males versus females. An anthropological approach might look at the conference as a venue wherein certain attitudes are manifest in behaviors, in the so-called ‘lived experience’ [8]. There are a variety of dimensions to conferences, dimensions which can serve as the foundation of research to understand the mind and motivations of those who attend the conference. These dimensions range from the conference as a venue of information to be disseminated and learned, involving different groups, such as academics versus practitioners, respectively [9, 10], as well as networking vs knowledge [11–13].  Then there is the ever-present dimension of the conference as a venue to introduce students, and to let the students interact with senior professionals [14, 15].

Table 2 presents the four questions and the 16 answers.   The actual questions were recorded, along with the answers, and then slightly edited to ensure proper English.  Note that the answers are simple, with three dots (…) replacing some connectives, to make reading easier.It is important to note that the elements or messages, i.e., the answers to the questions, are simple. They are descriptive, and generally feature a single idea. They will be combined in a simple way, as a set of phrases, centered, on the screen, one atop the other, with no effort to connect them. Although it seems quite ‘stark’ and unreal to have a paragraph or concept comprise a block of phrases with no connectives, the reality is that this structure makes the task easy for the respondent, who really ‘grazes’ for information, rather than reading the entire concept in depth.  When the same task is implemented with paragraphs created in better English style, as grammatically correct paragraphs, the task becomes onerous and boring. Mind Genomics studies are generally executed on the Internet, often with respondents recruited by a panel provider specializing in the process of panel creation and deployment for research studies. For this study, the researchers entered the questions, answers, and rating scale in a program designed to run these studies. The program, BimiLeap (short for Big Mind Learning Application), mixes the answers according to an experimental design, presenting 24 combinations of elements to each respondent who participates. The entire process takes 3–5 minutes for a respondent.

Table 2. Conference, list of elements.

 

Question A: What is the conference topic?

A1

teach how machines help you market and sell much better

A2

teach you how big data about people help you sell more

A3

marketing secrets to sell to customers

A4

learn how find a really good customer

 

Question B: What is special about the conference?

B1

features workshop …learn practice and grow

B2

have drinks and meals and snacks with real experts

B3

workshop to learn technology made easy and fun

B4

Meet interesting people who can really teach you

 

Question C: Who should attend the conference?

C1

made for new hired young folk

C2

for students to really make them grow

C3

business employers go to meet young potential hires

C4

students go to meet and select mentors

 

Question D: What is interesting about the conference beyond the topic?

D1

when you leave you free technology good & gift basket

D2

two days of fun BEFORE AND AFTER in a great location

D3

organized around an archaeological site you can explore

D4

near A SEASIDE TOWN IN SEASON

The respondents were 50 Americans, 18 years or older. The respondents were provided by a panel company specializing in providing anonymous respondents for these types of studies (Luc.id, Inc.)   The actual elements were created at a conference of professors and students. Each respondent evaluate a unique set of 24 vignettes, created by experimental design. The experimental design ensures that all 16 elements are statistically independent of each other, permitting the use of OLS, ordinary least-squares linear regression, to relate the presence or absence of the element to the rating.  An algorithm permuted or modified the specific combinations, maintaining the underlying experimental design, but ensuring that the specific combinations different from one respondent to another [16]. The research benefit of permutation is to generate a more representative and thus a more valid model because the researchtests more of the potential mixtures of elements. That is, rather than reducing variability by testing the same limited set of combinationsmany times, and suppressing variability by averaging it out, Mind Genomics deals with variability by covering a wider array of potential test combination. Mind Genomics is statistically powerful, and conservative by design, measuring many stimuli rather than imputing from a less noisy, far less representative sample of possible vignettes.

Ratings, transformations, and averages: The original ratings were assigned on a anchored 9-point scale (1=Do not choose … 9=Choose.) The practice of Mind Genomics is to divide the rating scale into two parts. We did this division two times. The first time was ‘Choose to attend’ (1–6 transformed to 0 to denote not choose to attend; 7–9 transformed to 100 to denote choose to attend).  The second time was ‘Reject’, (1–3 transformed to 100 to denote reject; 4–9 transformed to 0 to denote not reject.) The program further recorded the ‘consideration time’ (CT), operationally defined as the number of seconds between the appearance of the vignette on the screen and the respondent’s rating of the vignette on the 9-point scale.

Table 2 shows the mean ratings for the three dependent variables by key subgroups. These subgroups are total, gender, age, and the two mind-sets or clusters of respondents, with respondents in the same cluster showing similar patterns of response coefficients (see below).  It is clear from Table 2 that the subgroups differ from each other in their ratings.

Table 2A. Means of the dependent variables (Accept, Reject, Consideration Time) for key subgroups.

 

Conference – Means of Dependent Variables

Conference

Attend
(7–9 = 100)

Reject
(1–3 = 100)

CT
Consideration Time

Total

49

16

3.5

Male

57

13

3.0

Female

34

22

4.2

Young Age 21–39

43

8

2.9

Old Age 40+

51

20

3.8

Mind-Set 2A Attends for fun

48

16

4.0

Mind-Set 2B Attends for professional reasons

50

16

2.7

Males are much more likely to say ‘I will attend’ than are females (57 versus 34, meaning that 57% of the responses of males to the vignettes are 7–9, whereas only 34% of the responses of females are 7–9).

Older respondents are more likely to say I will attend than do younger respondents (51 vs 43)

Dividing the respondents into groups based upon the pattern of how elements drive ‘attend’ (i.e., mind-sets) suggest no difference in frequency of responding ‘attend,’ but as we will see, strong differences in the elements which drive them to say ‘attend.’

The differences in ‘reject’ can be interpreted in the same way.

When we measure the consideration time, we see that women take longer to respond, that older take longer to respond, and that Mind-Set 2A takes longer to respond

Thus far, all that the data has revealed is the average rating and the response time. Those measures provide some idea of the differences between groups. Furthermore, Mind Genomics provides far deeper information for the simple reason that the elements themselves are cognitively rich, having deep meaning.  It is not simply the stimulus, but the fact that the stimulus can be understand in and of itself.

Modeling to show causality: The next step, this time for deeper understanding, creates a simple model or equation, relating the presence/absence of the 16 elements to the binary ratings. The regression modeling, OLS regression (ordinary least-squares) works with the full data set of respondents in the subgroup. The output is a simple linear expression relating the presence/absence of the 16 elements to the rating, after the binary transformation.  The regression model lacks an additive constant, for the simple reason that in the absence of elements the respondent is not likely to either accept or reject the conference.  This is called ‘regression through the origin.’

We express the equation as: Binary transformed rating = k1(A1) + k2(A2) …k16(D4)

Deep learning – total panel, age and gender:  It is from the coefficients and their commonality that we learn the most about what drives ‘accept’ the conference, i.e., expect to attend.  Table 3 shows the strong performing elements presented in shaded cells, and bold font.  Strong performing is based upon the fact that in previous studies these coefficients are both statistically significant (from inferential statistics), and meaningful in terms of ‘real-word’ situations. When we look at the commonality of strong performing elements across elements and subgroups, we see different sets of strong-forming elements.  If we had to hazard a guess about which elements are consistently strong performers, we would say that the answers to Question D (What is interesting about the conference beyond the topic?).  That finding may be correct at the superficial level, but it leaves out the world of people who attend conferences to become stronger in their profession.

Table 3. Coefficients of the models relating the presence/absence of the elements to the ‘attend’ rating, after recoding

 

Conference – Attend
(ratings 1–6 recoded as 0; ratings of 7–9 recoded as 100)

Total

Young (21–39)

Old (40+)

Male

Fem

A1

teach how machines help you market and sell much better

13

13

13

15

4

A2

teach you how big data about people help you sell more

3

3

5

5

-4

A3

marketing secrets to sell to customers

10

3

13

4

18

A4

learn how find a really good customer

15

13

17

10

20

B1

features workshop..learn practice and grow

16

12

17

18

12

B2

have drinks and meals and snacks with real experts

17

11

20

20

12

B3

workshop to learn technology made easy and fun

14

8

17

16

10

B4

Meet interesting people who can really teach you

11

-1

17

10

12

C1

made for new hired young folk

5

11

2

15

-9

C2

for students to really make them grow

14

22

11

22

4

C3

business employers go to meet young potential hires

7

5

9

14

0

C4

students go to meet and select mentors

7

18

1

13

-3

D1

when you leave you free technology good & gift basket

26

19

30

24

28

D2

two days of fun BEFORE AND AFTER in a great location

28

31

26

32

23

D3

organized around an archaeological site you can explore

19

6

24

25

10

D4

near A SEASIDE TOWN IN SEASON

24

29

21

28

22

Beyond the discovery of ever-present individual differences, variation in the criteria of judgment, is the postulation by Mind Genomics that for every topic of experience, no matter how ‘micro’, there are a limited number of different groups, mind-sets, metaphorically alleles or variations of genes. These mind genomes do not need to covary with the typical groupings to which we have become accustomed, e.g., age, gender, and nor even behavior and attitude, such as attending conferences.

The comparison of Mind Genomes to the science of biological genomics is, to stress the point, metaphorical. In the biological science of Genomics, the belief is that there are actual alleles that can be manipulated and reinserted into cells to change their behavior. There is the belief that these alleles have actual physical reality. In the world of Mind Genomics, the mental alleles are hypothetical constructs, patterns of decision criteria which emerge from the statistical method of clustering, a procedure in the mathematics of numerical analysis. That is, there is no belief in the physical reality of the mind genome, the mental allele, but just a convenient, and sensible group of ideas which float together.

These mind genomes or mind-sets emerge from the pattern of coefficients for the different elements, with the pattern uncovered by experimentation (our respondent study with the 50 respondents), the creation of individual-level models (made possible by the experimental design), and then the clustering individuals by the pattern of their coefficients (application of clustering, a method in numerical analysis.)

When we follow the procedure of experimentation, modeling, clustering, afterwards extracting meaningful sets of ideas or clusters, we end up with three different groups.Clustering simply places the objects (here respondents) into a set of complementary, non-overlapping groups, using mathematical criteria. The objective to minimize the number of clusters (parsimony), as well as ensure that each cluster or mind-set makes sense (interpretability).  Table 4 shows the performance of all 16 elements by total, and by each of the two emergent mind-sets, i.e., emergent clusters of respondents based on the pattern of coefficients. It is clear from Table 4 that separating the mind-sets allows the strong performing elements to do far better than they do when the data from all 50 the respondents are combined to create the one group, total panel. Mind-set segmentation through clusteringremoves much of the suppression of element performance attributable to the opposing patterns of responses of different mind-sets to the same element.  The countervailing forces emerge, and can be separated from each other, placed by the researcher into the different mind-sets (clusters), with the result being radically different patterns of coefficients released by the suppressing, mutually cancelling effect by the opposite mind-set.

Table 4. Performance of elements driving Choosing a Conference. Data based on the total panel and the two mind-sets.

 

Dependent Variable: Attend the conference

Tot

MS 2A

MS2B

 

Mind-Set 1 – Attends for fun

 

 

 

D2

two days of fun BEFORE AND AFTER in a great location

28

35

16

D4

near A SEASIDE TOWN IN SEASON

24

32

12

D1

when you leave you free technology good & gift basket

26

26

25

D3

organized around an archaeological site you can explore

19

23

13

C2

for students to really make them grow

14

16

10

 

Mind-Set 2B– Attends for professional reasons

 

 

 

B2

have drinks and meals and snacks with real experts

17

10

27

B3

workshop to learn technology made easy and fun

14

8

23

B1

features workshop..learn practice and grow

16

12

21

B4

Meet interesting people who can really teach you

11

5

21

A4

learn how find a really good customer

15

14

19

A3

marketing secrets to sell to customers

10

8

17

 

Not strong in either mind-set

 

 

 

A1

teach how machines help you market and sell much better

13

14

12

C3

business employers go to meet young potential hires

7

7

7

A2

teach you how big data about people help you sell more

3

3

6

C1

made for new hired young folk

5

4

4

C4

students go to meet and select mentors

7

9

1

Engagement – Measurement of consideration time (CT) for conference elements: In order to identify the existence of mental processing of stimulus input, such as our elements, experimental psychologists introduced the notion of reaction time, later called response time, and now in this stage of Mind Genomics called ‘consideration time.’ The underlying notion is that longer consideration times signal that more complicated mental processing is occurring.The original measures of reaction time were done when the respondent was instructed to observe a test stimulus (see, feel, hear, taste, smell), and then report when the respondent could detect the stimulus (i.e. the stimulus was present), or report when the respondent could recognize the nature of the stimulus. The right-most column of Table 2 above presents the average consideration times (CT) for the 24 vignettes rated by each respondent in the relevant subgroups. Table 2 suggests that, on average, the time to read and rate a vignette is approximately 3.5 seconds.  The younger respondents read and rate the vignettes far more quickly than do the older respondents (2.9 seconds vs 3.8 seconds). Males read and rate the vignettes far more quickly than do females (3.0 seconds vs 4.2 seconds). Finally, Mind-Set 2B (Conferences for professional development) reads and rates the vignettes far more quickly than does Mind-Set 2A (Conferences for fun), specifically 2.7 seconds versus 4.0

Knowing the consideration time tells us something about the general speed of reading and decision- making but does not tell us anything about the consideration time given to the individual elements. That consideration time is a measure of engagement of the respondent with the message. The engagement may be short or long for a variety of reasons, such as length and complexity of the message, basic ‘stickiness’ of the message to keep the respondent focused, and so forth. The respondent cannot tell the researcher which particular element in a vignette ‘engages’ attention, but through experimental design and modeling, along with a measure of response time to the entire vignette, the researcher can estimate the number of seconds that is most likely taken up by the specific element, such as a particularly provocative phrase. Systematic design reveals just what just what phrases are ‘sticky’, when they are ‘sticky,’ and with whom.

The strategy is the same as used to develop the models relating the presence/absence of the 16 elements to the rating. The analysis uses OLS (ordinary least-squares) regression to relate the presence/absence of the elements to the consideration time, measured to the nearest 10thof a second.  The equation is the same, except for the dependent variable: Consideration Time (Time interval from presentation to rating) = k1(A1) + k2(A2) …k16(D4)

Table 5 suggests a different story for the commonality among the longest consideration times for the group:

Total panel –serious aspects such as workshops and mentors

Younger –mentors and growth

Older respondents – learning new technology easily and with fun

Males – workshops and mentors

Females – learn new technology, learn at the start of the career

Mind-Set 2A (Conferences are for fun) – learning new skills, then many of the professional growth elements

Mind-Set 2 B (Conferences are for professional development) – no elements show unusually long engagement. Equal attention is paid to all elements

Table 5. Consideration time for all elements by total panel and key subgroups (conference).Element coefficients of 1.2 seconds or higher are shown in shaded cells.

 

Consideration Time for each element
Conference

Tot

Young (21–39)

Old (40+)

Male

Fem

MS 2A- Fun

MS2B – Prof. Development

B3

workshop to learn technology made easy and fun

1.5

1.0

1.8

1.0

2.4

1.7

1.1

B1

features workshop …learn practice and grow

1.3

1.1

1.3

1.3

1.3

1.5

0.8

C2

for students to really make them grow

1.2

1.4

1.2

0.8

1.6

1.4

1.0

C4

students go to meet and select mentors

1.2

1.4

1.1

1.2

1.1

1.5

0.6

D2

two days of fun BEFORE AND AFTER in a great location

1.2

1.1

1.3

1.1

1.4

1.5

0.7

B2

have drinks and meals and snacks with real experts

1.2

0.9

1.2

1.1

1.3

1.3

1.1

C3

business employers go to meet young potential hires

1.1

1.1

1.2

0.9

1.4

1.3

0.9

C1

made for new hired young folk

1.0

0.7

1.2

0.6

1.6

1.3

0.6

D3

organized around an archaeological site you can explore

0.9

0.8

1.0

0.6

1.2

1.0

0.7

A3

marketing secrets to sell to customers

0.8

0.2

1.1

0.8

0.9

0.7

1.1

D1

when you leave you free technology good & gift basket

0.8

0.7

0.9

0.7

1.1

0.8

0.8

D4

near A SEASIDE TOWN IN SEASON

0.8

0.7

0.9

0.5

1.2

1.0

0.6

B4

Meet interesting people who can really teach you

0.8

0.5

0.9

0.7

0.9

0.9

0.7

A1

teach how machines help you market and sell much better

0.8

0.6

0.8

1.0

0.6

0.9

0.6

A2

teach you how big data about people help you sell more

0.7

0.6

0.8

0.8

0.9

0.8

0.7

A4

learn how find a really good customer

0.7

0.5

0.7

0.8

0.7

0.8

0.4

Study 2 – ‘Selling a political candidate’

If the topic of conferences is of interest to academics and to those sponsoring conferences, in contrast, the topic of political candidates and their messaging is of interest to virtually everyone, or almost everyone, especially in elections where two or more sides, radically opposite, vie for power.   Furthermore, election and the messaging of the candidates must address the many different dimensions on which a candidate can appeal to her or his audience, and the many different facets, the granularity of each dimension, that must somehow be considered

More than 80 years ago, the mind of the voter was already of interest [17], but of course one could go back centuries to Machiavelli, to Aristotle, and to Plato for even older points of view. These philosophers talked a great deal about citizens and their leaders. Many of their points, including appeal to emotion, hold today.  One need only read Machiavelli’s ‘Prince,’ Aristotle’s ‘Politics’ or Plato’s ‘Dialogue’ to see the politics of today presented by the eminent thinkers of the past. Today’s world works with tools taken from marketing, attempting to persuade people to vote in the same way one might persuade people to buy toothpaste [18].  There is a great deal of effort put in by consultants, polling organizations, and so forth to identify messages which at once most strongly resonate with the electorate, as well as being appropriate, realistic, and believable. Despite the best efforts of marketers to provide honest data, perhaps somewhat copy-edited (‘massaged’), today’s political messaging is believed a lot less than was the case years and decades before [19].

Marketing theory has also entered political messaging and polling. The notion of inward vs outward orientation in the mind of a consumer has been applied to an Australian election, revealing the application of this construct to election messaging [20].This inward versus outward orientation more clearly focuses on what affects the voter, and moves beyond the more tradition of description of one’s behavior, such as mudslinging, defined both as allegations about the candidate’s family, but also references to an opponent’s voting record, broken campaign promises, rumors on health and financial dealings, and the use of harsh language.

More recent approaches to studying political communication focus on how to legitimize one’s point of view, and not just to convince the voter based upon one or two key points. Legitimizing one’s point of view is akin to building one’s brand, again recognizing the mind of marketing, as it enters the political arena [21] discussed the political communication as exemplified by George Bush and by Barack Obama, when they had already won the election, and were trying to convince the electorate about their efforts of the war on terror, in 2007 and 2009. In Reye’s words, ‘strategies of legitimization can be used individually or in combination with others and justify social practices through: (1) emotions (particularly fear), (2) a hypothetical future, (3) rationality, (4) voices of expertise and (5) altruism.’By 2010, the marketing concepthad entered the world of communication. The five strategies, or motivations for message, just above, would be quite familiar to today’s marketer. The final aspect making a study of political messaging interesting is the increasing importance of social media on the political process. Research published almost a decade ago suggest that in the early years of social media the interplay of social media and political viewpoint was not particularly strong [22]. Kim’s words of a decade ago can be contrasted with the emergence of political messaging in the form both of real news and of fake news.  It is worthwhile quoting Kim’s now-passe language, quite important in 2011, and probably based upon research conducted the year or two before. It would hard to substantiate Kim’s words today, as of this writing.

The increasing popularity of social network sites (SNSs) has raised questions about the role of social network media in the democratic process. This study explores how use of SNSs influences individuals’ exposure to political difference. The findings show a positive and significant relationship between SNSs and exposure to challenging viewpoints, supporting the idea that SNSs contribute to individuals’ exposure to cross-cutting political points of view. Partisanship was not found to interact with SNS use, suggesting that SNSs contribute to expanding exposure to dissimilar political views across individuals’ partisanship. Online political messaging also has a direct effect on exposure to dissimilar viewpoints, and it mediates the association between SNSs and exposure to cross-cutting political views.  (Bold added for emphasis)

Specifics of the candidate study: The principles underlying the Mind Genomics studies remain the same, no matter what the topic.  The second study, done around the same time concerned a political candidate, of an unnamed political party. The respondents were US adults, recruited by the same company as the respondents in Study 1 on ‘selling a conference.’

The key differences in the two studies were the topic, the elements (Table 6), and the use of a 5-point scale, rather than a 9-point scale for the scale. For the rating of ‘win’, the 5-point scale was transformed to the binary values of 0 (ratings 1–3), and 100 (ratings 4–5). For the rating of ‘lose,’ the 50point scale was transformed the binary value of 100 (ratings 1–2), and 0 (ratings 3–5). All modeling was done using the binary scale, not the original scale.

Table 6. Candidate – List of elements

 

Question A: What is the situation of the country?

A1

The country has economic problems

A2

The people are skeptical about politics in general

A3

The country is experiencing political instability

A4

The people suffer from unemployment

 

Question B: Describe the candidate’s personality.

B1

He/she is rightfully egocentric

B2

He/she concerned about people well-being

B3

He/she has a vision to develop the country

B4

He/she is going to be the people’s voice in government

 

Question C: How does the candidate draws people to himself/herself?

C1

He/she is always on tv

C2

He/she has been active all the time not only during the campaign

C3

He/she listens to people personally

C4

He/she talks about own achievement

 

Question D: How does the candidate call to action?

D1

He/she is a role model

D2

He/she tell others to do his/her job

D3

He/she corrupts people for vote

D4

He/she doesn’t care about acting at all

Table 7 give a sense of the response patterns for the different vignettes, across the different groups. What is most interesting is that when the topic is political, something serious and relevant to the respondents, the consideration time is a second longer than the consideration time for the conference (3.5 seconds for the conference, 4.4 seconds for the candidate.) The experimental design is the same, the elements are approximately of the same size, but the respondents spend more time reading.  This pattern, longer consideration times for important topics, has continued to emerge again and again in experiments by author Moskowitz (unpublished data)

Table 7. Means of the dependent variables (Accept, Reject, Consideration Time) for key subgroups

 

Candidate – Means of Dependent Variables

 Candidate

Vote For
(4–5
à100)

Vote Against (1–2à 100)

Consideration Time

Total

37

35

4.4

Young (21–39)

34

34

3.9

Old (40+)

38

35

4.8

Male

31

36

4.2

Female

41

34

4.7

MS2C – Protect

26

36

4.5

MS 2D – Develop

44

34

4.4

Table 8 shows the results for Total, Age and Gender, respectively.

Table 8. Performance of elements driving Choosing a Conference. Data based on the total panel, age and gender, respectively.

 

 

Tot

Young (21–39)

Old (40+)

Male

Female

A1

The country has economic problems

8

13

6

20

-1

A2

The people are skeptical about politics in general

13

20

10

17

10

A3

The country is experiencing political instability

15

21

11

21

11

A4

The people suffer from unemployment

15

15

16

22

10

B1

He/she is rightfully egocentric

12

9

14

12

12

B2

He/she concerns about people’s well-being

20

17

23

17

23

B3

He/she has a vision to develop the country

19

24

17

20

18

B4

He/she is going to be the people’s voice in government

20

18

22

20

21

C1

He/she is always on tv

4

2

4

0

7

C2

He/she has been active all the time not only during the campaign

14

17

11

9

19

C3

He/she listens to people personally

20

18

21

12

27

C4

He/she talks about own achievement

0

-8

4

-3

3

D1

He/she is a role model

21

17

24

12

28

D2

He/she tell others to do his/her job

-4

-14

2

-9

-1

D3

He/she corrupts people for vote

-6

-7

-5

-13

-2

D4

He/she doesn’t care about acting at all

1

-3

2

-13

10

The key drivers for winning are the personal characteristics of the candidate, especially the care about the people and being a role model.

He/she concerned about people well-being

He/she has a vision to develop the country

He/she is going to be the people’s voice in government

He/she concerns about people well-being

He/she has a vision to develop the country

He/she is going to be the people’s voice in government

Some key differences emerge, mostly in terms of degree

Men are concerned about the situation in the country

Women are concerned about the candidate ‘being involved’

Younger respondents do not like a boastful, dominating person who tells others what to do. In contrast, older respondents don’t care.  This is a subtle but an importance difference between different age cohorts, representing an emerging sensitivity to ‘authenticity’

Applying the clustering approach to the 50 coefficients generates two clearly different, and interpretable mind-sets, shown in Table 9. Mind-Set 1 responds to the candidate as a leader in the unstable times. Mind-Set 2 responds to the candidate as a nation builder.

Table 9. Performance of elements driving voting for a candidate. Data based on the total panel and the two mind-sets.

 

 

Tot

MS2C

MS2D

 

Mind-Set 2C – Candidate as a leader

 

 

 

A2

The people are skeptical about politics in general

13

21

6

A3

The country is experiencing political instability

15

19

11

D1

He/she is a role model

21

19

24

 

Mind-Set 2D – Candidate as nation builder

 

 

 

B3

He/she has a vision to develop the country

19

-2

35

B2

He/she concerns about people’s well-being

20

5

31

B4

He/she is going to be the people’s voice in government

20

7

29

B1

He/she is rightfully egocentric

12

-2

23

C3

He/she listens to people personally

20

15

22

 

Elements not strongly motivating to either mind-set

 

 

 

A4

The people suffer from unemployment

15

15

14

C2

He/she has been active all the time not only during the campaign

14

13

14

D4

He/she doesn’t care about acting at all

1

-1

5

A1

The country has economic problems

8

15

3

C1

He/she is always on tv

4

7

0

D2

He/she tell others to do his/her job

-4

-7

0

D3

He/she corrupts people for vote

-6

-5

-6

C4

He/she talks about own achievement

0

7

-7

We finish the detailed analyses of the by looking at the consideration time attributable to each element. Recall from the previous analysis of conferences that the form of the model for consideration time comprised a simple linear model, without an additive constant.  The experimental design for this study of a candidate is precisely the same as the experimental design for the study of a conference, namely 24 vignettes comprising 2–4 elements per vignette. When we deconstruct the contribution of each element to consideration time (Table 10) we find that virtually all but three of the consideration times are 1.0 second or longer, several twice as long at 2.0 and 2.1 seconds. Thus, the topic itself, is a major driver of consideration time, a subject to be explored more fully.  There is no clear pattern of covariation between the response time and who the respondent is, except that the younger respondents show somewhat shorter consideration times, very much shorter for descriptions of the candidate’s personal behavior (e.g., C1 and C4.)

Table 10. Consideration time for all elements by total panel and key subgroups (conference)

 

Consideration time for each element: Election of a candidate

Tot

Age 20–39

Age 40 Plus

Male

Female

MS1 Political leader

MS2 Builder

D4

He/she doesn’t care about acting at all

2.0

2.0

2.0

2.0

2.0

1.5

2.4

C2

He/she has been active all the time not only during the campaign

2.0

1.8

2.0

2.2

1.8

2.0

1.9

B4

He/she is going to be the people’s voice in government

1.9

1.5

2.1

1.9

1.9

1.8

2.0

A4

The people suffer from unemployment

1.9

1.8

1.9

1.7

2.0

2.2

1.7

B1

He/she is rightfully egocentric

1.8

1.8

1.9

2.0

1.6

1.9

1.7

C3

He/she listens to people personally

1.7

1.0

2.1

1.9

1.6

1.9

1.6

B3

He/she has a vision to develop the country

1.7

1.2

2.1

1.9

1.6

1.9

1.6

A2

The people are skeptical about politics in general

1.7

1.3

1.8

1.5

1.8

1.9

1.5

A1

The country has economic problems

1.7

1.7

1.7

1.6

1.8

1.8

1.6

D3

He/she corrupts people for vote

1.6

1.6

1.6

1.3

1.8

1.4

1.8

C4

He/she talks about own achievement

1.6

0.9

1.9

1.7

1.5

1.9

1.4

C1

He/she is always on tv

1.6

0.7

2.0

1.8

1.4

1.8

1.5

B2

He/she concerns about people’s well-being

1.6

1.3

1.8

1.7

1.5

1.7

1.4

A3

The country is experiencing political instability

1.6

1.4

1.7

1.3

1.8

1.6

1.5

D1

He/she is a role model

1.5

1.6

1.4

1.3

1.6

1.4

1.6

D2

He/she tell others to do his/her job

1.4

1.3

1.5

0.9

1.8

1.2

1.5

Who belongs to these mind-sets, and how to discover them

The mind-sets for both the conference and the candidate make sense. Yet, a standard cross tabulation of membership in the mind-set versus the standard classifications of gender and age suggest that the mind-sets do not divide simply across easy-to-measure subgroups based upon who a person IS. Table 11 shows the cross tabulation of mind-set membership versus age and gender. There is no clear relation. Indeed from author Moskowitz’s experience, except for the most obvious of cases (e.g., age versus concern with problem of dying), the relation between the way a person thinks and who the person IS appears to be tenuous at best.  Furthermore, even asking a person about general thoughts regarding a topic does not suffice to place a person into a mind-set

Table 11. Two-way table showing the relation between membership in a mind-seg (column) and both age and gender, respectively.

Conference

Total

MS2A:  Fun Seeker

MS2B: Prof.  Development

Total

39

25

14

Male

22

15

7

Female

17

10

7

Age 23–39

11

9

2

Age 40+

28

16

12

Candidate

Total

MS2C: Political Leader

MS2D: Nation Builder

Total

54

23

31

Male

25

13

12

Female

29

10

19

Age 23–39

19

7

12

Age 40+

35

16

19

A new way be developed to probe membership in a group defined by the specifics or granular aspects of the way a person thinks about a topic. Conferences and candidates are large subjects. The mind-sets which emerge are limited to the topic revolving around questions and answers investigated in the Mind Genomics study. It may well be that the easiest way to discover the membership of a person in a mind-set segment is to accept the fact that the mind-set segment is granular at best. That ‘best’ may be to assign a new person to the granular-based mind-set uncovered in the Mind Genomics experiment. Authors Gere and Moskowitz have created an algorithm based on the separation of the mind-sets across the 16 elements. Using a Monte-Carlo simulation, they identified a set of six elements, the pattern of binary answers to which, suggest membership in one mind-set or the other.   Figure 1 shows the PVI, the personal viewpoint identifier, emerging from this exercise.

Mind Genomics-035 PSYJ_F1

Figure 1. The PVI (personal viewpoint identifier), comprising six questions for each topic. The pattern of answers assigns a respondent to one of the two mind-sets.

Discussion

The typical study of a topic involves a few stimuli, rarely varied systematically, but evaluated by many people, respondents in the world of public opinion polling and consumer research, subjects or observers in the world of psychology.  The objective of these studies is typically to confirm a hypothesis. The use of large numbers of respondents has become sacrosanct in many areas of science, for the simple reason that with these large number of respondents the sampling distribution of ratings is more precise, with smaller standard errors. Mind Genomics as presented here provides the researcher with a different strategy. Rather than being developed within the constraints and world-view of the traditional world of the ‘hypothetico-deductive,’ Mind Genomics approaches the topic by exploring a wide, albeit feasible, range of alternative aspects, evaluated by the respondent in formats, vignettes, simulating a more typical way that nature presents information to people, namely in the form of  mixtures.  The systematic variation of the composition of these mixtures by experimental design allow the researcher to pick out the operative variables to which the respondent attends.

As we review the process of the two studies, we come upon the following key factors which differentiate Mind Genomics studies from other studies of the same topic:

Mind Genomics studies focus on the mind of the respondent, weaving a story, but without having the respondent elaborate and tell the story. Qualitative research focuses on the mind of the respondent as well but requires that the respondent participate in a dialog. The experienced researcher, like an experienced therapist, may pull out underlying motives, thoughts, defenses, and biases, but the researcher should be experienced must shunt aside presuppositions. In contrast, Mind Genomics, attempting the same outcome, works with responses to cognitively rich expressions, the elements, not chosen by the respondent, but by the researcher. Mind Genomics studies can be executed more rapidly, more generally, and more cost-effectively.  What Mind Genomics lacks, however, is the skilled interpretation, when such skill exists. Mind Genomics studies can be likened to the MRI of the Mind.  Each individual Mind Genomics study creates 24 vignettes for each respondent, with the vignettes differing from respondent to respondent. Thus, in one Mind Genomics study with 30 respondents, we deal with 720 different snapshots of the same problem. One need not know the ‘correct’ or best combinations to test. Mind Genomics studies create, metaphorically, a realistic ‘picture’ of the topic from which one can discover new things or reaffirm hypotheses and conjectures which seem simplistic after the fact, but hard to confirm ahead of time.

We have illustrated two different studies and show slightly different dynamics of each. The speed and ease of a Mind Genomics study makes it possible to execute one or two studies a day and create a rich library of knowledge about any topic involving the decision of a respondent when faced with various pieces of information. A science of such decision rules, appropriate indeed and archives, may constitute a new direction for sciences of the mind, and of society.

Acknowledgement 

Attila Gere wishes to acknowledge and thank the Premium Postdoctoral Research Program of the Hungarian Academy of Sciences.

References

  1. Box GEP, Hunter WP, Hunter JS (1978) Statistics for experimenters, New York, John Wiley.
  2. Moskowitz HR (2012) ‘Mind genomics’: The experimental, inductive science of the ordinary, & its application to aspects of food & feeding. Physiology & Behavior 107: 606–613. [Crossref]
  3. Moskowitz HR, Gofman A, Beckley J, Ashman H (2006) Founding a new science: Mind Genomics. Journal of Sensory Studies 21: 266–307.
  4. Ryan M, Farrar S (2000) Using conjoint analysis to elicit preferences for health care. Bmj 320: 1530–1533. [Crossref]
  5. Stevens R, Bressler M, Silver L (2016) Challenges in marketing academic conferences: a pilot study. Services Marketing Quarterly 37: 200–207.
  6. Parker BJ (2007) What makes a professional conference worth attending? Strategic Finance 88: 13.
  7. Cherrstrom CA (2012) Making connections: Attending professional conferences. Adult Learning 23: 148–152.
  8. Mair J, Frew E (2018) Academic conferences: a female duo-ethnography. Current issues in Tourism 21: 2152–2172.
  9. November P (2004) Seven reasons why marketing practitioners should ignore marketing academic research. Australasian Marketing Journal 12: 39–50.
  10. Nyilasy G, Reid LN (2007) The academician–practitioner gap in advertising. International Journal of Advertising 26: 425–445.
  11. Anderson L, Anderson T (2010) Online professional development conferences: An effective, economical & eco-friendly option. Canadian Journal of Learning & Technology 11: 35.
  12. Rogers T, Davidson R (2015) Marketing destinations & venues for conferences, conventions & business events. Routledge.
  13. Hughes T, Bence D, Grisoni L, O’regan N, Wornham D (2011) Scholarship that matters: Academic–practitioner engagement in business & management. Academy of Management Learning & Education 10: 40–57.
  14. Gardner SK, Barnes BJ (2007) Graduate student involvement: Socialization for the professional role. Journal of College Student Development 48: 369–387.
  15. Mata H, Latham TP, Ransome Y (2010) Benefits of professional organization membership & participation in national conferences: Considerations for students & new professionals. Health Promotion practice 11: 450–453.
  16. Gofman A, Moskowitz H (2010) Isomorphic permuted experimental designs & their application in conjoint analysis. Journal of Sensory Studies 25: 127–145.
  17. Herring EP (1938) How does the voter make up his mind? Public Opinion Quarterly 2: 24–35.
  18. Harris P, Lock A (2010) “Mind the gap”: the rise of political marketing & a perspective on its future agenda. European Journal of Marketing 44: 297–307.
  19. Brants K, Voltmer K (2011) Introduction: Mediatization & de-centralization of political communication. In: Political Communication in Postmodern Democracy, 1–16 Palgrave Macmillan, London.
  20. O’Cass A (2001) The internal-external marketing orientation of a political party: social implications of political party marketing orientation. Journal of Public Affairs: An International Journal 1: 136–152.
  21. Reyes A (2011) Strategies of legitimization in political discourse: From words to actions. Discourse & Society 22: 781–807.
  22. Kim Y (2011) The contribution of social network sites to exposure to political difference: The relationships among SNSs, online political messaging, and exposure to cross-cutting perspectives. Computers in Human Behavior 27: 971–977.
  23. Stewart CJ (1975) Voter perception of mud-slinging in political communication. Communication Studies 26: 279–286.

Promoting Medication-Adherence by Uncovering Patient’s Mindsets and Adjusting Clinician-Patient Communication to Mindsets: A Mind Genomics Cartography

Abstract

We present a new approach to understanding how patients want doctors to communicate to them. The approach uses Mind Genomics, an emerging science in experimental psychology, which looks at the way people make decisions about the everyday. Respondents in an experiment evaluated different combinations of messages (elements) in vignettes. The results suggest three minds (privacy-oriented; doctor oriented; control-oriented), requiring three different types of messages. These mind-sets also pay attention to the messages in different ways, as shown by the pattern of their response times. We present a PVI (personal viewpoint identifier), which in six questions can suggest the mind-set to which a new person might belong.

Introduction

Patient self-management programs are the aim of health systems and public health policy makers. The main goal of health systems is to improve clinical outcomes of patients by engaging them to adhere to medications, to adopt a healthy lifestyle and to properly manage their illnesses. Patient adherence is defined as the degree to which patients follow physician’s guidelines and recommendations. Patient non-adherence has been a challenge for clinicians with evidence indicating that 25% to 50% of patients are non-adherent [1–4]. Furthermore, patients suffering a more severe illness in serious diseases were surprisingly less adherent [5]. Consequently, across illnesses non-adherence results in comorbidities, re-admissions to hospitals, in lower quality of life and in economic burdens for public health systems. Adherence to guidelines and medications was found to promote illness-self management (e.g., appointments, screening, exercise, and diet).Adherence is affected by: clinician-patient relationship, the illness itself, the treatment, patient characteristics and socioeconomic factors [6].

Patients expect their physicians to inspire them through communication leading to patient trust which is strongly related to medication-adherence[7–9]. Physician-patient communication was found to enhance patient adherence to decrease re-admissions [10,11]. To promote adherence patients need to understand the illness, the risks it entails and the treatment benefits [11]. Clinician-patient communication is an essential in adherence promotion [11–14]. Moreover, the odds of patient adherence are 2.16 times higher if a clinician communicates effectively [2,5,15].

Communication entails support, empathy and compassion leveraging collaborative patient-physician decision-making [9,12]. Whereas ‘content communication’ focuses on clinical aspects of the disease (e.g., the illness, the treatment regimens), ‘process communication’ focuses on psychosocial aspects (motivation, drivers, life–meaning, gathering information about the patient and environment, understanding how to remove barriers to adherence and identifying steps in the change process towards adherence.

‘Process communication has been report found to effectively raise patient-adherence [2,10,16–19]. Furthermore, patients who perceived their clinicians as their partners to the change process demonstrated a 19% higher medication-adherence. Furthermore, training physicians on ‘process communication’ improved patient-adherence by 12% [5,18,19]Essentials of behavioral research: methods and data analysis McGraw-Hill; 2007.

Despite evidence those clinicians’ skills of process communication are central to patient-adherence; clinicians mostly use content communication and have difficulties crossing this chasm [20]. Several factors underlie the challenge of crossing this chasm. First, there is a lack of sufficient training on psychosocial communication during and after medical school [20]. Second, there is a low prioritization of such skills in training programs [21]. Third, there is a lack of incentives for physicians to participate in such training [22]. Finally, there are misconceptions among physicians who perceive psychosocial communication as time consuming [23] when in fact it requires shorter, more effective time [18].

Previous studies suggest that interventions to improve psychosocial communication among clinicians should focus on a variety of aspects, not just one. These aspects are, respectively, verbal and nonverbal communication, affective communication, psychosocial communication and task-oriented behavior that create opportunities for active patient involvement throughout the change process towards patient-adherence [24]. Previous studies indicate that in order to reduce barriers which stand in the way of optimal health outcomes, communication is to be personalized enabling clinicians to understand what is most relevant for each particular patient and tailor the messages accordingly [4].

But what do we know about the mind of the patient? How can we find out what the patient feels to be important? What does the patient feel is relevant and irrelevant for her or him? In response to existent discourse in the literature, in 2011we conducted an internet experiment using Mind-Genomics to investigate combinations of messages on ‘living with the regimen’ (Moskowitz, unpublished observations).We identified three mind-sets. This study extends the 2011 study looking more closely at messages about how people feel about themselves in terms of how the doctor communicates with them. Our objective is to identify participants by psychographic mindsets so clinicians may quickly identify the belonging of each patient to a mindset and use tailored effective communication congruent to that mindset-segment in the context of medication adherence.

Method

Mind Genomics works in a Socratic fashion, first identifying a topic, then requiring the researcher to ask four questions, and finally requiring the researcher to provide four separate answers to each question. Inspired by existing literature and research instruments, we shaped questions which ‘tell a story’ [25–30]. Once the questions are asked, the answers are quickly provided. Asking the questions forces the researcher to think critically. Table 1 shows the four questions and the four answers to each question. The series of questions probe the way the person feels about information. The ‘story’ underlying the four questions is not sequential, but rather topic, as if an interview were being conducted with a person to under how the person feels about giving and receiving information about his or her own health status.

Table 1. Raw material comprising four questions, and four answers to each question

Question A: How would you like your doctor to discuss your health with you?

A1

Doctor talks to me, face to face… not just those phone calls with clinical message

A2

Doctor explains to me WHY this medicine, and what should I DO

A3

My friends explain this stuff to me… I’m more comfortable with them

A4

Doctor guides me to the Internet sites… so I CAN TAKE CONTROL

Question B: What honestly is your relationship with your health?

B1

I’m pretty private about my health… no one’s business

B2

I don’t feel like going to the doctor… even for the most severe symptoms… I can take care of it

B3

When it comes to illness, I’m on Google, so I really become an expert

B4

I’m nervous about health – but really want to be healthy to see my kids, grandkids, or even relatives and friends in the years to come

Question C: How do you interact with your family about your health?

C1

My family is always there to listen, and support me… I like that

C2

My family and others butt-in to my health… I want my privacy

C3

I really am happy when someone takes control, and tells me what to take, and schedules my meds for me

C4

I’m pretty private… my health meds are my business… and maybe the doctor’s, but that’s all

Question D: Do friends and family play an important role in your life?

D1

My family means the world to me

D2

I reach out to talk to friends about my health and illness

D3

I reserve my friends for non-medical talks, like politics, or people

D4

My friends really are there to listen to me about my medical experience – sometimes I feel I’m wearing out my welcome

Procedure

Vignettes: The test stimuli for Mind Genomics comprise easy-to-read vignettes, containing 2–4 answers or elements, at most one answer or element from each question. The vignettes are created according to an experimental design, which prescribes the specific combination. Each respondent evaluated 24 vignettes created according to the same basic design, with the specific combinations changing in a deliberate fashion according to a permutation scheme [31]. Thus, the entire experiment covered 24×100 or 2400 vignettes, most of which differed from each other.

It is important to note that the Mind Genomics approach to understanding is similar metaphorically to the MRI machine, which takes many different ‘pictures’ of the underlying tissue, each picture from a different angle and vantage point. Afterwards, a computer program combines these different views into a single 3-D image of the underlying tissue. Each individual picture may have error, but the entire pattern becomes clear once these individual pictures are combined. In a like fashion, Mind Genomics gets the response to many different vignettes, and then synthesizes the overall pattern. Each individual observation is ‘noisy’ with a base size of ‘1’ but the pattern is not as noisy.

The approach of Mind-Genomics covers a wide range of alternative clinical and psychosocial communication concepts, each with elements revealing response patterns by using various permutations of the same stimuli, responses to different combinations of the answers of elements, in order to obtain a stable estimate of the underlying pattern Conventional science attempts to minimize the error around each observation through replication of the same stimulus (average to increase precision)or through reduction of extraneous factors which could increase the error variability (suppressing noise to increase precision).

The respondents were selected at random from a pool of 20+ million respondents in the United States, with approximately equal distribution of age and gender. The respondents were part of the panel provided by the strategic partner of Mind Genomics, Luc.id, Inc. Respondents were compensated by Luc.id.

Each respondent who participated clicked on an embedded link in the email invitation and was taken to a first slide which oriented the respondent. The respondent was told to consider the entire vignette, the combination of elements (answers) as a ‘whole’ and to rate it on the scale below. The questions were never shown to the respondent. Only the answers were shown; the questions served simply as a way to elicit the set of appropriate answers that would be shown to the respondent in the vignette.

Imagine if these qualities were reflected on a magnet. How does this capture your thoughts?

1= Not at all like me. If this is a magnet, it just won’t work for me

5= Very much like me. This magnet will really help me

A surface analysis of the responses – distribution and means

Most surveys work with the responses to single questions and compute the mean of the responses. Mind Genomics proceeds by experimentation, presenting the respondent with combinations of answers or elements, and obtains their rating. The actual ratings themselves pertain to different test stimuli. Furthermore, an inspection of the different patterns across gender and ages fails to give us any insight into the mind of the respondent with respect to feelings about discussing one’s own state of health and receptivity to health information. The means across key subgroups (Table 2) provides little insight, other than perhaps that older respondents had a longer response time, on average, than did younger respondents. A deeper analysis is necessary to understanding the meaning of the data, not just the surface morphology of the response patterns.

Table 2. Mean ratings on the 5-point rating scale, by total panel, gender, and ages

 

5- Point RATING

Binary TOP2 (Works YES)

Binary BOT2 (Works No)

Response Time

Total

3.2

42

31

5.0

Male

3.1

42

32

4.7

Female

3.2

42

31

5.4

Age 18–30

3.2

38

30

4.3

Age 31–49

3.4

53

27

4.5

Age 50–64

2.9

34

37

6.1

Transforming the data in preparation for regression modeling

In consumer research an oft-heard complaint from managers who use the data is ‘what does the rating point mean?’ In consumer research, the values of the scales are not necessarily easy to understand. That is, for researchers and respondents it seems easy to use the 5-point or 9-point or even a 100-point like rt scale. It may take a bit of use for a respondent, but sooner or later, usually sooner, the respondent falls into a pattern and intuitively senses that ‘this vignette is a 3 or a 4.’

One strategy commonly used, and adopted here, divides the scale into two regions, typically the high region (scale points 4–5) to denote a positive feeling about the vignette, and the remaining low region (scale points 1–3) to denote a negative feeling. We are interested in both sides of the scale, however, specifically what ‘works’ and what ‘don’t work’. Thus, we divide the scale twice, first into the top part and then second into the bottom part:

Works YES – Ratings 1–3 transformed to 0, ratings 4–5 transformed to 100

Works NO – Ratings 1–2 transformed to 100, ratings 3–5 transformed to 0.

The transformation removes some of the granular information but makes the results easy to understand. Managers who work with the data understand in an intuitive sense, because the information is presented in a all-or-none fashion.

Regression Modeling

The experimental design makes it straightforward to apply OLS (ordinary least-squares) regression to the raw data, after transformation. The data matrix comprises 16 independent variables, the elements, coded as 1 when present in the vignette, and coded as 0 when absent from the vignette. The matrix comprises three dependent variables, the binary transformation for Works YES (4–5 coded as 100, 1–3 coded as 0), the binary transformation for Works NO (1–2 coded as 100, 3–5 coded as 0), and the response time in seconds with the resolution to the nearest tenth of second. The response time is defined as the recorded time between the appearance of the vignette on the respondent’s screen and the time to assign a rating, which the respondent did by pressing a key.

Results –Total Panel

OLS regression generates an equation relating the presence/absence of the 16 answers or elements to the response. Table 2 shows the parameters of the three equations, one each for the positive Works YES, the negative Works NO, and the response time.

The additive constant (Works YES, Works NO) shows the estimated percent of the time the answer would be ‘Works YES or Works NO, in the absence of any elements. The additive constant represents a baseline, but not an actual situation because all vignettes by design comprised 2–4 elements or answers.’

The coefficient for each element shows the additive percent of the responses that would be expected to shift from ‘not Works YES’ to ‘Works Yes’ (or from ‘not Works NO’ to ‘Works NO), when the element is incorporated into a vignette. Statistical analyses as well as previous research by author Moskowitz suggest a standard error of approximately 4 for the coefficient, making values of 6–7 begin to reach statistical significance.

The results lead to some immediate and easy interpretation because the test elements are cognitively rich. We don’t have to stand back and search for a pattern in the way we do when we are looking at the pattern described by set of otherwise mute measures. Rather, we can understand the nature of a pattern simply by looking at the elements which score well, with high coefficients for the two binary scales (Works YES, Works NO) and long response times.

What ‘works’ for the respondent (Adherence promotion): The additive constant is 43, meaning that in the absence of anything else, we expect about 43% of the responses to be 4–5 for ‘Works YES.’ This means that if we were to ask a person whether giving and receiving medical information from various sources in general ‘works for that person’ almost 50% of the time we would get a positive answer. The strongest performers comprise a mix of statements about getting information directly from the doctor (Doctor talks to me, face to face… not just those phone calls with clinical message) as well as emotional messages (I’m nervous about health – but really want to be healthy to see my kids, grandkids, or even relatives and friends in the years to come and My family means the world to me.)

What doesn’t ‘work’ for the respondent (Adherence prevention): The additive constant is 30; meaning about 30% of the time we will get responses that say ‘doesn’t work for me’ the key message which resonates in a negative way is ‘I don’t feel like going to the doctor… even for the most severe symptoms… I can take care of it. This is not an easy negative to resolve.

Response time: The model for response time does not have an additive constant. The rationale is that without any elements, there is no response at all.

Studies on health drive respondents to pay a great deal of attention to the vignettes. Table 2 shows that the average for the total panel is approximately 5 seconds for a vignette. The response time, when deconstructed into the contributions of the different messages, show that there is a range of response times, all of which are high compared to the response times from previous studies. In this study the estimated response times for the individual answers or elements vary from a high of 1.8 seconds to a low of 1.1 seconds. We end up with these long response times when we deal with topics relevant to the respondent, issues which engage and make the respondent think. In contrast, when we deal with less relevant topics, e.g., studies about products such as foods, we see far shorter response times. It might be that the messages are easier with foods, being tag lines and short descriptions. Whatever the reason for the difference, the response times are far longer here.

The longer response times are those which ‘engage.’ They may be positive or negative, but they ‘engage’ the respondent, holding the attention. The most engaging elements are these below, describing who the person is, and perhaps forcing the respondent to compare him or herself. One can sense that each of these statements is a ‘conversation opener.’

When it comes to illness, I’m on Google, so I really become an expert I’m pretty private about my health… no one’s business

I really am happy when someone takes control, and tells me what to take, and schedules my meds for me

My family and others butt-in to my health… I want my privacy

I’m nervous about health – but really want to be healthy to see my kids, grandkids, or even relatives and friends in the years to come

I don’t feel like going to the doctor… even for the most severe symptoms… I can take care of it

In contrast, the least engaging elements are those of practice, with a sense that there is no conversation to be started

Doctor explains to me WHY this medicine, and what should I DO

I reach out to talk to friends about my health and illness

Table 3. Coefficients relating the presence/absence of the 16 answers (elements) to the binary transformed ratings, and to response time. The table is sorted by Works YES

Works YES

Works NO

Resp Time

Additive constant

43

30

A1

Doctor talks to me, face to face… not just those phone calls with clinical message

7

-8

1.3

B4

I’m nervous about health – but really want to be healthy to see my kids, grandkids, or even relatives and friends in the years to come

6

-1

1.6

D1

My family means the world to me

6

-6

1.3

A2

Doctor explains to me WHY this medicine, and what should I DO

5

-5

1.2

D4

My friends really are there to listen to me about my medical experience – sometimes I feel I’m wearing out my welcome

1

2

1.5

C4

I’m pretty private… my health meds are my business… and maybe the doctor’s, but that’s all

1

0

1.4

A4

Doctor guides me to the Internet sites… so I CAN TAKE CONTROL

0

-3

1.4

B3

When it comes to illness, I’m on Google, so I really become an expert

-1

3

1.8

C1

My family is always there to listen, and support me… I like that

-1

0

1.5

B1

I’m pretty private about my health… no one’s business

-2

5

1.7

A3

My friends explain this stuff to me… I’m more comfortable with them

-2

0

1.3

D3

I reserve my friends for non-medical talks, like politics, or people

-3

1

1.4

D2

I reach out to talk to friends about my health and illness

-3

-2

1.1

C3

I really am happy when someone takes control, and tells me what to take, and schedules my meds for me

-5

6

1.7

C2

My family and others butt-in to my health… I want my privacy

-6

4

1.7

B2

I don’t feel like going to the doctor… even for the most severe symptoms… I can take care of it

-7

11

1.6

Scenario Analysis: Uncovering Pair-Wise Interactions among Answers/Elements: The messages that we encounter in the environment comprise combinations of ideas, rather than single ideas in ‘splendid isolation.’ We know that in the world of food, the taste of a food is determine by the interplay of ingredients, and that experimental design of ingredients can help us understand the nature of that interplay, also called ‘pairwise interaction’. In consumer research with ideas, we may test single messages (promise testing), or test combinations of messages in a final format (concept testing), but rarely do we search for significant pairwise interactions in the world of ideas. There are so-called ‘creative’ in the advertising agency who may be aware that some ideas ‘synergize’ when in pairs, but this knowledge is specific, experienced-based, and hard to create in a systematic fashion on a go-forward basis.

A key benefit of the Mind Genomics approach is the ability to cover many combinations of ideas in the vignettes, all combinations prescribed by a basic experimental design which is permuted (Gofman & Moskowitz, 2010.) Adhering to the experimental design forces the research to work with a wide number of different combinations. In fact, among the 2400 vignettes created for this study, most are unique. Within the 2400 combinations, specific pairs of messages appear several times. It is this property that the various pairs of messages appear several times across the permutations which makes it possible to hold one the options of one question constant a specific option (e.g., one of the options for Question A: How would you like your doctor to discuss your health with you?), and then assess how the vignettes perform when that specific option is held constant.

Table 4 presents the scenario analysis for the positive responses (Works YES), and Table 5 presents the scenario analysis for the negative response (Works NO). The analysis works in a straightforward manner, following these steps:

Table 4. Scenario analysis, revealing pairwise Interactions to drive perceived positive responses, ‘Works YES’

Element held constant in the vignette

A0

A1

 A2

A3

A4

Top 2 – Works YES (Positive Outcome)

 

 

No element from question A

Doctor talks to me, face to face… not just those phone calls with clinical message

Doctor explains to me WHY this medicine, and what should I DO

My friends explain this stuff to me… I’m more comfortable with them

Doctor guides me to the Internet sites… so I CAN TAKE CONTROL

A0

A1

A2

A3

A4

Additive Constant

28

53

50

50

34

B4

I’m nervous about health – but really want to be healthy to see my kids, grandkids, or even relatives and friends in the years to come

15

10

1

-5

17

D1

My family means the world to me

14

-8

3

16

11

C4

I’m pretty private… my health meds are my business… and maybe the doctor’s, but that’s all

11

-5

1

-9

11

B1

I’m pretty private about my health… no one’s business

7

7

-4

-17

-2

D2

I reach out to talk to friends about my health and illness

6

-9

-4

-7

3

B3

When it comes to illness, I’m on Google, so I really become an expert

5

12

0

-8

-6

C2

My family and others butt-in to my health… I want my privacy

2

-15

-10

-1

-5

B2

I don’t feel like going to the doctor… even for the most severe symptoms… I can take care of it

1

1

-5

-24

-6

C1

My family is always there to listen, and support me… I like that

1

-5

1

-1

-3

C3

I really am happy when someone takes control, and tells me what to take, and schedules my meds for me

0

-7

-3

-3

-7

D4

My friends really are there to listen to me about my medical experience – sometimes I feel I’m wearing out my welcome

-2

-2

-1

-2

17

D3

I reserve my friends for non-medical talks, like politics, or people

-6

-8

-3

5

4

Table 5. Scenario analysis, revealing pairwise Interactions to drive perceived negative responses, ‘Works NO’

Bot 2 – Works NO (Negative Outcome)

No element from question A

Doctor talks to me, face to face… not just those phone calls with clinical message

Doctor explains to me WHY this medicine, and what should I DO

My friends explain this stuff to me… I’m more comfortable with them

Doctor guides me to the Internet sites… so I CAN TAKE CONTROL

A0

A1

A2

A3

A4

Additive Constant

37

21

23

27

31

C3

I really am happy when someone takes control, and tells me what to take, and schedules my meds for me

9

1

7

8

7

C2

My family and others butt-in to my health… I want my privacy

6

4

4

5

5

C1

My family is always there to listen, and support me… I like that

5

3

0

-2

-1

B2

I don’t feel like going to the doctor… even for the most severe symptoms… I can take care of it

4

7

7

16

13

D3

I reserve my friends for non-medical talks, like politics, or people

2

2

6

-4

-6

D4

My friends really are there to listen to me about my medical experience – sometimes I feel I’m wearing out my welcome

2

8

2

-2

-4

C4

I’m pretty private… my health meds are my business… and maybe the doctor’s, but that’s all

0

0

1

7

-8

B1

I’m pretty private about my health… no one’s business

-5

0

7

12

9

D1

My family means the world to me

-6

2

-2

-17

-9

D2

I reach out to talk to friends about my health and illness

-8

8

0

-3

-8

B3

When it comes to illness, I’m on Google, so I really become an expert

-9

-3

4

9

8

B4

I’m nervous about health – but really want to be healthy to see my kids, grandkids, or even relatives and friends in the years to come

-11

-6

-2

8

-6

  1. Identify the variable to be held constant. In our study, this is Question A: How would you like your doctor to discuss your health with you?
  2. In our 4×4 design (four questions, four answers per question), Question A has five alternatives, comprising the four answers and the ‘no answer’ option wherein Question A does not contribute to a vignette.
  3. We sort the full set of 2400 records, one record per vignette per respondent, based upon the specific answer. This step ‘stratifies’ the database, into five strata, one stratum for each answer. One stratum comprises those vignettes without an answer to Question A.
  4. We then run the OLS regression on each stratum, but do not use A1-A4 as independent variables since they are held constant in a stratum.
  5. The coefficients tell us the contribution of each element to WORKS YES, for a specific answer.
  6. Thus, when we have A0, we deal with no answer from Question A.
  7. The additive constant is 28, meaning that for these vignettes we are likely to get only 28% positive response (works for ME, rating 4–5).The additive constant, 28, is probably the lowest level we will reach in basic response.
  8. Three very strong performing answers emerge. These are likely to lead to strong positive feelings, even starting from the low baseline of 28

    I’m nervous about health – but really want to be healthy to see my kids, grandkids, or even relatives and friends in the years to come

    My family means the world to me

    I’m pretty private… my health meds are my business… and maybe the doctor’s, but that’s all

  9. Now let us move to the strongest performing answer, A1: Doctor talks to me, face to face… not just those phone calls with clinical message. When this answer is the keystone of the vignette, the additive constant jumps up to 53. That means that in the absence of anything else, just knowing that message increases the frequency of positive answers 4–5 on the 5-point scale, namely Works YES
  10. When we combine this strong basic idea presented in A1 with the two answers or elements below, we end up with an additional 10% to 12% positive responses.

    When it comes to illness, I’m on Google, so I really become an expert

    I’m nervous about health – but really want to be healthy to see my kids, grandkids, or even relatives and friends in the years to come

  11. When we run the scenario analysis looking at the Works NO (a negative outcome), we see that without any element from question A, the additive constant is highest (37), and then decreases as the doctor becomes increasing involved. When the doctor talks with the respondent, the additive constant is lowest (A1 = face to face = additive constant 21; A2 = doctor explains = additive constant 23.)

    The most negative elements come from interactions where either the friends explain the medical material, or the doctor guides the respondent to the internet, allowing the respondent to take control.

  12. Response time. We can perform the same scenario analysis. This time, however, we eliminate the condition where an answer to A does not appear (A0). Table 6 shows the dramatic effects of interaction. The response time changes depending upon the specific element from question A about how the respondent wants to get information. A dramatic example comes from answer A1 (doctor talks to me face to face…). When A1 is paired with B1 (I’m pretty private about my health … no one’s business) the response time for element B1 is 3.0 seconds. When A4 (Doctor guides me to the internet sites…) is paired with B1, the response time for element B1 is just about half, 1.4 seconds.

Table 6. Scenario analysis, revealing pairwise Interactions to drive response time

 

Doctor talks to me, face to face… not just those phone calls with clinical message

Doctor explains to me WHY this medicine, and what should I DO

My friends explain this stuff to me… I’m more comfortable with them

Doctor guides me to the Internet sites… so I CAN TAKE CONTROL

A1

A2

A3

A4

B1

I’m pretty private about my health… no one’s business

3.0

2.1

2.2

1.4

B3

When it comes to illness, I’m on Google, so I really become an expert

2.6

2.3

2.2

1.8

C1

My family is always there to listen, and support me… I like that

2.5

1.4

1.6

2.3

B4

I’m nervous about health – but really want to be healthy to see my kids, grandkids, or even relatives and friends in the years to come

2.3

2.0

2.3

1.3

D4

My friends really are there to listen to me about my medical experience – sometimes I feel I’m wearing out my welcome

1.2

2.4

2.0

2.5

B2

I don’t feel like going to the doctor… even for the most severe symptoms… I can take care of it

2.2

1.8

2.5

1.4

C3

I really am happy when someone takes control, and tells me what to take, and schedules my meds for me

2.0

1.6

2.0

2.6

C2

My family and others butt-into my health… I want my privacy

1.5

1.8

1.7

2.4

D3

I reserve my friends for non-medical talks, like politics, or people

1.7

2.0

2.0

2.2

C4

I’m pretty private… my health meds are my business… and maybe the doctor’s, but that’s all

1.8

1.5

1.8

2.0

D1

My family means the world to me

1.7

1.9

1.6

2.0

D2

I reach out to talk to friends about my health and illness

1.2

2.0

1.7

1.8

It is clear from Table 6 that there is cognitive processing occurring, with the data suggesting that mutually contradictory elements, in terms of implications, the respond processes the information, attempting to resolve these contradictory elements.

Responses from Key Subgroups

Positive Outcome (Works YES): Table 7 presents the performance of the elements by key subgroups, comprising gender, age, and stated concern about their health. In the interest of easing the inspection, we present only those elements which score well with at least one of the key subgroups.

Table 7. Performance of the answers/elements by key subgroup for the criterion ofWorks YES. Only strong performing elements for at least one subgroup are shown

Top 2 – Works YES

Male

Female

Age 18–30

Age 31–49

FW 50+

Don’t think

Healthy

Concerned

Additive Constant

45

42

29

58

33

26

48

43

A1

Doctor talks to me, face to face… not just those phone calls with clinical message

5

10

7

4

12

17

-3

16

A2

Doctor explains to me WHY this medicine, and what should I DO

9

1

2

7

4

6

2

7

A3

My friends explain this stuff to me… I’m more comfortable with them

0

-3

1

3

-6

17

-6

0

A4

Doctor guides me to the Internet sites… so I CAN TAKE CONTROL

2

-2

3

4

-2

22

-4

2

B3

When it comes to illness, I’m on Google, so I really become an expert

-4

3

2

-2

-1

9

-1

-2

B4

I’m nervous about health – but really want to be healthy to see my kids, grandkids, or even relatives and friends in the years to come

3

8

10

1

8

-1

1

11

D1

My family means the world to me

4

8

3

-1

16

1

4

8

D4

My friends really are there to listen to me about my medical experience – sometimes I feel I’m wearing out my welcome

4

-2

13

-4

-2

5

0

1

The key differences emerge from the additive constants and a few elements, only. Most respondents are positive. The least positives are two groups; those age 18–30 (additive constant = 29) and those age 50+ (additive constant 33) and those not concerned with their health (additive constant = 26). The only groups which surprises are those age 50+.

Looking across subgroups, we find two messages which appear to do well on a consistent basis

Doctor talks to me, face to face… not just those phone calls with clinical message

But really want to be healthy to see my kids, grandkids, or even relatives and friends in the years to come

Looking down, within a subgroup, we find some patterns which strongly resonate, and are meaningful when we think about the needs and wants of the subgroup.

Those age 50+

I’m nervous about health – but really want to be healthy to see my kids, grandkids, or even relatives and friends in the years to come

My family means the world to me

Those who classify themselves as not concerned

Doctor talks to me, face to face… not just those phone calls with clinical message

My friends explain this stuff to me… I’m more comfortable with them

Doctor guides me to the Internet sites… so I CAN TAKE CONTROL

When it comes to illness, I’m on Google, so I really become an expert

When we perform the same analysis, this time for the lower part of the scale (Works NO), where ratings 1–2 were assigned 100, and ratings 3–5 were assigned 0, we find a different pattern. We again present only those elements which score strongly among at least one of the subgroups.

When we look at the key subgroups, we find that most of the groups begin with a low additive constant, which means that they feel these messages will not do any harm. The two groups which surprise are those who are age 50+ (additive constant = 44) and those who say that they are concerned about their health (additive constant = 48.)The likelihood is probably their fear that the ‘wrong’ thing could exacerbate a problem. In contrast those who are age 31–49 show a very low additive constant (12), as do those who classify themselves as health (additive constant = 18).

The additive constant provides only part of the story. Some of the elements drive a perception of poor outcomes, especially those who call themselves healthy. A pleasant surprise is that the elements which these self-described healthy respondents feel to lead to a bad outcome are those which talk about avoiding the medical establishment. That is, those who consider themselves health are already aware of good practices, and react negatively to poor practices, as shown by the high coefficients for this reversed scale.

I don’t feel like going to the doctor… even for the most severe symptoms… I can take care of it

I’m pretty private about my health… no one’s business

My friends explain this stuff to me… I’m more comfortable with them

Emergent Mind Sets Showing Different Patterns of What is Important

One of the ingoing premises of Mind Genomics is that within any topic area where people make decisions or have points of view there exist mind-sets, groups of ideas which ‘go together.’ Mind Genomics posits that at any specific time, a given individual will have only one of the several possible mind-sets, although over time, e.g., years or due to some unforeseen circumstance, one’s mind-set will change.

The metaphor for a mind-set it a mental genome. There is no limit to the number of such mental genomes, at least in terms of defining them by experiments. Virtually every topic can be broken down into smaller and smaller topics, and studied, from the very general to the most granular. In that respect, Mind Genomics differs from its namesake, Biological Genomics, which posits that there are a limited number of possible genes. In Mind Genomics, each topic area comprises a limited number of mind genomes, but there are uncountable topics.

The notion of mind-sets in the population, these so-called mind genomes, opens a variety of vistas. From the vantage point of psychology, the mind-genomes present the opportunity to study individual differences in the world of the everyday, and to systematize these differences, perhaps even finding ‘supersets’ of mind genomes which go across many different types of behavior. From the vantage point of biology, discovering mind-genomes holds the possibility of ‘correlating’ mind-genomes with actual genomes. And finally, from the vantage point of economics and commerce, discovering the pattern of a person’s mind genomes leads to better customer experience, and perhaps more responsiveness to suggestions about lifestyle modifications in the search for better health. The last is the focus of this study, the search for how to best communicate to people.

The process of uncovering mind genomes or mind-sets is empirical, modeling the relation between elements and responses (our Works YES model), clustering the respondents on the basis of the pattern of their coefficients, and finally extracting clusters which are few in number (parsimony), and which are coherent and meaningful, telling a ‘simple story’ (interpretability).Clustering has become a standard method in exploratory data analysis (e.g., Dubes & Jain, 1980.)

The approach to creating these mind-sets has already been documented extensively in [25–30]. It is vital to keep in mind that modeling and clustering is virtually automatic and intellectual agnostic. It takes a researcher to determine whether the clusters, the so-called mind-sets, really make sense when interpreted. There is no way for the clustering algorithm to easily interpret the meaning of the clusters other than perhaps doing a word count. The involvement of the research is vital, albeit not particularly taxing. The computer program does all the work.

The clustering based on the positive outcome models (Works YES) suggest three interpretable mind-sets, shown in Table 9 fop the positive outcome, Works YES, and in Table 10 for the negative outcome, Works NO. The names for the mind-sets were selected on the basis the elements which scored highest for the Works YES models. The mind-sets make sense (privacy seeker; doctor focus; control focus) for both the positive and the negative models (Works YES, Works NO), respectively. The clustering also parallels preliminary results from the aforementioned study run eight years before, in 2011(Moskowitz, unpublished), which suggested three similar three mind-sets of this type. It is important to note that these mind-sets are not ‘set in stone,’ but rather represent interpretable areas in what is more likely a continuum of preferences.

Table 9. Performance of the answers/elements by three emergent mind-sets for the criterion of Works YES

 Positive Outcome – Works YES
(Basis for the mind-set segmentation)

MS3 Privacy-seeker

MS2 Doctor focus

MS1 Control focus

Additive constant

45

50

34

C4

I’m pretty private… my health meds are my business… and maybe the doctor’s, but that’s all

15

-1

-13

A1

Doctor talks to me, face to face… not just those phone calls with clinical message

-7

15

16

A2

Doctor explains to me WHY this medicine, and what should I DO

-11

11

16

A4

Doctor guides me to the Internet sites… so I CAN TAKE CONTROL

-15

11

8

D1

My family means the world to me

-5

10

15

B4

I’m nervous about health – but really want to be healthy to see my kids, grandkids, or even relatives and friends in the years to come

3

2

14

D4

My friends really are there to listen to me about my medical experience – sometimes I feel I’m wearing out my welcome

-9

5

9

D2

I reach out to talk to friends about my health and illness

-11

-3

8

B3

When it comes to illness, I’m on Google, so I really become an expert

5

-16

8

A3

My friends explain this stuff to me… I’m more comfortable with them

-16

6

7

B1

I’m pretty private about my health… no one’s business

5

-19

5

D3

I reserve my friends for non-medical talks, like politics, or people

-2

-8

3

B2

I don’t feel like going to the doctor… even for the most severe symptoms… I can take care of it

5

-23

-6

C3

I really am happy when someone takes control, and tells me what to take, and schedules my meds for me

0

-3

-12

C1

My family is always there to listen, and support me… I like that

4

7

-14

C2

My family and others butt-in to my health… I want my privacy

2

-2

-18

Table 10. Performance of the answers/elements by three emergent mind-sets for the criterion of Works NO

Negative Outcome – Works NO

MS3 Privacy-focus

MS2 Doctor focus

MS1 Control focus

Additive constant

24

34

31

A3

My friends explain this stuff to me… I’m more comfortable with them

16

-5

-11

D4

My friends really are there to listen to me about my medical experience – sometimes I feel I’m wearing out my welcome

11

-8

-1

A2

Doctor explains to me WHY this medicine, and what should I DO

10

-12

-12

A4

Doctor guides me to the Internet sites… so I CAN TAKE CONTROL

10

-9

-12

B2

I don’t feel like going to the doctor… even for the most severe symptoms… I can take care of it

8

12

13

C3

I really am happy when someone takes control, and tells me what to take, and schedules my meds for me

5

9

6

B1

I’m pretty private about my health… no one’s business

4

9

4

C4

I’m pretty private… my health meds are my business… and maybe the doctor’s, but that’s all

-9

1

9

C1

My family is always there to listen, and support me… I like that

0

-8

8

A1

Doctor talks to me, face to face… not just those phone calls with clinical message

2

-14

-12

B3

When it comes to illness, I’m on Google, so I really become an expert

5

7

-2

B4

I’m nervous about health – but really want to be healthy to see my kids, grandkids, or even relatives and friends in the years to come

-2

-1

-1

C2

My family and others butt-in to my health… I want my privacy

2

6

7

D1

My family means the world to me

-4

-8

-7

D2

I reach out to talk to friends about my health and illness

2

-2

-6

D3

I reserve my friends for non-medical talks, like politics, or people

-3

3

1

Response Time (engagement) – Key Subgroups: Table 11 shows us the differences in response time across the 16 elements. The data are repeated for the total panel, along with the estimated response times for each element by each key subgroup. The patterns differ by subgroup. Some of the key results are:

  1. Males focus for longer times about being an expert and wanting privacy.

    When it comes to illness, I’m on Google, so I really become an expert

    I’m pretty private about my health… no one’s business

  2. Females focus slight longer about most of the elements than do males. Two elements capture their attention, but do not capture the attention of males

    Doctor talks to me, face to face… not just those phone calls with clinical message

    My friends explain this stuff to me… I’m more comfortable with them

  3. The youngest respondents (age 18–30) focus on only one element

    My friends really are there to listen to me about my medical experience – sometimes I feel I’m wearing out my welcome

  4. The oldest respondents focus a lot more time than other respondents on the need for expertise and privacy

    When it comes to illness, I’m on Google, so I really become an expert

    I’m pretty private about my health… no one’s business

    My family and others butt-in to my health… I want my privacy

  5. Those who say they are not concerned focus a great deal on one element

    I don’t feel like going to the doctor… even for the most severe symptoms… I can take care of it

  6. Those who say they are healthy focus on

    When it comes to illness, I’m on Google, so I really become an expert

    I’m pretty private about my health… no one’s business

  7. Those say they are concerned about their health focus a great deal on two issues, opposites of each other

    My family and others butt-in to my health… I want my privacy

    I really am happy when someone takes control, and tells me what to take, and schedules my meds for me

  8. The privacy mind-set focuses on privacy, but also on the lack of privacy (someone else taking control). Keep in mind that this is response time, not a judgment. The respondents in this mind-set pay attention to the statement about someone else taking control, rather than just disregarding it.

    When it comes to illness, I’m on Google, so I really become an expert

    My family and others butt-in to my health… I want my privacy

    I’m pretty private about my health… no one’s business

    I really am happy when someone takes control, and tells me what to take, and schedules my meds for me

  9. The doctor mind-set actually spends more time on elements which do not agree with their mind-set and spend little time on elements dealing with the doctor. It is as if they are ‘wired’ to accept the information of the doctor but have to think about contravening data.

    My friends explain this stuff to me… I’m more comfortable with them

    When it comes to illness, I’m on Google, so I really become an expert

    My family and others butt-in to my health… I want my privacy

  10. The control mind-set focus on loss of control, again spending little time on elements which agree with their mind-setI really am happy when someone takes control, and tells me what to take, and schedules my meds for me

Table 8. Performance of the answers/elements by key subgroup for the criterion of Works NO. Only strong performing elements for at least one subgroup are shown

 

Bot 2 – Works NO

Male

Female

Age 18–30

Age 31–49

Age 50+

Don’t think

Healthy

Concerned

Additive Constant

29

30

34

12

44

32

18

38

A3

My friends explain this stuff to me… I’m more comfortable with them

2

-1

-2

2

0

-9

10

-7

B1

I’m pretty private about my health… no one’s business

4

6

2

10

2

1

12

1

B2

I don’t feel like going to the doctor… even for the most severe symptoms… I can take care of it

13

9

2

15

13

-4

14

10

B3

When it comes to illness, I’m on Google, so I really become an expert

3

4

4

7

-1

-7

8

1

B4

I’m nervous about health – but really want to be healthy to see my kids, grandkids, or even relatives and friends in the years to come

1

-3

-9

6

-4

0

9

-10

C3

I really am happy when someone takes control, and tells me what to take, and schedules my meds for me

4

9

6

6

10

-7

9

5

D1

My family means the world to me

-4

-8

-16

2

-10

10

-8

-5

D2

I reach out to talk to friends about my health and illness

-4

1

-7

1

-1

13

-1

-2

Table 11. Response times for elements, by total panel and key subgroups

 

 

total

Male

Female

A18–30

A31–49

50+

Not concerned

Healthy

Concern

Doctor focus

Control focus

B3

When it comes to illness, I’m on Google, so I really become an expert

1.8

1.7

1.9

1.4

1.6

2.1

2.2

1.9

1.6

1.9

1.6

B1

I’m pretty private about my health… no one’s business

1.7

1.7

1.7

1.5

1.3

2.2

1.6

2.0

1.5

1.8

1.5

C2

My family and others butt-in to my health… I want my privacy

1.7

1.4

2.0

1.4

1.7

2.0

1.3

1.4

2.0

1.4

1.8

C3

I really am happy when someone takes control, and tells me what to take, and schedules my meds for me

1.7

1.5

1.8

1.0

1.8

1.9

1.6

1.2

2.0

1.4

1.9

B2

I don’t feel like going to the doctor… even for the most severe symptoms… I can take care of it

1.6

1.4

1.7

1.2

1.5

1.8

2.6

1.7

1.3

1.9

1.2

B4

I’m nervous about health – but really want to be healthy to see my kids, grandkids, or even relatives and friends in the years to come

1.6

1.6

1.6

1.4

1.6

1.6

1.5

1.5

1.6

1.8

1.4

C1

My family is always there to listen, and support me… I like that

1.5

1.5

1.5

1.1

1.4

1.8

1.8

1.1

1.9

1.3

1.7

D4

My friends really are there to listen to me about my medical experience – sometimes I feel I’m wearing out my welcome

1.5

1.5

1.6

1.9

1.0

1.9

2.0

1.2

1.8

1.8

1.3

A4

Doctor guides me to the Internet sites… so I CAN TAKE CONTROL

1.4

1.2

1.6

1.1

1.3

1.7

-0.3

1.4

1.6

1.5

1.3

C4

I’m pretty private… my health meds are my business… and maybe the doctor’s, but that’s all

1.4

1.3

1.5

1.0

1.3

1.8

1.1

1.0

1.8

1.2

1.3

D3

I reserve my friends for non-medical talks, like politics, or people

1.4

1.4

1.4

1.4

1.1

1.8

1.7

1.4

1.4

1.7

1.1

A1

Doctor talks to me, face to face… not just those phone calls with clinical message

1.3

1.0

1.6

0.9

1.1

1.8

-0.2

1.3

1.5

1.3

1.4

A3

My friends explain this stuff to me… I’m more comfortable with them

1.3

1.0

1.7

1.0

1.4

1.5

0.6

1.2

1.5

2.0

1.0

D1

My family means the world to me

1.3

1.6

0.9

1.5

0.9

1.6

1.9

1.2

1.3

1.6

1.3

A2

Doctor explains to me WHY this medicine, and what should I DO

1.2

1.0

1.4

1.1

1.1

1.6

0.6

1.0

1.5

1.4

1.3

D2

I reach out to talk to friends about my health and illness

1.1

0.9

1.3

1.4

0.7

1.3

0.3

1.1

1.1

1.4

1.0

Identifying Sample Mindsets at the Clinic

The conventional wisdom in consumer research is that we can use a person’s demographics or psychographics to predict the mind-set to which the person belongs. The actual practice is to cluster people based upon their demographics, attitudes and/or behavior, arriving at a set of individuals who LOOK different by standard measures, and then to map these clusters to different ways of thinking about the same problem.

 The conventional approach occasionally works but fails to deal with the granularity of the situations having many aspects. The different aspects of a single topic, such as dealing with medical information, may generate a variety of different groups of mind-sets, depending upon the topic of medical information, whether that be simply informative, or prescriptive, and forth. Conventional research is simply too blunt an instrument to assign people to these different arrays of mind-sets, each of which emerges from different aspects of the same general problem. Once granularity becomes a factor in one’s knowledge, the standard methods no longer work, in light of the vastly increased sophistication of one’s knowledge about a topic.

An example of the difficulty of traditional methods to assign new people to the three mind-sets uncovered here can be sensed from Table 12, which shows the membership pattern in the three mind-sets by gender, by age, and by self-described concern with one’s health. The distributions are similar across the three mind-sets. One either needs much more data, from many other measured aspects of each person, or a different way to establish mind-set membership in this newly uncovered array of three mind-sets emerging from the granular topic of the way one wants to give and get medical information.

Table 12. Distribution of mind-set membership by gender, age, and self-described concern with one’s health

Privacy focus

Doctor focus

Control focus

Total

100

38

29

33

 

Male

51

18

16

17

Female

49

20

13

16

 

Age 18–30

21

11

5

5

Age w

39

14

12

13

Age 50+

37

12

11

14

Not answered

3

1

1

1

 

Healthy

44

20

12

12

Concerned

49

17

13

19

Never think about it

7

1

4

2

Discovering these three mind-sets in the population by a PVI (Personal Viewpoint Identifier)

The ideal situation in research is to discover a grouping of consumers, e.g., our three mind-sets, and then discover some easy-to-measure set of variables which, in concert, assign a person to a mind-set. With such an assignment rule it may be possible to scan a database of millions of people, and assign each person in the database to one of the empirically discovered mind-sets. That process may work, but the occasions are few and far between.

An alternative method uses the coefficients from the three mind-sets to create a typing tool, a set of questions with simple answers, so that the pattern of answers assigns a person to one of the three mind-sets. The method uses the coefficients for Works YES (Table 9), identifies the most discriminating patterns, and then simulates many thousands of data sets, perturbing each data set thousands of times. These data sets are, for each mind-set, the 16 coefficients and the additive constant. The process is a so-called Monte-Carlo simulation.

The actual PVI is available at the link below, as of this writing (summer, 2019).

http://pvi360.com/TypingToolPage.aspx?projectid=78&userid= 2018

Figure 1 shows the information collected from the respondent (classification), and Figure 2 shows the actual PVI questions. In practice they are randomized. Following the six questions, the patterns of answers to which assign a person to a mind-set, we see four additional questions that the respondent who is doing the typing can answer, to provide additional information.

Mind Genomics-026 - JCRM Journal_F1

Figure 1. The self-classification, completed at the start of the PVI

Mind Genomics-026 - JCRM Journal_F2Figure 2. The actual PVI showing the six PVI questions, and the four general questions below

Discussion and conclusions

This study identified mindsets regarding how the person would like to communicate with the physician the underlying goal being to increase adherence through proper communication. Communication messaging typically involves identifying a subgroup by common characteristics of its members and according the information to group members by these characteristics (Kreuter, Strecher& Glassman, 1999). The notion underlying this approach is that group members possess similar characteristics and, therefore, will be influenced by the same message. Similarly, in health communication, messaging may be customized to a subgroup, members of which share characteristics such as illness, health conditions and needs, etc. Individuals, however, are most persuaded by personally relevant communication and are more likely to pay attention and to process such information more thoroughly (Petty &Cacioppo, 2012).

Since fitting a message to meet personal needs of patients, rather than group criteria, is more effective for influencing attitudes and health behaviors, we suggest that to promote adherence, clinicians should tailor their messages to individuals. Sophisticated approaches to tailor communication aimed at changing complex health behaviors such as adherence, call upon clinicians to integrate detailed information into communication messages for each patient (Cantor &Kihlstrom, 2000).An advantage of such strategies for communication is that messages tailored to a patient do not need to be modified very often (Schmid, Rivers, Latimer &Salovey, 2008).

Our viewpoint enables clinicians to identify the sample mindset to which a patient in the population belongs, for a specific topic, i.e., granular. Messages about adherence and non-adherence should be congruent with those specifically strong elements for the mind-set to which the patient belongs for the particular topic. There are some messages which appear to be universal, such as the need of patients to have eye contact with the clinician. At the deeper level, the level of granular message; the data suggests three mind-sets, membership in which should be known to the physician and guide style of communication.

People belonging to the first mindset focus on privacy and expect their clinician to take control (e.g., tell me what to take, schedules my meds for me).

People belonging to the second mindset accept what the clinician advises them but spend time discussing it with other patients and enhancing their knowledge on Google. People in this mindset expect their clinician to carry a dialogue respecting the information they learned and their thoughts.

People belonging to the third mindset, need to have control. Aiming at behavioral changes and adherence promotion, clinicians might adopt communication with a tonality of process oriented, along with personal relevance for the patient.

Tailoring the message to the patient requires the clinician to assess each patient belonging to a mindset by asking the six questions according to our viewpoint identifier.

Acknowledgement

Attila Gere thanks the support of the Premium Postdoctoral Researcher Program of the Hungarian Academy of Sciences

References

  1. DiMatteo MR (2004) Variations in patients’ adherence to medical recommendations: a quantitative review of 50 years of research. MedicalCare 42: 200–209.
  2. Haskard-Zolnierek KB, DiMatteo MR (2009) Physician communication and patient adherence to treatment: a meta-analysis. Medical care 47: 826.
  3. Vermeire E, Hearnshaw H, Van Royen P (2001) Patient adherence to treatment: three decades of research, a comprehensive review. J Clin Pharm Ther26: 331–342.
  4. Zolnierek KB, DiMatteo MR(2009) Physician communication and patient adherence to treatment: a meta-analysis. Medical care 47: 826.]
  5. DiMatteo MR, Haskard KB, Williams SL (2007) Health beliefs, disease severity, and patient adherence: a meta-analysis. Medical Care45: 521–528.
  6. Sabate E (2003) Adherence to long-term therapies: Evidence for action. Geneva: World Health Organization.
  7. Gabay G, Moskowitz HR (2012)the algebra of health concerns: implications of consumer perception of health loss, illness and the breakdown of the health system on anxiety. International Journal of Consumer Studies36: 635–646.
  8. Gabay G (2015) Perceived control over health, communication and patient- physician trust. Patient Education and Counseling98: 1550–1557.
  9. Beck RS, Daughtridge R, Sloane PD (2002) Physician-patient communication in the primary care office: a systematic review. Journal of the American Board of Family Practice15: 25–38.
  10. Gabay G (2016) Exploring perceived control and self-rated health in re-admissions among younger adults: A retrospective Study. Patient Education and Counseling 99: 800–806.
  11. Osterberg L, Blaschke T (2005) Adherence to medication. N Engl J Med 353: 487–497.
  12. Chewning B, Sleath B (1996) Medication decision-making and management: a client-centered model. SocSci Med 42: 389–398.
  13. Squier RW (1990) A model of empathic understanding and adherence to treatment regimens in practitioner-patient relationships. SocSci Med 30: 325–339.
  14. Stewart MA (1984) what is a successful doctor-patient interview? A study of interactions and outcomes. SocSci Med 19: 67–175.
  15. DiMatteo MR, Haskard-Zolnierek KB, Martin LR (2012) Improving patient adherence: a three-factor model to guide practice. Health Psychology Review 1: 74–91.
  16. Haynes RB, Yao X, Degani A, Kripalani S, Garg A, et al.(2005) Interventions to enhance medication adherence. Cochrane Database Systematic Review 4
  17. Haynes R, Ackloo E, Sahota N, McDonald H, Yao X (2008) Interventions for enhancing medication adherence. Cochrane Database of Systematic Review 2: CD000011.
  18. Ratanawongsa N, Karter AJ, Parker MM, Lyles CR, Heisler M, et al. (2013Communication and medication refill adherence: the Diabetes Study of Northern California. JAMA internal medicine11: 173–210.
  19. Rosenthal R, Rosnow R (2007) Essentials of behavioral research: methods and data analysis. McGraw-Hill.
  20. Levinson W, Lesser CS, Epstein RM (2010) Developing physician communication skills for patient-centered care. Health affairs29: 1308–1310.
  21. Epstein RM, Street RL (2007) Patient-centered communication in cancer care: promoting healing and reducing suffering. National Cancer Institute.
  22. Brown RF, Butow PN, Dunn SM, Tattersall MH (2001) Promoting patient participation and shortening cancer consultations: a randomised trial. British Journal of Cancer 85: 1273.
  23. Tulsky JA (2005) Interventions to enhance communication among patients, providers, and families. Journal of palliative medicine 8: 95.
  24. Rao JK, Anderson LA, Inui TS (2007) Communication interventions make a difference in conversations between physicians and patients: a systematic review of the evidence. Med Care45: 340–349.
  25. Gabay G, Zemel G, Gere A, Zemel R, Papajorgji P, et al. (2018) On the threshold: What concerns healthy people about the prospect of cancer.Cancer Studies and Therapeutics Journal 3: 1–10.
  26. Gabay G, Gere A, Stanley J, Habsburg-Lothringen C, Moskowitz HR(2019) Health threats awareness – Responses to warning messages about cancer and smartphone Usage. Cancer Studies Therapy Journal4: 1–10.
  27. Gabay G, Gere A, Zemel G, Moskowitz D, Shifron R, et al. (2019) Expectations and attitudes regarding chronic pain control: An exploration using Mind Genomics. Internal Medicine Research Open Journal4: 1–10.
  28. Gabay G, Gere A, Moskowitz HR (2019) Uncovering communication messages for health promotion: The case of arthritis. Integrated Journal of Orthopedic Traumatology2: 1–13.
  29. Gabay G, Gere A, Moskowitz HR. (2019) Understanding effective web messaging – The Case of Menopause. Integrated Gynecology & Obstetrics Journal 2: 1–16.
  30. Gabay G, Gere A, Stanley J, Habsburg-Lothringen C, Moskowitz HR (2019) Health threats awareness – Responses to warning messages about Cancer and smartphone usage. Cancer Studies Therapeutics Journal4: 1–10.
  31. Gofman A, Moskowitz HR (2010) Isomorphic permuted experimental designs and their application in conjoint analysis. Journal of Sensory Studies 25: 127–45.
  32. Beck RS, Daughtridge R, Sloane PD (2002) Physician-patient communication in the primary care office: a systematic review. Journal of the American Board of Family Practice15: 25–38.
  33. Brown RF, Butow PN, Dunn SM, Tattersall MH (2001) Promoting patient participation and shortening cancer consultations: a randomised trial. British Journal of Cancer 85: 1273.
  34. Campbell, James D, Hans O, Mauksch, Helen J Neikirk, Hosokawa CM (1990) Collaborative practice and provider styles of delivering health care. Social Science & Medicine 30: 1359–1365.
  35. Cantor N, Kihlstrom JF (2000) Social intelligence. Handbook of intelligence 2: 359–379.
  36. Charlton CR, DearingKS, Berry JA, Johnson MJ (2008) Nurse practitioners’ communication styles and their impact on patient outcomes: an integrated literature review. Journal of the American Academy of Nurse Practitioners 20: 382–388.
  37. Chewning B, Sleath B (1996) Medication decision-making and management: a client-centered model. SocSci Med42: 389–398.
  38. Coeling, Van EH, Cukr PR (2000) Communication styles that promote perceptions of collaboration, quality, and nurse satisfaction. Journal of Nursing Care Quality14: 63–74.
  39. DiMatteo MR (2004) Variations in patients’ adherence to medical recommendations: a quantitative review of 50 years of research. MedicalCare 42: 200–209.
  40. DiMatteo MR, Haskard KB, Williams SL (2007) Health beliefs, disease severity, and patient adherence: a meta-analysis. Medical Care 45: 521–528.
  41. DiMatteo MR, Haskard-Zolnierek KB, Martin LR (2012) Improving patient adherence: a three-factor model to guide practice. Health Psychology Review 1: 74–91.
  42. Dubes R, Jain AK (1980) Clustering methodologies in exploratory data analysis. In Advances in Computers 1: 13–228.
  43. Epstein RM, Street RL (2007) Patient-centered communication in cancer care: promoting healing and reducing suffering. National Cancer Institute
  44. Gabay G (2015) Perceived control over health, communication and patient- physician trust. Patient Education and Counseling98: 1550–1557.
  45. Gabay G (2016) Exploring perceived control and self-rated health in re-admissions among younger adults: A retrospective Study. Patient Education and Counseling 99: 800–806.
  46. Gabay G, Moskowitz HR (2012)the algebra of health concerns: implications of consumer perception of health loss, illness and the breakdown of the health system on anxiety. International Journal of Consumer Studies36: 635–646.
  47. Gabay G, Zemel G, Gere A, Zemel R, Papajorgji P, et al. (2018) On the threshold: What concerns healthy people about the prospect of cancer.Cancer Studies and Therapeutics Journal 3: 1–10.
  48. Gabay G, Gere A, Stanley J, Habsburg-Lothringen C, Moskowitz HR(2019) Health threats awareness – Responses to warning messages about cancer and smartphone Usage. Cancer Studies Therapy Journal4: 1–10.
  49. Gabay G, Gere A, Zemel G, Moskowitz D, Shifron R, et al. (2019) Expectations and attitudes regarding chronic pain control: An exploration using Mind Genomics. Internal Medicine Research Open Journal4: 1–10.
  50. Gabay G, Gere A, Moskowitz HR (2019) Uncovering communication messages for health promotion: The case of arthritis. Integrated Journal of Orthopedic Traumatology2: 1–13.
  51. Gabay G, Gere A, Moskowitz HR. (2019) Understanding effective web messaging – The Case of Menopause. Integrated Gynecology & Obstetrics Journal 2: 1–16.
  52. Gabay G, Gere A, Stanley J, Habsburg-Lothringen C, Moskowitz HR (2019) Health threats awareness – Responses to warning messages about Cancer and smartphone usage. Cancer Studies Therapeutics Journal4: 1–10.
  53. Gofman A, Moskowitz HR (2010) Isomorphic permuted experimental designs and their application in conjoint analysis. Journal of Sensory Studies 25: 127–45.
  54. Haskard-Zolnierek KB, DiMatteo MR (2009) Physician communication and patient adherence to treatment: a meta-analysis. Medical care 47: 826.
  55. Haynes R, Ackloo E, Sahota N, McDonald H, Yao X (2008) Interventions for enhancing medication adherence. Cochrane Database of Systematic Review 2: CD000011.
  56. Haynes RB, Yao X, Degani A, Kripalani S, Garg A, et al.(2005) Interventions to enhance medication adherence. Cochrane Database Systematic Review 4
  57. Kreuter MW, Strecher VJ, Glassman B (1999) One size does not fit all: the case for tailoring print materials. Annals of behavioral medicine 21: 276.
  58. Levinson W, Lesser CS, Epstein RM (2010) Developing physician communication skills for patient-centered care. Health affairs 29: 1308–1310.
  59. Osterberg L, Blaschke T (2005) Adherence to medication. N Engl J. Med 353: 487–497.
  60. Petty RE, Cacioppo JT(2012) Communication and persuasion: Central and peripheral routes to attitude change. Springer Science & Business Media 6.
  61. Ratanawongsa N, Karter AJ, Parker MM, Lyles CR, Heisler M, et al. (2013) Communication and medication refill adherence: the Diabetes Study of Northern California. JAMA internal medicine 11: 173–210.
  62. Rao JK, Anderson LA, Inui TS (2007) Communication interventions make a difference in conversations between physicians and patients: a systematic review of the evidence. Med Care 45: 340–349.
  63. Rosenthal R, Rosnow R (2007) Essentials of behavioral research: methods and data analysis. McGraw-Hill.
  64. Sabate E (2003) Adherence to long-term therapies: Evidence for action. Geneva: World Health Organization.
  65. Schmid KL, Rivers SE, Latimer AE, Salove P (2008) Targeting or tailoring?. Marketing health services 28: 32–37.
  66. Squier RW (1990) A model of empathic understanding and adherence to treatment regimens in practitioner-patient relationships. SocSci Med 30: 325–339.
  67. Stewart MA (1984) what is a successful doctor-patient interview? A study of interactions and outcomes. SocSci Med 19: 67–175.
  68. Tulsky JA (2005) Interventions to enhance communication among patients, providers, and families. Journal of palliative medicine 8: 95.
  69. Vermeire E, Hearnshaw H, Van Royen P (2001) Patient adherence to treatment: three decades of research, a comprehensive review. J Clin Pharm Ther26: 331–342.
  70. Williams-Piehota P, Schneider TR, Pizarro J, Mowad L, Salovey P (2003) Matching health messages to information-processing styles: Need for cognition and mammography utilization. Health Communication15: 375–392.
  71. Zolnierek KB, DiMatteo MR(2009) Physician communication and patient adherence to treatment: a meta-analysis. Medical care 47: 826.

Tinnitus in Adolescents – Intrinsic and Extrinsic factors

DOI: 10.31038/OHT.2020112

Abstract

Objective: To identify factors influencing the onset and the development of tinnitus among adolescents.

Patients and methods: 1260 high school students in Gothenburg participated in a health screening program during their first and third year of high school (age 16 and 19). Measurements included screening audiometry (thresholds were measured if the students failed the 20 dB HL) and patient reported outcomes, covering; noise exposure, use of cell phones, psychological well-being and students’ experiences of spontaneous tinnitus (ST), noise induced tinnitus (NIT) and temporary thresholds shift (TTS). Half of the group participated in occupational education programs (n=662), which was considered by the school health authorities as a noisy environment, and the other half in quiet, mostly theoretical programs (n=598).

Results: Over the three years in school, the students did not develop more hearing loss, tinnitus or TTS, than their initial level. Hearing loss did not correlate to ST, NIT or TTS. Frequent use of cell phones was highly correlated to NIT and TTS. The most important noise exposure factors were playing an instrument or attending concerts. An interesting observation was the influence of anxiety in all reported symptoms, i.e. ST, NIT and TTS.

Conclusion: This study points to the multifaceted nature of tinnitus, where noise exposure and anxiety are two strong influencing factors. However, hearing loss as measured by screening audiometry, did not correlate to the presence of tinnitus. The students listening habits, such as playing instruments and listening to music, live or recorded, correlated significantly to ST, NIT and TTS in this population. In our study, the single most influential factor for any form of subjective hearing symptoms is anxiety, which has also previously been reported for adults.

Key words

Adolescent, Anxiety, Child, Hearing loss, Noise, Stress, Tinnitus

Key messages

Live music is more highly linked to the emergence of tinnitus than listening to portable music players. When adolescents seek help for tinnitus of any kind, look for signs of untreated anxiety disorder.

Introduction

Noise can lead to hearing loss but also to stress reactions and stress related diseases [1–4]. Tinnitus is often one of the results of noise, where both hearing loss and stress reactions contribute to the symptom. Children’s auditory systems differ from adults in anatomy of the outer ear, sound transfer function [5] and central processing [6]. As concluded in an earlier review [7], longitudinal studies that focus on factors contributing to hearing loss in children are few/sparse. So far there is no direct evidence linking high frequency hearing loss and noise in children, as there is for adults, yet clear correlations with hereditary factors exist. Noise exposure in children’s leisure time is not regulated per se as it is in the work place, and schools in Sweden are not entitled to the same monitoring as the adult work places are Young people and children seeking medical help for tinnitus, report more often that tinnitus started after noise exposure, be it school hours or leisure [7]. Although there are reports on high noise levels in the elementary schools or pre-schools [8–10], it is the adult that complains of noise-induced tinnitus and the child or toddler is given less consideration. When asked, children report experience of tinnitus in between 30% and 53% [11–14]. Experience of temporary threshold shift (TTS) in the young population has not been the focus of many studies, yet those that do examine TTS [15, 16], report frequencies of 35% recurrence in teenagers. This recurrence seems to increase with experience of noise induced tinnitus (NIT), hearing loss, tobacco use and heredity of hearing loss [1]. Prolonged noise exposure has been shown to damage hearing [17], lower cognitive performance [18, 19] and evoke tinnitus [2, 20–22]. Noise induced tinnitus can signal minor cochlear lesions as well as a dysfunction of the efferent system [23, 24] and can also be linked to a vulnerable psychological type [25]. Similar to spontaneous tinnitus (ST), a connection to psychiatric disorders has been established [26–28] and a serotonergic vulnerability suggested [29]. The presence of serotonin in the auditory system has been well documented [30] and there are discussions on the functional link between tinnitus and depression [26, 27, 30, 31]. Despite this, we still do not know whether children and adolescents are more sensitive to noise and/or more prone to developing any kind of tinnitus, even though there are observations suggesting that the young auditory pathway does not function in the same way as the adult [6]. The ability to understand speech in a noisy environment develops over time and young children suffer the consequences of ambient noise the most [32]. The assumption that music is less hazardous than occupational noise is generally based on studies which have investigated the hearing in professional musicians and one experimental study on 10 volunteers [33–35]. However, the listening patterns and the voluntary exposure to live or recorded music may differ in adults versus the younger population [36, 37] and, as for occupational noise, in the young population it consists mainly of the school environment. It is difficult to compare epidemiological studies on tinnitus in children, as well as in adults, as the definitions of the symptom vary. Prevalence studies of tinnitus in children and adolescents also differ (with regards to hearing status of the study population) depending on whether it is an unselected or selected population. There are numerous studies on young adults, starting from 18 years of age, but not that many select a strictly paediatric population. A brief summary of tinnitus prevalence in children, recorded in studies dating back from 1972, is listed in Table 1. A more comprehensive review has been done by Rosing et al [38], but still battling with the same issues of lack of definitions of the studied symptoms and heterogeneous study populations.

Table 1. Prevalence of tinnitus in children reported in 1972–2016

Authors (year of publication)

n

Age range

Prevalence of tinnitus (any kind)  % within group

Normal hearing

Any HI

Hearing tests not performed

Nodar (1972)

2000

10–18

13

Graham (1979)

92

12–18

66

Graham (1981)

66

12–18

29

Mills and Cherry (1984)

110

4–17

44

30

Nodar (1984)

56

?

55

Mills et al (1986)

93

?

29

Viani (1989)

102

6–17

23

Martin and Snashall (1994)

67

2–16

50

50

Aust (2002)

1420

5–17

7

Holgers (2003)

964

7

13

9

Holgers and Pettersson (2005)

671

13–16

53

Holgers and Juul (2006)

274

9–16

46

Aksoy et al (2007)

1020

6–16

15

Savastano (2007)

1100

6–16

26

8

Coelho et al (2007)

506

5–12

38

45

Raj-Koziak et al (2011)

60212

7

32

43

Figueiredo et al (2011)

100

15–30

18

Juul et al (2011)

756

7

41

58

Giles et al (2012)

145

19–26

15

Bartnik et al (2012)

59

7–17

44

56

Mahboubi et al (2013)

3520

12–19

7.5

10

Park et al (2014)

3047

12–19

18

18

Humphriss et al (2016)

7092

11

28

Table 1. Prevalence or occurrence of tinnitus in children, with the original numbers extracted and re-calculated as to allow the easiest inter-study comparison.

There are distinctions between objective and subjective tinnitus, distinctions based on aetiology, impact or triggers. In this study, the definition of tinnitus in terms of subjective tinnitus will be that of an aberrant perception of sound unrelated to an acoustic source of stimulation, internal or external. Spontaneous tinnitus will be defined as subjective tinnitus without any prior acoustic stimulation and noise induced tinnitus as tinnitus appearing in close time connection to prior noise exposure, subjectively defined.

Subjects and methods

Starting in the year 2004, 1260 high school students in Gothenburg were given the opportunity to participate in a health screening program during their first and their third/last year of high school (age 16 and 19). Written consent from both the students and their parents were obtained. Of these 1260 students, 155 declined to participate. The young students were enrolled in equal parts from noisy, occupational education programs (n=662) and not noisy, mostly theoretical programs (n=598). Hearing thresholds were obtained from 1105 students in the first year (611 in noisy programs and 494 in quiet programs) and 816 students were followed up in the third year (493 and 325, respectively). The exclusion criterion for follow-up in the third grade was discontinuation of their studies, since it proved to be difficult to follow the drop-out students.

Screening audiometry: The screening program was performed by a school nurse, trained in performing screening audiometry. The tests were performed in the school nurses offices, so as to mirror the standard school entry screening conditions. Standard pure tone audiometry in both ears, with ear phones over 0.5, 1, 2, 3, 4, 6 and 8 kHz was conducted out at 20 dB HL. Thresholds were measured if the student did not pass the screening level, i.e., they did not obtain the 20 dB HL on at least one frequency.

Questionnaire: The nurse collected anthropometric data and administered an extensive questionnaire battery regarding the students’ own perception of health and well-being (including 1. HADS – Hospital Anxiety and Depression Scale [39], 2. noise exposure during school and leisure time and 3. hearing problems such as spontaneous tinnitus, noise induced tinnitus or temporary threshold shift). The students also responded to questions regarding their listening habits, in terms of playing instruments, attending concerts, listening to music on stereos or portables devices, playing computer games, going to the cinema, target shooting, use of mobile phones (with or without hands-free earphones) and use of hearing protection devices. Excerpt from the questionnaire is presented at the end. The same questions covering the experience of ST, NIT and TTS have also been used in previous studies from our research group [1, 11] on a total of 1635 children and adolescents. The questions are not yet formally validated but have been constructed based on previously revised questionnaires. These in turn, have been assessed by the audiologist performing all school entry hearing screenings to be easily understood even by young children.

Statistics: The dependent variables were the three: Spontaneous Tinnitus (ST), Noise Induced Tinnitus (NIT) and Temporary Threshold Shift (TTS). The hearing data were analysed frequency by frequency in correlation analyses, as well as dichotomised in multiple stepwise logistic regression analyses to groups of Hearing loss “Yes”/”No” (meaning screening audiometry level 20 dB failed or passed). The independent variables were: Gender, Noisy Program, Hearing Loss, Anxiety, Depression and for the listening habits – Instruments, Concerts, All live music (created by pooling Instruments and Concerts), Computer, Disco, Mobile phone, Mobile phone with headphones and Recorded music. For statistical purposes, all questionnaire answers were dichotomised, where response options “Never” and “Once/Rarely” were treated as “No” and “Often/Sometimes” and “Very often” were treated as “Yes”. When analysing the HAD-scale, scores above the cut-off level of 7 were considered as positive for depression-related symptoms and above 9 for anxiety, in accordance with the recommendations for application in adolescents [40]. For each subject, the difference between the results of each variable in the first year (Year 1) and the third year (Year 3) was calculated. The created ∆-variables were used where applicable. All noise variables were tested for correlations using Spearman’s rho or univariate logistic regression. The analyses were conducted identically for all three dependent variables (ST, NT, TTS). The independent variables with significant outcome were put in a multiple stepwise logistic regression analysis. The probabilities attained in the final models were then applied in ROC-curves for calculation of model strength with Area under the Curve (AUC). Variables were tested for, and fulfilled the criteria for normal distribution. Grading of correlation strength was as follows: 0 < |r| < .3 weak correlation, 3 < |r| < .7 moderate correlation, |r| > 0.7 strong correlation. Data were analysed using SPSS 19.0 for Windows. This study was approved by the Ethical Committee in Gothenburg (125–04) and performed according to the Helsinki declaration.

Results

Descriptives:

More boys than girls joined occupational education programs and more boys with pre-existing hearing loss entered these programs rather than the quieter theoretical programs, see Table 2. The students did not differ in experience of NIT, ST or TTS in respect of the chosen program, but overall, girls were more likely to report any of these three symptoms.

Table 2. Noisy program vs. hearing and gender at the start of the program

Gender

Hearing loss either side

No

Yes

Total

Boy

Noisy program

No

N

202

39

241

% within hearing loss

37,1%

26,2%

34,8%

Yes

N

342

110

452

p=0,015

% within hearing loss

62,9%

73,8%

65,2%

Total

N

544

149

693

Girl

Noisy program

No

N

207

45

252

% within hearing loss

60,7%

64,3%

61,3%

Yes

N

134

25

159

p=0,593

% within hearing loss

39,3%

35,7%

38,7%

Total

N

341

70

411

Total

Noisy program

No

N

409

84

493

% within hearing loss

46,2%

38,4%

44,7%

Yes

N

476

135

611

p=0,040

% within hearing loss

53,8%

61,6%

55,3%

Total

N

885

219

1104

Table 2. Distribution of gender in the noisy and quiet programs. Correlations between noisy or quiet program and hearing loss either side (pass = No, fail = Yes); Chi2-test. Percentage numbers represent the proportion of students with normal hearing (first column) or hearing loss (second column) within the respective program.

In the third year, many students had dropped out from school, mostly within the theoretical programs, thus reducing the observed number from 1105 to 816. The follow-up screening audiometry did differ slightly in some students in isolated frequencies and created therefore odd effects of statistically significant difference at 500 Hz in the left ear alone, due to seven students in the quiet group reporting 5 dB better thresholds and 8 students in the noisy group reporting 5 dB worse thresholds. The same effect was present in the right ear at 3000 Hz with sixteen students in the noisy group reporting a 5 dB worse threshold. In the clinical setting we do not consider such minute changes in isolated frequencies as significant, why this mathematical result is considered to be representative of a mass effect of multiple comparisons. When calculating with the dichotomised variable Hearing loss, there were no significant differences between the sufferers

Correlations and regression analyses:

All the noise variables and HADS reports were tested for correlations using univariate logistic regression. The variables with significant outcome were used in multiple stepwise logistic regression analyses. The probabilities attained in final model were then applied in ROC-curves for calculation of model strength with Area under the Curve (AUC). The odds ratios for the variables in the final models are presented, with their confidence intervals, in Figures 1 and 2. Figure 1 presents the models for ST, NIT and TTS in Year 1 and Figure 2 for the ST, NIT and TTS in Year 3. For cinema, target shooting and use of noise protection, there were no significant correlations (data not shown) (Insert Fig 1, 2).

OHT-2020-101_Jolanta Juul_f1

Figure 1. Logistic regression of the dependent variables ST, NIT and TTS for Year 1. The results from the three multivariate stepwise logistic regression analyses of the independent variables Gender, Hearing Loss, Noisy Program, Anxiety, Depression and listening habits (listed in Subjects and Methods).

OHT-2020-101_Jolanta Juul_f2

Figure 2. Logistic regression of the dependent variables ST, NIT and TTS for Year 3. The results from the three multivariate stepwise logistic regression analyses of the independent variables Gender, Hearing Loss, Noisy Program, Anxiety, Depression and listening habits (listed in Subjects and Methods).

Playing instruments and attending concerts were pooled in to one variable, called ‘All Live Music’, as to separate from ‘Recorded Music’, which here signifies portable music players, iPod, mp3 or stereo. As seen in clinical practice, the three hearing symptoms (ST, NIT and TTS) often coincide. In our results, ST shared weak to moderate correlations with NIT and TTS, whereas NIT and TTS shared correlations of moderate strength, all with p-values of <0,001, see Table 3.

Table 3. Correlations ST, NIT and TTS

Year 1 Spearman’s rho

ST

NIT

TTS

ST

Correlation Coefficient

1,000

0,287

0,167

Sig. (2-tailed)

<,001

<,001

N

1104

1102

1099

NIT

Correlation Coefficient

0,287

1,000

0,372

Sig. (2-tailed)

<,001

<,001

N

1102

1108

1103

TTS

Correlation Coefficient

0,167

0,372

1,000

Sig. (2-tailed)

<,001

<,001

N

1099

1103

1104

Year 3 Spearman’s rho

ST

NIT

TTS

ST

Correlation Coefficient

1,000

0,404

0,287

Sig. (2-tailed)

<,001

<,001

N

807

807

807

NIT

Correlation Coefficient

0,404

1,000

0,399

Sig. (2-tailed)

<,001

<,001

N

807

815

815

TTS

Correlation Coefficient

0,287

0,399

1,000

Sig. (2-tailed)

<,001

<,001

N

807

815

816

Table 3. Correlations between Spontaneous Tinnitus, Noise Induced Tinnitus and Temporary Threshold Shift; Spearman’s rho.

The relevant results and models for each symptom group follow below.

Spontaneous Tinnitus:

In Year 1, 33 % of the children (N=368 children, 37% of the girls and 31% of the boys) reported recurrent ST. Two years later the numbers had risen to 37% (39% of the girls, 36% of the boys). A pre-existing hearing loss at the first audiometry in Year 1 did not correlate to ST but heredity of hearing loss did correlate. History of prior ear infections or transmyringeal drainage (TMD) correlated with ST only, see Table 4.

Table 4. ST vs. Ear infections

Ear infections

Total

Never

1-2 times

Many times

TMD in childhood

ST

No

N

378

228

62

55

723

Expected

353,2

233,7

74,8

61,4

Yes

N

151

122

50

37

360

Expected

175,8

116,3

37,2

30,6

p=0,001

Table 4. Spontaneous Tinnitus vs. ear infections and transmyringeal drainage, N observed and expected, Chi2-test.

Children affected with ST scored significantly higher on both the anxiety and depression parts of the HADS. Through multiple stepwise logistic regression analysis we obtained an overall model for the development of ST. The final variables for Year 1 and Year 3 are presented in Figures 1 and 2. For both years the model for ST contained All Live Music and Anxiety. In Year 1 the linear constant was ST: =-1.055 +0.238xAll Live Music +1.026xAnxiety with AUC = 0.614 and for Year 3 it was ST: =-0.972 + 0.391xAll Live Music +0.772xAnxiety with AUC = 0.625. Fitted probabilities with confidence intervals from these models are shown in Figure 3, diamonds showing Year 1 and circles Year 3.

OHT-2020-101_Jolanta Juul_f3

Figure 3. Fitted probabilities of suffering from spontaneous tinnitus if anxiety or noise exposure from live music is present. Diamonds represent Year 1 and filled circles Year 3. The lines signify confidence intervals of 95%.

Noise Induced Tinnitus:

During the first phase of data collection, 55% of the students (N=610, 64% of the girls and 50% of the boys) reported recurrent NIT. Two years later 54% (58% of the girls, 52% of the boys) still experienced the symptom. Pre-existing hearing loss at entry did not correlate to NIT, but heredity did. Children affected with NIT scored significantly higher on the anxiety part of the HADS, but the results did not reach significance in regard of self-reported depressive traits. The multiple stepwise logistic regression analysis results are presented in Figures 1 and 2. In Year 1 the multiple stepwise regression model for NIT showed the strongest correlates to be: Gender, All Live Music and Anxiety, in comparison to Year 3, where the variables differed slightly: i.e., All Live Music, Disco, Hands-free and Anxiety instead. The linear constants were as follows: for Year 1 NIT: =-0.319 + 0.544xGender +0.418xAll Live Music + 0.610xAnxiety (AUC = 0.631) and for Year 3 NIT: =-0.507 + 0.542xAll Live Music +0.414xDisco+0.457xHands-free+ 0.514xAnxiety (AUC = 0.632). This is the only model where gender is statistically significant and also only in Year 1. In the first year, an unusually large portion of the girls (64 % vs. 49%) reported having experience of NIT, while the other symptoms remained in parity with the boys. In the third year, that difference was no longer discernible.

Temporary Threshold Shift:

In the first grade, 39% (N=425, 43% of the girls and 36% of the boys) confirmed recurrent TTS. Two years later the number had increased to 54% (equal gender distribution). Pre-existing hearing loss at school entry did not correlate to TTS, but heredity for hearing loss did. Children reporting TTS scored significantly higher on both the anxiety and depression parts of the HADS. Frequent use of cell phones was highly correlated to NIT and TTS, but the use of earphones did not seem to have any protective influence. The logistic regression presented in Figures 1 and 2 showed the strongest variables to be: All Live Music, Mobile, Recorded Music and Anxiety in Year 1 and All Live Music, Computer and Anxiety in Year 3. The linear constants present as: TTS for Year 1: =-1.396 + 0.517xAll Live Music + 0.374xMobile + 0.317xRecorded Music + 0.688xAnxiety (with AUC = 0.638), TTS for Year 3: =-0.663 + 0.479xAll Live Music -0.357xComputer + 0.523xAnxiety (with AUC = 0.637). For Year 1, mobiles were of significant importance in the development of TTS. The same pattern was present also for Year 3, however, the multiple regression analysis for this variable did not show statistical significance with p= 0.071, yet certainly a trend. The main outcomes of this study were the models of strongest correlates. These models point to several noise exposure factors were live music seems to represent a hazardous environment and possibly unprotected listening habits. These models have a rather weak strength when calculated for with AUC, but what is markedly apparent is the influence of anxiety in all reported symptoms.

Discussion

First and foremost we must answer the question whether the working environment of our students is appropriate, at least from the perspective of noise exposure. The students did not develop more hearing loss, tinnitus or TTS over the three years in school, reassuring as protective measures go. An Argentinian study noticed nevertheless a slight increase in hearing thresholds using a similar observation paradigm as we (15 year olds retested two years later) in youths reporting exposure to loud music[41]. A shortcoming of this type of investigation is the screening audiometry. We do not map the full extent of the subjects hearing but stop at the 20 dB level. Also, in a clinical setting we do not acknowledge small changes in isolated frequencies but in cohort studies we look for trends, were even small changes might prove important. Pre-existing hearing loss at the start of the investigation did not correlate to ST, NIT or TTS in either Year 1 or Year 3. This might be a result of precautionary behaviour and noise avoidance in individuals with subjectively known impaired hearing. Heredity of hearing loss did correlate to all three symptoms, which is more difficult to explain. We can speculate that perhaps the individuals with heredity of hearing loss have not yet developed evidently lowered thresholds but may signal their higher vulnerability with the presence of tinnitus. More girls reported (any of the) hearing symptoms and surprisingly more NIT in the first year and not the third. This finding is interesting and difficult to interpret, since there are two conflicting possible arguments. There are discussions suggesting estradiol serves a protective function in the female auditory system[42] however, this effect could be counterbalanced by a higher prevalence of anxiety in girls[43]. A recent meta-analysis of tinnitus in a pooled population of over 28,000 adolescents confirmed this gender difference [44]. As this study focuses on environmental and psychological impacts, the overall models for each symptom do not include any of the other two hearing symptoms. Although this was calculated for, we feel the presentation is simpler and easier to follow logically without what can be strongly considered as confounding factors. Adding NIT and TTS to the final ST regression model, adding ST and TTS to NIT and ST/NIT to the TTS model did in fact increase the overall strength of the models but only just slightly and at the cost of losing some of the other variables, without any obvious logical pattern to it. As shown in Table 2, the experience of NIT or TTS does correlate weakly to ST, but it is between the variables NIT and TTS we see the strongest correlation, likely signifying that both are more noise related by nature than is ST. We believe that perhaps all three symptoms are interconnected and represent different facets of auditory sensitivity. When calculating for factors influencing the onset of any kind of the discussed hearing symptoms, we should focus on what can be prevented or alleviated (such as noise exposure or anxiety) rather than what describes an already present and probably unavoidable sensitivity (such as concurrent TTS or NIT). The observed difference, with a higher prevalence of already present hearing loss in the occupational education group, could represent different prior noise exposure habits or perhaps are these two socioeconomically different groups with different health service seeking pattern? The noise in school did not seem to influence the youngsters negatively, but the following 16 hours of leisure time were of significance, for instance when looking for just one powerful noise impact factor, playing instruments and attending concerts appear (one or the other) in all of the analyses. These are activities where protecting one’s hearing is controversial and not always possible or wanted [45]. We also noticed a pattern were the variables annotating playing instruments or attending concerts were the two strongest of environmental factors, yet they tended to alternate in strength and sometimes cancel each other. As these two factors arguably could represent more or less the same environment and listening habits, they were pooled into one variable and analysed together. The fact that playing computer games seemed to protect from TTS in Year 3, having a negative B-value, could perhaps represent that year’s population of gamers as being less interested in attending live music scenes and instead choosing the home and the computer as leisure activities? Or perhaps it could be an effect of noise protection from sound conditioning [46]? Mobile phones were noted as a factor in TTS but this is more difficult to explain since the technology had evolved rapidly between the years Year 1 and Year 3 and mobile phones were being merged with portable music players. In Year 1, only 6.4% students used earphones vs. 12.4% in Year 3, while the number reporting use of mobile phones remained unaltered at 70%. Unfortunately, we do not know what the students referred to when answering the question of how much they used their mobile phone with or without hands-free earphones, i.e. if it was for phone calls and therefore being exposed to possibly harmful electromagnetic radiation or if it was for listening to music and thus being exposed to possible high speaker output levels [47]. Both expositions are potential factors in the development of tinnitus [36, 48, 49]. More interestingly, all three hearing symptoms were highly correlated to anxiety and such a correlation, between tinnitus and mood disorders, has been previously established in adults. Generally, anxiety is much more common than depression in youngsters [7], a finding which was also again demonstrated by the frequency numbers in this study. While in the adult population tinnitus appears more strongly correlated to depression than anxiety [27], the reverse seems to be the case for adolescents. The influences for this are yet to be established, if it is due to the psychological development of the young mind or perhaps a slightly different balance in the neurotransmitter systems [50]. Irrespective of cause, the importance of identifying symptoms of anxiety and depression in a youngster complaining of tinnitus is apparent. This study further highlights the importance of educating the young population in terms of noise protection at live venues, both as a visitor and a performer, and once a youth does seek help for tinnitus of any kind, then signs of an untreated anxiety disorder need to be investigated.

Questionnaire regarding hearing symptom and listening habits:

  1. After you have listened to loud music or noise, have you ever noticed a worsening of your hearing shortly after the cessation of the music or noise? (TTS)

       No, never

       Yes, once

       Sometimes

       Often

  2. After you have listened to loud music or noise, have you ever noticed a ringing, buzzing, hissing or beeping noise in your ears shortly after the cessation of the music or noise? (NIT)

       No, never

       Yes, once

       Sometimes

       Often

  3. Have you ever noticed a ringing, buzzing, hissing or beeping sound in your ears even if you have not been exposed to loud noise? (ST)

       No, never

       Yes, once

       Sometimes

       Often

If you have answered NO to the questions 2 and 3, you can skip the questions 5 through 7.

  1. How often do you have a ringing, buzzing, hissing or beeping sound in your ears?

       Rarely

       Often

       All the time

  2. Is the sound bothersome for you?

       No

       Sometimes

       Often

       Always

  3. How did the sound start?

       Suddenly

       Gradually

  4. How long have you had this sound?

    ..…..weeks …….months

  5. How often do you:

    Never

    Sometimes

    Often

    Very often

    Use noise protection in noisy environments?

    listen to recorded music in mp3, ipod or equal?

    Talk on your mobile phone?

    Use handsfree ear phones with your mobile phone?

  6. How often do you:

    Go to concerts?

    Never

    Rarely

    6–12/yr

    Twice/month

    Several/month

    Go to disco?

    Go to cinema?

    Play instruments?

    Use PlayStation/computer/equal with head phones

    Shoot for target practice/use exploding materials?

Reference

  1. Holgers KM, Pettersson B (2005) Noise Exposure and Subjective Hearing Symptoms among School Children in Sweden. Noise Health 7: 27–37. (Crossref)
  2. Baigi A, Oden AAlmlid-Larsen VBarrenäs MLHolgers KM (2011) Tinnitus in the general population with a focus on noise and stress: a public health study. Ear Hear 32: 787–789. (Crossref)
  3. Daniel E (2007) Noise and hearing loss: a review. J Sch Health 77: 225–231. (Crossref)
  4. Evans GW, Lercher PMeis MIsing HKofler WW (2001) Community noise exposure and stress in children. J Acoust Soc Am 109: 1023–1027. (Crossref)
  5. Hellstrom PA (1995) Soud transfer function and hearing. Studies of the acoustics of the external ear and auditory canal in man. In Otolaryngology and audiology University of Goteborg: Goteborg.
  6. Moller AR, Rollins PR (2002) The non-classical auditory pathways are involved in hearing in children but not in adults. Neurosci Lett 319: 41–44. (Crossref)
  7. Holgers KM, Juul J (2006) The suffering of tinnitus in childhood and adolescence. Int J Audiol 45: 267–272. (Crossref)
  8. Eysel-Gosepath K, Daut TPinger ALehmacher WErren T (2012) Sound levels and their effects on children in a German primary school. Eur Arch Otorhinolaryngol 269: 2475–2483 (Crossref)
  9. Walinder R, Gunnarsson KRuneson RSmedje G (2007) Physiological and psychological stress reactions in relation to classroom noise. Scand J Work Environ Health 33: 260–666. (Crossref)
  10. Sjodin F, Kjellberg AKnutsson ALandstrom ULindberg L (2012) Noise exposure and auditory effects on preschool personnel. Noise Health 14: 72–82. (Crossref)
  11. Holgers KM (2003) Tinnitus in 7-year-old children. Eur J Pediatr 162: 276–278. (Crossref)
  12. Savastano M (2007) Characteristics of tinnitus in childhood. Eur J Pediatr 166: 797–801. (Crossref)
  13. Juul J, Barrenas ML, Holgers KM (2012) Tinnitus and hearing in 7-year-old children. Arch Dis Child 97: 28–30. (Crossref)
  14. Park B, Choi HGLee HJAn SYKim SW (2014) Analysis of the prevalence of and risk factors for tinnitus in a young population. Otol Neurotol 35: 1218–1222. (Crossref)
  15. Miyakita T, Hellstrom PAFrimanson EAxelsson A (1992) Effect of low level acoustic stimulation on temporary threshold shift in young humans. Hear Res 60: 149–55. (Crossref)
  16. Holmes AE, Widén SEErlandsson SCarver CLWhite LL (2007) Perceived hearing status and attitudes toward noise in young adults. Am J Audiol 16: 182–189. (Crossref)
  17. Brookhouser PE, Worthington DW, Kelly WJ (1992) Noise-induced hearing loss in children. Laryngoscope 102: 645–55.
  18. Jamieson DG, Kranjc GYu KHodgetts WE (2004) Speech intelligibility of young school-aged children in the presence of real-life classroom noise. J Am Acad Audiol 15: 508–17. (Crossref)
  19. Persson Waye K, Bengtsson JKjellberg ABenton S (2001) Low frequency noise “pollution” interferes with performance. Noise Health 4: 33–49. (Crossref)
  20. Bulbul SF, Muluk NBCakir EPTufan E (2009) Subjective tinnitus and hearing problems in adolescents. Int J Pediatr Otorhinolaryngol 73: 1124–1131. (Crossref)
  21. Coelho CB, Sanchez TG, Tyler RS (2007) Tinnitus in children and associated risk factors. Prog Brain Res 166: 179–191. (Crossref)
  22. Moore DR, Zobay OMackinnon RCWhitmer WMAkeroyd MA (2017) Lifetime leisure music exposure associated with increased frequency of tinnitus. Hear Res 347: 18–27. (Crossref)
  23. Lindblad AC, Hagerman B, Rosenhall U (2011) Noise-induced tinnitus: a comparison between four clinical groups without apparent hearing loss. Noise Health 13: 423–431 (Crossref).
  24. Hinalaf M, Maggi ALHüg MXKogan PVillalobo JP et al. (2017) Tinnitus, Medial Olivocochlear System, and Music Exposure in Adolescents. Noise Health 19: 95–102. (Crossref)
  25. Meric C, Gartner MCollet LChéry-Croze S (1998) Psychopathological profile of tinnitus sufferers: evidence concerning the relationship between tinnitus features and impact on life. Audiol Neurootol 3: 240–252. (Crossref)
  26. Zoger S, Svedlund J, Holgers KM (2001) Psychiatric disorders in tinnitus patients without severe hearing impairment: 24 month follow-up of patients at an audiological clinic. Audiology 40: 133–140. (Crossref)
  27. Malakouti S, Mahmoudian MAlifattahi NSalehi M (2011) Comorbidity of chronic tinnitus and mental disorders. Int Tinnitus J 16: 118–122. (Crossref)
  28. Langguth B, Kleinjung TFischer BHajak GEichhammer P, et al. (2007) Tinnitus severity, depression, and the big five personality traits. Prog Brain Res 166: 221–225. (Crossref)
  29. Holgers KM, Zoger Sigyn, Svedlund Jan (2003) Tinnitus suffering: a marker for a vulnerability in the serotonergic system?. Audiological Medicine 1: 138–143.
  30. Thompson GC, Thompson AMGarrett KMBritton BH, et al. (1994) Serotonin and serotonin receptors in the central auditory system. Otolaryngol Head Neck Surg 110: 93–102. (Crossref)
  31. Tyler RS, Coelho C, Noble W (2006) Tinnitus: standard of care, personality differences, genetic factors. ORL J Otorhinolaryngol Relat Spec 68: 14–19. (Crossref)
  32. Bradley JS, Sato H (2008) The intelligibility of speech in elementary school classrooms. J Acoust Soc Am 123: 2078–2086. (Crossref)
  33. Axelsson A, Lindgren F (1981), Pop music and hearing. Ear Hear 2: 64–69. (Crossref)
  34. Axelsson A, Lindgren F (1981) Hearing in classical musicians. Acta Otolaryngol Suppl 377: 3–74. (Crossref)
  35. Lindgren F, Axelsson A (1983) Temporary threshold shift after exposure to noise and music of equal energy. Ear Hear 4: 197–201. (Crossref)
  36. McNeill K, Keith SEFeder KKonkle ATMichaud DS (2010) MP3 player listening habits of 17 to 23 year old university students. J Acoust Soc Am 128: 646–53. (Crossref)
  37. Vogel I, Brug JHosli EJvan der Ploeg CPRaat H (2008) MP3 players and hearing loss: adolescents’ perceptions of loud music and hearing conservation. J Pediatr 152: 400–404. (Crossref)
  38. Rosing, S.N., Schmidt JHWedderkopp NBaguley DM (2016) Prevalence of tinnitus and hyperacusis in children and adolescents: a systematic review. BMJ Open 6. (Crossref)
  39. Bjelland I, Dahl AAHaug TTNeckelmann D (2002) The validity of the Hospital Anxiety and Depression Scale. An updated literature review. J Psychosom Res 52: 69–77. (Crossref)
  40. White D, Leach CSims RAtkinson MCottrell D (1999) Validation of the Hospital Anxiety and Depression Scale for use with adolescents. Br J Psychiatry 175: 452–454. (Crossref)
  41. Biassoni EC, Serra MRHinalaf MAbraham MPavlik M, et al. (2014) Hearing and loud music exposure in a group of adolescents at the ages of 14–15 and retested at 17–18. Noise Health. 16: 331–341. (Crossref)
  42. Charitidi K, Meltser ITahera YCanlon B (2009) Functional responses of estrogen receptors in the male and female auditory system. Hear Res 252: 71–78. (Crossref)
  43. Moksnes UK, Espnes GA, Lillefjell M (2012) Sense of coherence and emotional health in adolescents. J Adolesc 35: 433–441. (Crossref)
  44. Lee DY, Kim YH (2018) Risk factors of pediatric tinnitus: Systematic review and meta-analysis. Laryngoscope 128: 1462–1468. (Crossref)
  45. Hunter A (2018) “There are more important things to worry about”: attitudes and behaviours towards leisure noise and use of hearing protection in young adults. Int J Audiol 57: 449–456. (Crossref)
  46. Niu X, Tahera Y, Canlon B (2004) Protection against acoustic trauma by forward and backward sound conditioning. Audiol Neurootol 9: 265–273. (Crossref)
  47. Olsson H, Juul J, Holgers K (2009) Cell phones, Personal Music Players and Temporary Threshold Shifts in 16-year-old students. ln: Huong S. 13th Asean ORL and Head & Neck Surgery Congress, Medimond International Proceedings: Siem Reap, Angkor, Cambodia.
  48. Hutter HP, Moshammer HWallner PCartellieri MDenk-Linnert DM, et al. (2010) Tinnitus and mobile phone use. Occup Environ Med 67: 804–808. (Crossref)
  49. Widen SE, Basjo SMöller CKahari K (2017) Headphone listening habits and hearing thresholds in swedish adolescents. Noise Health 19: 125–132. (Crossref)
  50. Axelson DA, Birmaher B (2001) Relation between anxiety and depressive disorders in childhood and adolescence. Depress Anxiety 14: 67–78. (Crossref)

Efficacy of L-Ornithine L-Aspartate for the prevention and Treatment of Hepatic Encephalopathy in Cirrhosis: An Update of the Evidence Base

DOI: 10.31038/JPPR.2019243

Abstract

The advent of well-established procedures for the determination of clinical trial quality based on risk of bias assessments has resulted insubstantial improvements in the quality of systematic reviews and meta-analyses relating to the assessment of Randomized Controlled Trials (RCTs) on the efficacy of treatments for a range of clinical conditions. In the current review, manual and electronic searches of databases using appropriate keywords were used to assess the evidence base for the use of L-ornithine L-aspartate (LOLA) for the prevention and treatment of Hepatic Encephalopathy (HE), a common neuropsychiatric complication of liver cirrhosis. Making use of current risk of bias techniques, seven systematic reviews with accompanying meta-analyses were identified in which the results of RCTs on the efficacy of LOLA for the treatment of HE were analyzed. A clear consensus of opinion was observed in support of the efficacy of LOLA for lowering of blood ammonia and for the concomitant improvement of mental status in patients with overt HE (OHE) and in five of the six meta-analyses in patients with minimal HE (MHE). Evidence in support of a beneficial effect of LOLA for the prevention of OHE in patients with cirrhosis was reported in a novel systematic review and meta-analysis involving the analysis of six RCTs in patients with cirrhosis and a range of clinical presentations where successful OHE prevention/prophylaxis was accompanied in all cases by significant reductions of blood ammonia. Both, intravenous and oral formulations of LOLA were found to be effective. Reduction in the progression of MHE to OHE was independently confirmed in a subsequent meta-analysis. Two systematic reviews with network meta-analyses compared the efficacy of LOLA to other available agents. Only treatment with LOLA or branched-chain amino acids (BCAAs) resulted in significant improvements in mental status and LOLA was judged to be the most effective agent with respect to clinical improvement and concomitant reduction of blood ammonia. In the case of MHE, rifaximin, lactulose and LOLA were equivalent in clinical efficacy and were each superior to probiotics. LOLA was superior to lactulose or probiotics for the prevention of episodes of OHE in patients with MHE compared to placebo/no treatment; rifaximin was ineffective in this regard.

Keywords

L-ornithine L-aspartate, LOLA, hepatic encephalopathy, clinical trials, RCTs, hyperammonemia, meta-analysis, systematic review, prevention, treatment, cirrhosis, sarcopenia, prophylaxis

Introduction

A variety of agents with the capacity to lower circulating ammonia represent the mainstay for the prevention and treatment of Hepatic Encephalopathy (HE) in patients with cirrhosis. Such agents include non-absorbable disaccharides, antibiotics, ammonia-sequestering compounds and metabolic intermediates related to the operation of the urea cycle. L-ornithine L-aspartate (LOLA) is a 1:1 stable salt of the naturally-occurring amino acids L-ornithine and L-aspartic acid. LOLA has well-established pharmacokinetic and pharmacodynamic properties and is available in either intravenous or oral formulations [1]. Increases in the use of LOLA for HE prevention and treatment of HE in patients with cirrhosis has resulted in a significant increase in the number of reports of the findings of RCTs on the efficacy of LOLA in this patient population and a number of reviews and meta-analyses on the subject have recently been published. For the current study, manual and electronic searches of databases using appropriate keywords were used to review and update the evidence base for the efficacy of LOLA for the prevention and treatment of HE in patients with cirrhosis. Particular attention was paid to assessment of the results of published RCTs, critical reviews, systematic reviews and meta-analyses in which the results of these trials were assessed. In addition, comparisons of the efficacy of LOLA compared to other currently-available agents listed above has been addressed by assessment of the results of the results of two network meta-analyses. Since its discovery as an effective ammonia-lowering agent some 50 years ago [2], LOLA has been shown to act by virtue of the fact that one of its constituents, L-ornithine is a urea cycle substrate and both amino acids are substrates for transaminase reactions in multiple tissues including liver, brain and skeletal muscle leading to the production of glutamate, the obligate substrate for Glutamine Synthetase (GS). These two metabolic pathways, namelythe synthesis of urea (liver) and of glutamine (liver, brain, skeletal muscle) represent the major pathways for the elimination of excess ammonia under normal physiological conditions. In both acute and chronic liver failure, the metabolic capacity of the liver is severely compromised and urea and glutamine synthesis may fall to below 20% of normal values. This results in a spectacular increase in capacity of skeletal muscle to replace liver as the major ammonia-removal organ, a mechanism that results from increased expression of the gene coding for GS in muscle [3] resulting in increases in enzyme activities and increased glutamine synthesis. [4] In this way, it has been demonstrated that LOLA is effective for the treatment of muscle wasting (sarcopenia) in cirrhosis [5], a condition which, like HE is caused, at least in part, by the toxic actions of ammonia [6]. However, improvements in metabolic ammonia-removal mechanisms are not the only ones where by LOLA treatment has beneficial effects on HE in cirrhosis. It has been demonstrated that LOLA has significant hepato-protective actions [7] mediated by the synthesis of the anti-oxidant glutathione (GSH) as well as the production of nitric oxide leading to improvements in hepatic microcirculation. [7, 8]

Efficacy of LOLA for the treatment of hyper ammonemia and HE in cirrhosis

Beneficial effects of intravenous or oral formulations of LOLA have been reported in over 25 published Randomized Controlled Trials (RCTs). In most cases efficacy was defined in terms of LOLA’s ammonia-lowering actions together with improvements in HE grade (for OHE) or psychometric test scores (for MHE). The last three years have seen the completion of several new trials and meta-analyses devoted to the assessment of the efficacy of LOLA for the treatment of HE in cirrhosis some of which have challenged or confirmed the results of earlier work. Consequently, the present review is an up-to-date summary of the results of systematic reviews (with meta-analyses where available) of RCTs published through December 2019 on the efficacy of LOLA for the prevention and treatment of HE in patients with cirrhosis.

1.1  Efficacy of LOLA for the treatment of HE in cirrhosis: early critical reviews of RCTs

Results of clinical trials conducted in the 1980’s and 1990’s suggested that LOLA had the potential to lower blood ammonia and decrease the severity of HE. In order to assess this possibility two critical analyses were undertaken. In the first analysis, a search of indexed medical journals in which the results of RCTs were described in patients with cirrhosis and HE treated with LOLA. Four RCTs published during the period 1993–2000 for a total of 217 patients met inclusion criteria two of which made use of a parallel group design that included patients with MHE and two trials using a crossover design and patients with low-grade (I or II) OHE. [9] LOLA treatment led to lowering of blood ammonia [9] in patients with HE when compared to placebo using either intravenous (iv) or oral formulation of LOLA. This lowering of blood ammonia was accompanied by improvements in psychometric test scores but was not uniformly accompanied by improvements in mental status measured using the PSE Index procedure [9] (Table 1).

Table 1. Critical reviews of RCTs for LOLA treatment of HE in cirrhosis

Study ID

Year

No of trials

No of patients

Type of HE

Ammonia-lowering

Outcome parameters

Reference

Perez Hernandez JL

2011

5

623

MHE, OHE

Yes

Improvement of mental status, Ammonia, Hospitalization time

Ann Hepatol 2011; 10 (Suppl 2): S66-S69

Summary
Database searches of controlled trials identified six meeting the inclusion criteria for a total of 623 patients. LOLA infusions let to improvement in neuropsychiatric status, decreased serum ammonia with minimal adverse events.

Soarez PC

2009

4

217

MHE, OHE

Yes

Ammonia; Improvement in psychometric test

Arq Gastroenterol 2009 Jul-Sep; 46(3): 241–7.

Summary
Database searches of controlled clinical trials (English language) yielded four RCT’s with a total of 217 patients for inclusion in the analysis. LOLA (iv or oral) treatment resulted in reduced hyperammonemia compared to placebo and improved psychometric test scores. Small trial/patient numbers and low methodological quality limited beneficial effect in patients with OHE.

In a second critical analysis published two years later, searches were made of RCTs that were again published in indexed journals as well as in Medline, Cochrane and PubMed databases in which the efficacy of ivLOLA was assessed in patients with cirrhosis and HE. Six trials met inclusion criteria for a total of 623 patients 422 of which had cirrhosis while the remainder had acute liver failure [10].Trial quality was assessed using the Jadad Composite scale. [11] Venous ammonia concentrations decreased in the LOLA treatment group compared to placebo and these decreases were accompanied by significant improvements in the stage of HE assessed by West Haven criteria (Table 1).

1.2  Efficacy of LOLA for the treatment of HE in cirrhosis: systematic reviews of RCTs with meta-analyses

Results of seven systematic reviews each accompanied by meta-analysis of the results of RCTs on the efficacy of LOLA for the efficacy of treatment of MHE/OHE in patients with cirrhosis have been completed and published in the last 20 years starting with an in house analysis of five trials from Merz Pharmaceuticals (Germany) [12] Subsequent analyses by investigators from China. [13–15] Europe [16, 17] Canada [18] and India [19] followed involving up to 36 trials and 2377 patients with cirrhosis and HE. Summaries of the numbers of RCTs, patients, year, type of HE, outcome parameters, publication reference and short synopsis of the major findings are provided in Table 2.

Table 2. Systematic reviews with meta-analysis of RCTs for LOLA treatment of HE in cirrhosis

Study ID

Year

No of trials

No of patients

Type of HE

Ammonia-lowering

Outcome parameters

Reference

Butterworth RF

2018

10

884

MHE, OHE

Yes

Benefit for OHE; MHE iv/oral, NH3-lowering

J Clin Exp Hepatol. 2018; 8(3):301–313.

Summary
Electronic and manual searches were made of databases to identify RCTs for inclusion. Ten RCTs were included for a total of 884 patients with cirrhosis and HE Random effects model used to express pooled risk ratio (RR) or Mean difference (MD).  Both intravenous and oral formulations of LOLA found to be effective for lowering of blood ammonia [MD: -17.5 µmol/l (-27.73, -7.26)] p<0.0008 and improvement of mental state for patients with MHE [RR: 2.15, 95% CI: 1.48–3.14) p<0.0001)] or OHE [RR: 1.19, 95% CI: 1.01–1.39, p<0.03]. Oral LOLA was particularly effective for treatment of MHE.

Goh ET

2018

22

1375

MHE, OHE

Yes

Benefit for OHE/MHE, NH3-lowering

Cochrane Database Syst Rev. 2018;5:CD012410

Summary
Electronic and manual searches of databases, conference proceedings and correspondence with investigators and pharmaceutical companies yielded 22 RCTs involving 1375 patients with cirrhosis and HE or risk of development of HE for which outcome data was available. LOLA had a beneficial effect on HE compared to placebo/no intervention for all trials [RR: 0.70, 95% CI: 0.59–0.88] but evidence was judged to be very low quality leading investigators to conclude that outcomes were uncertain. However, subsequent sub-group analyses of completed RCTs and/or RCTs with findings published as full papers demonstrated significant improvements in mental state: 12 completed trials, 994 patients : RR:0.63, 95% CI: 0.48–0.83, p<0.001], 12 published trials, 1032 patients: RR:0.65,95% CI: 0.50–0.85, p<0.0017]. Both iv and oral formulations appeared to be effective in this analysis.

Bai M

2013

8

646

MHE, OHE

Yes

Benefit for OHE; MHE, NH3-lowering

J Gastroenterol Hepatol. 2013; 28 (5):783–92.

Summary
Searches of databases revealed 8 RCTs that assessed the efficacy of LOLA for treatment of HE in 646 patients with cirrhosis. LOLA was significantly more effective than placebo/no intervention for improvement in all types of HE [RR: 1.49, 95% CI: 1.10–2.01, p<0.01] as well as for patients with OHE or MHE when analysed separately. These improvements were accompanied by significant reductions in fasting blood ammonia [MD: -18.26, 95% CI: -26.96—9.56, p<0.01].

Hu Wei

2012

6

432

MHE, OHE

Yes

Serum ammonia, NCT-A, Clinical remission rate

Chin J Evidence-based Med 2012; (12)7: 799–803

Summary
Database searches of RCT’s of LOLA (iv or oral) for treatment of HE in cirrhosis yielded six placebo-controlled trials and 432 patients. LOLA significantly reduced serum ammonia (p<0.0001), improved NCT-A scores (p<0.0001) and clinical remission rates (p<0.01).

Jiang Q

2009

3

212

Chronic OHE (1,2)

Yes

Benefit for OHE not MHE

J Gastroenterol Hepatol. 2009 Jan;24 (1):9–14

Summary
Searches of electronic databases yielded 3 RCTs of 212 patients of sufficiently high quality (assessed by Jadad score) for inclusion in the analysis. LOLA significantly improved HE scores [RR: 1.89, 95% CI: 1.32–2.71, p<0.0005]. Subgroup analysis revealed significant efficacy of LOLA compared to placebo (2 trials) or lactulose (1 trial) in patients with grades I or II HE but not in patients with MHE.

Delcker M

2000

5

246

MHE, OHE

Yes

Ammonia, improvement of mental state, psychometric test scores

Hepatology 2000; 32(4):604

Summary
This review with meta-analysis was the first conducted by the manufacturers of LOLA and consisted of assessment of the efficacy of iv LOLA in 5 RCTs versus placebo. Two of the trials were subsequently published. Treatment with LOLA for 7 days resulted in significant improvements of NCT-A scores and mental state as a function of the lowering of blood ammonia.

Results were, in general, remarkably consistent with all seven meta-analyses showing evidence of improvements of mental state in patients with MHE or OHE [12–19] that was accompanied by lowering of blood ammonia in all cases. When assessed separately, either intravenous or oral formulations of LOLA were found to be effective for the treatment of HE [15–18] However, occasional inconsistencies were noted and this was attributed to differences in experimental design, inclusion/exclusion criteria or methodology used for the determination of mental state. For example, in one earlier study the patient population included cirrhotics as well as patients with Acute Liver Failure (ALF) [14]; the pathophysiology and treatment goals for the two conditions are quite distinct. In a second study, LOLA treatment was found to be ineffective for improvement of psychometric test scores in patients with MHE [13] but was found to be effective in all subsequent analyses in which this was addressed [15,18]. One possible explanation likely relates to the differences in the nature of the psychometric test procedures used in these analyses (e.g. use of the outdated PSE Index scoring system in one analysis[13]versus multiple well-established psychometric testing procedures such as NCT-A, B and PHES in the others). It is important to note that there are also areas of investigation relating to the efficacy of LOLA for the treatment of HE in cirrhosis that have been largely omitted from these earlier analyses. For example, few of these analyses investigated the possible beneficial effects of LOLA on ammonia lowering or mental state improvement in patients with higher grades (III and IV) of HE [12,14].In addition, there are no published systematic reviews and/or meta-analyses relating to the efficacy of LOLA for the prevention and treatment of HE in cirrhosis in which the new system of classification of HE (i.e. Covert, Overt grades II,III,IV) was employed. The advent of well-established procedures for the determination of trial quality based on risk of bias assessments has led to significant improvements in the quality of subsequent systematic reviews with meta-analyses. Such procedures include use of the Jadad Composite Scoring system [11] and, more recently, by the Cochrane Handbook for Systematic Reviews and Interventions[20]. Combinations of the two systems have also been employed[18,21].These systems used for assessment of risk of bias of each RCT take into account sequence generation during randomization, allocated sequence concealment, blinding of participants and personnel and completeness of outcome data[11,20]. In the first systematic review with meta-analysis undertaken under the above guidelines, Bai and co-workers searched manual and/or electronic databases to reveal eight RCTs with 646 patients with cirrhosis and OHE or MHE in which the efficacy of LOLA (iv or oral formulations) was compared to placebo/no intervention [15]. Study endpoints were improvement in HE and lowering of blood ammonia. LOLA was significantly more effective than placebo/no intervention for improvement of all types of HE with RR: 1.49, 95% CI:1.10–2.01, p<0.01 by Random Effects model. Significant benefit was also recorded for improvement of OHE with RR: 1.33, 95% CI: 1.04–1.69, p<0.02 by Random Effects model as well as for MHE with RR: 2.25, 95%CI: 1.33–2.82, p<0.01 by Fixed Effects model. Reduction of fasting blood ammonia significantly favored LOLA over placebo/no intervention with p<0.01. In a subsequent systematic review with meta-analysis, 10 RCTs with 884 patients with cirrhosis and HE satisfied inclusion criteria. [18]  Study quality and risk of bias were assessed using the Jadad Composite scale combined with the Cochrane Scoring Tool and the Random Effects Model was employed to express pooled Risk Ratio (RR) or Mean Difference (MD) with associated 95% Confidence Intervals (CI). Comparison with placebo/no intervention control data, LOLA was found to be significantly more effective for improvement of mental scores in all types of HE [RR: 1.36, 95% CI: 1.10–1.69, p<0.005] as well as in patients with OHE [RR: 1.19, 95% CI: 1.01–1.39, p<0.03] or MHE [RR: 2.15, 95% CI: 1.48–3.14, p< 0.0001]. LOLA treatment resulted in significant lowering of blood ammonia in these patient groups [MD: -17.5umol/L, 95% CI: -27.73 to -7.26, p<0.008]. The oral formulation of LOLA was found to be particularly effective for the treatment of patients with MHE. A similar systematic review with meta-analysis identified 15 RCTs and 1023 patients with cirrhosis and HE in which treatment with LOLA resulted in significant benefit for subgroups of patients with acute episodes of HE or with chronic HE but not in patients with MHE in an initial analysis of the data [16]. One year later, a large number of additional trials were added to this particular investigation giving a total of 36 RCTs with 2377 patients. Regrettably, data for the majority of these additional trials was found to be seriously lacking due to early trial abandonment as well as incomplete information required for assessment of risk of bias and trial outcomes leading the investigators to rate them as very low quality and to express uncertainty in the reliability of the findings [17]. Fortunately, there was a sufficient number of completed and/or published trials in this study to permit subgroup analysis in relation to the efficacy of LOLA for the treatment of HE. The relevant data was:

For completed trials [12 trials, 994 patients, RR: 0.63, 95% CI: 0.48–0.83, p<0.001]

For published trials [12 trials, 1026 patients, RR: 0.65, 95% CI: 0.50–0.85, p<0.00017]

These findings confirm those of three previous systematic reviews with meta-analysis dedicated to the assessment of the efficacy of LOLA for the treatment of OHE or MHE [15–19]

1.3  Efficacy of ammonia scavengers other than LOLA for the treatment of HE in cirrhosis: results of a meta-analysis

Searches of on-line databases and clinical trials registries yielded 11 RCTs that met inclusion criteria. [22] Meta-analysis using Risk Ratios (RR) or Mean Differences (MD) with 95% CI was performed with bias assessment. By design, the agents selected for this analysis did not include LOLA even though, as demonstrated and discussed in section 2.2 (above), it is the best-established agent currently employed clinically for the treatment of HE that specifically targets ammonia. Selection of most of these agents was undoubtedly inspired by their successful use for ammonia-lowering in cases of acute or chronic hyperammonemia associated with congenital deficiencies of urea cycle enzymes. Such agents included sodium benzoate (three trials), glycerol phenylbutyrate (one trial) and ornithine phenylacetate (two trials) in addition to AST-120 (two trials) and polyethylene glycol (three trials) for a total of 499 patients receiving test substance versus 444 receiving placebo or lactulose. Eight of the eleven trials were assessed as very low quality having high risks of bias. [22] Not surprisingly, significant reductions of blood ammonia were observed in placebo-controlled trials of sodium benzoate, glycerol phenylbutyrate and ornithine phenylacetate but with no observable effects of the latter substance on HE grade. Sodium benzoate, polyethylene glycoland AST-120 treatments failed to show significant improvements in HE grade compared to lactulose. These results led the authors to conclude that, although there was potential for reduction of blood ammonia by these agents, their effects on clinical outcome remain uncertain. This appeared to be primarily due to the low quality of the trials selected for the analysis. [22]

1.4  Efficacy of LOLA for OHE prevention and prophylaxis: systematic review with meta-analysis

There is a paucity of available published reports of systematic reviews with meta-analysis of RCTs dedicated to the evaluation of the efficacy of LOLA for the prevention of HE in patients with cirrhosis. Sporadic reports are limited in number to sub-groups of patients but results so far have been inconsistent [16,19] largely due to small trial numbers and low patient enrollment in addition to very low quality of the data leading investigators to conclude that the evidence for prevention of either OHE or MHE was uncertain. [17] Consequently a new systematic review with meta-analysis was undertaken to review the evidence base in support of a beneficial effect of LOLA for the prevention/prophylaxis of OHE in patients with cirrhosis. Electronic and manual searches identified 6 RCTs that met inclusion criteria for a total of 384 patients. [21] Five of the six trials were considered to be high quality with low risk of bias by Jadad-Cochrane criteria. LOLA treatment led to a significant reduction in the rate of progression of MHE to OHE compared to placebo/no intervention (three trials) with RR: 0.23, 95% CI: 0.07–0.73, p<0.01. LOLA treatment was also effective for secondary OHE prophylaxis, for primary OHE prophylaxis following gastrointestinal bleeding (one trial) and for post-TIPSS prophylaxis (one trial). Successful OHE prevention/prophylaxis was accompanied by significant reductions of blood ammonia and either iv or oral formulations of LOLA appeared to be effective for the slowing of progression of MHE to OHE. The effectiveness of LOLA versus placebo for reduction of the progression of MHE to OHE in patients with cirrhosis was independently confirmed in a subsequent meta-analysis. [19]

Table 3. Systematic reviews with meta-analysis of RCTs for OHE prevention/prophylaxis by LOLA

Butterworth RF

2019

6

384

MHE, OHE

No

OHE prevention; progression from MHE to OHE

Metab Brain Dis 2019. https://doi.org/10.1007/s11011-019-00463-8

Summary
Electronic and manual searches together with pre-established inclusion/exclusion criteria revealed 6 RCTs for a total of 384 patients with cirrhosis at risk for development of OHE. Treatment with iv or oral LOLA led to significant reductions in the risk of progression to OHE in patients with MHE [3 trials with RR: 0.23, 95% CI:0.07–0.73) p,0.01. LOLA was also effective for secondary OHE prophylaxis [1 trial with RR: 0.389, 95% CI: 0.174–0.870, p<0.002] and for OHE prophylaxis following acute variceal bleeding [ 1 trial with RR: 0.42, 95% CI: 0.16–0.98, p<0.03] and for OHE prophylaxis post-TIPSS [1 trial with OR:0.20, 95% CI: 0.06–0.88, p<0.03]. OHE prevention/prophylaxis was accompanied by significant reductions of blood ammonia. Both iv and oral formulations of LOLA were effective.

JPPR 19 - 123_Butterworth RF_F1

Figure 1a. Forest Plot for the efficacy of LOLA versus placebo/no intervention for the prevention of progression of MHE to OHE (Abid et al. 2011; Mittal et al. 2011; Alvares-da-Silva et al. 2014), secondary OHE prophylaxis (Varakanahalli et al. 2018), primary OHE prophylaxis(Higuera-de-la-Tijera et al. 2018) or post-TIPSS OHE prophylaxis (Bai et al. 2014)

JPPR 19 - 123_Butterworth RF_F2

Figure 1b. Forest plot for the efficacy of LOLA versus placebo/no intervention for the prevention of progression from MHE to OHE in patients with cirrhosis

Efficacy of LOLA compared to other currently-available agents for the treatment of HE in cirrhosis: network meta-analyses

RCTs directly comparing the efficacy of LOLA with other available agents such as non-absorbable disaccharides, antibiotics and probiotics have consistently shown that LOLA is equivalent and, in some cases, superior to these alternatives. For example, in an RCT published in 2006, patients randomized to lactulose or LOLA manifested comparable decreases of blood ammonia but only patients in the LOLA arm of the trial showed improvements in psychometric test scores, mental state grade, asterixis grade or EEG. [23] These observations were followed by two systematic reviews with network meta-analyses in which the efficacy of LOLA for the treatment of HE in patients with cirrhosis was compared to other available agents. The first analysis addressed the treatment of OHE [23], the second one focused on the treatment of MHE and on the progression from MHE to OHE [19].

Table 4. Network meta-analyses of RCTs comparing efficacy of LOLA versus other available agents for treatment of HE in cirrhosis

Study ID

Year

No of trials

No of patients

Type of HE

Ammonia-lowering

Outcome parameters

Reference

Dhiman RK

2019

25

1563

MHE, OHE

Yes

Comparable efficacy of LOLA for reversal of MHE; Prevention of OHE

Clin Gastroenterol Hepatol. 2019 Aug 30. pii: S1542–565(19) 30969–3. doi: 10.1016/j.cgh.2019.08.047

Summary
A systematic search of databases for RCTs evaluating treatments for MHE and prevention of deterioration to OHE resulted in a Network meta-analysis with surface under cumulated ranking (SUCRA) for rifaximin, lactulose, probiotics, probiotics + lactulose or LOLA compared to placebo/no treatment. Twenty five trials identified with 1563 patients with cirrhosis and MHE. LOLA was effective for reversal of MHE [ OR: 4.45, 95% PrI: 2.67–7.42, SUCRA: 47.2%, moderate quality] compared to placebo/no treatment and LOLA and lactulose were most effective for preventing episodes of OHE. Comparative analysis revealed no superiority between other agents and LOLA.

Zhu GQ

2015

20

1.007

OHE

No

LOLA=BCAA>LAC>NEO

Aliment Pharmacol Ther 2015; 41: 624–635

Summary
Literature searches including databases revealed 20 eligible RCTs for inclusion in this Network meta-analysis comparing efficacy of LOLA to that of BCAAs, non-absorbable disaccharides and neomycin compared to observation. The analysis combined direct and indirect evidence to estimate Odds Ratio (OR) and mean difference (MD) between treatments. Compared to observation, only LOLA [OR: 3.71, p<0.001] and BCAAs [OR: 3.37, p<0.001] improved clinical efficacy significantly. There was a trend suggesting that LOLA was the most effective intervention with respect to clinical improvement [OR” 1.10]. LOLA treatment resulted in a significant reduction in blood ammonia [MD:-20.18, 95% CI: -40.12—0.27].

1.5  Network meta-analysis: treatment of OHE by LOLA vs other agents

Electronic and manual searches of key databases yielded 20 RCTs that satisfied inclusion criteria for 1007 patients with cirrhosis and OHE who were treated with non-absorbable disaccharides, neomycin, rifaximin, LOLA or BCAAs versus observation only. Network meta-analysis combined direct and indirect evidence to obtain Odds Ratios (ORs) or Mean Differences (MDs) between treatments based on clinical outcomes. [23] Compared to observation only, treatment with LOLA [OR: 3.71, p< 0.001] or BCAAs [OR: 3.37, p<0.001] resulted in significant improvements in clinical efficacy. It was also concluded that LOLA had the potential to be the most effective intervention with respect to clinical improvement [OR: 1.10], rifaximin [OR: 1.31], non-absorbable disaccharides [OR: 2.75] or neomycin [OR: 2.22]. Moreover, LOLA treatment resulted in a significant reduction in blood ammonia [MD: -20.18, 95% CI: -40.12 to -0.27]compared to observation alone.

1.6  Network meta-analysis: treatment of MHE by LOLA vs other agents

Search of databases for RCTs evaluating available treatments for MHE in patients with cirrhosis yielded 25 trials for 1563 patients that satisfied inclusion criteria. There were two primary outcomes, namely reversal of MHE and prevention of progression from MHE to OHE using meta-analysis followed by Network meta-analysis. SUCRA was employed to pool direct and indirect estimates and to rank the various treatments.

Rifaximin, lactulose and LOLA were equivalent in efficacy and were each superior to probiotics with or without lactulose shown below:

  • Rifaximin [OR:7.53, 95% PrI: 4.45–12.73, SUCRA: 89.2%; moderate quality]
  • Lactulose [OR: 5.39, 95% PrI: 3.60–8.07, SUCRA: 67.2%; moderate quality]
  • LOLA [OR: 4.45, 95% PrI: 2.67–7.42, SUCRA: 47.2%; moderate quality]
  • Probiotics+ lactulose [OR: 4.66, 95% PrI: 1.90–11.39, SUCRA: 52.4%; low quality]
  • Probiotics [OR: 3.89, 95%PrI: 2.52–6.02, SUCRA: 34.1%; low quality]

LOLA was superior to lactulose or probiotics for the prevention of episodes of OHE in patients with MHE compared to placebo/no treatment as shown below:

  • LOLA [OR: 0.19, 95% PrI: 0.04–0.91, SUCRA: 75.1%; moderate quality]
  • Lactulose [OR: 0.22, 95% PrI: 0.09–0.52, SUCRA: 73.9%; moderate quality]
  • Probiotics [OR: 0.27, 95% PrI: 0.11–0.62, SUCRA: 59.6%; low quality.

Rifaximin, on the other hand, was ineffective for OHE prevention [19].

Conclusion

The advent of well-established procedures for the determination of trial quality based on risk of bias assessments such as the Jadad Composite Scoring system followed, more recently, by the Cochrane Handbook for Systematic Reviews and Interventions has resulted in significant improvements in the quality of systematic reviews and meta-analyses of clinical trials. Making use of such procedures, seven systematic reviews with accompanying meta-analysis were published in the last 20 years all of which focused on the analysis of the results of RCTs on the efficacy of LOLA for the efficacy of treatment of MHE and/or OHE in patients with cirrhosis. An initial in-house meta-analysis by Merz Pharmaceuticals (Germany) published in 2000 was followed by systematic reviews and meta-analyses conducted by international investigators from China, Europe, Canada and India. Analysis of the findings from these seven meta-analyses reveals a clear consensus of opinion in support of the efficacy of LOLA for lowering of blood ammonia and for the concomitant improvement of mental status in patients with cirrhosis and OHE in all cases. For MHE, results from five of the six meta-analyses in which it was assessed also yielded significant positive results. A recent meta-analysis assessing the efficacy of other agents with the demonstrated capacity to lower blood ammonia in a range of clinical settings confirmed the lowering of blood ammonia by most agents. However, effects on HE severity were inconsistent leading the investigators to question the quality of the studies. By design, LOLA had not been included in the list of agents assessed in this analysis. The evidence in support of a beneficial effect of LOLA for the prevention of OHE in patients with cirrhosis was reviewed in a novel systematic review and meta-analysis involving six RCTs for a total of 384 patients in a range of clinical presentations. LOLA treatment led to a significant reduction in progression of MHE to OHE compared to placebo/no intervention (three trials) and LOLA treatment was also effective for secondary OHE prophylaxis (one trial), primary OHE prophylaxis following variceal bleeding (one trial) and for post-TIPSS prophylaxis (one trial). Successful OHE prevention/prophylaxis was accompanied in all cases by significant reductions of blood ammonia and either iv or oral formulations of LOLA appeared to be effective for the slowing of progression of MHE to OHE. The effectiveness of LOLA versus placebo for reduction of the progression of MHE to OHE in patients with cirrhosis [20] was independently confirmed in a subsequent meta-analysis. The efficacy of LOLA was compared to other currently-available agents for the treatment of HE in cirrhosis using the technique of network meta-analyses. Two systematic reviews with network meta-analyses have been published in which the efficacy of LOLA for the treatment of HE in patients with cirrhosis was compared to other available agents. The first analysis addressed the treatment of OHE; the second one focused on the treatment of MHE as well as the progression from MHE to OHE.

For treatment of OHE, only treatment with LOLA or BCAAs resulted in significant improvements in clinical efficacy. It was also concluded that LOLA had the potential to be the most effective intervention with respect to clinical improvement and LOLA treatment resulted in concomitant reductions of blood ammonia. For the treatment of MHE, rifaximin, lactulose and LOLA were found to be equivalent in efficacy and were each superior to probiotics with or without lactulose. LOLA was superior to lactulose or probiotics for the prevention of episodes of OHE in patients with MHE compared to placebo/no treatment. Rifaximin, on the other hand, was found to be ineffective for OHE prevention.

References

  1. Kircheis G and Lüth S (2019) Pharmacokinetic and Pharmacodynamic Properties of L-Ornithine L-Aspartate (LOLA) in Hepatic Encephalopathy. Drugs 79: 23–29. [crossref]
  2. Butterworth RF (2019) L-Ornithine L-Aspartate (LOLA) for the Treatment of Hepatic Encephalopathy in Cirrhosis: Novel Insights and Translation to the Clinic. Drugs 79: 1–3. [crossref]
  3. Desjardins P, Rao KV, Michalak A, Rose C, Butterworth RF (1999) Effect of portacaval anastomosis on glutamine synthetase protein and gene expression in brain, liver and skeletal muscle. Metab Brain Dis 14: 273–80. [crossref]
  4. Chatauret N, Desjardins P, Zwingmann C, Rose C, Rao KV et.al (2006) Direct molecular and spectroscopic evidence for increased ammonia removal capacity of skeletal muscle in acute liver failure. J Hepatol 44: 1083–8. [crossref]
  5. Butterworth RF (2019) L-Ornithine L-Aspartate for the Treatment of Sarcopenia in Chronic Liver Disease: The Taming of a Vicious Cycle. Can J Gastroenterol Hepatol : 8182195 [crossref]
  6. Kumar A, Davuluri G, Silva RNE, Engelen MPKJ, Ten Have GAM et.al (2017) Ammonia lowering reverses sarcopenia of cirrhosis by restoring skeletal muscle proteostasis. Hepatology 65: 2045–2058. [crossref]
  7. Butterworth RF (2019) L-Ornithine L-Aspartate: Multimodal Therapeutic Agent for Hyperammonemia and Hepatic Encephalopathy in Cirrhosis. J Pharmacol Pharm Res 2: 1–7.
  8. Ijaz S, Yang W, Winslet MC, Seifalian AM (2005) The role of nitric oxide in the modulation ofhepatic microcirculation and tissue oxygenation in an experimental animal model of hepatic steatosis. Microvasc Res 70: 129–136. [crossref]
  9. Pérez Hernández JL, Higuera de la Tijera F, Serralde-Zúñiga AE, Abdo Francis JM (2011) Critical analysis of studies evaluating the efficacy of infusion of L-ornithine L-aspartate in clinical hepatic encephalopathy in patients with liver failure. Ann Hepatol 2: 66–69. [crossref]
  10. Soárez PC, Oliveira AC, Padovan J, Parise ER, Ferraz MB (2009) A critical analysis of studies assessing L-ornithine-L-aspartate (LOLA) in hepatic encephalopathy treatment. Arq Gastroenterol 46: 241–247. [crossref]
  11. Jadad AR1, Moore RA, Carroll D, Jenkinson C, Reynolds DJ et al. (1996)  Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control Clin Trials 17: 1–12. [crossref]
  12. Delcker M, Jalan R, Schumacher M, Comes G (2000) L-ornithine-L-aspartate vs placebo in the treatment of hepatic encephalopathy: A meta-analysis of randomised placebo-controlled trials using individual data. Hepatology 32: 604. (abstract)
  13. Jiang Q, Jiang XH, Zheng MH, Chen YP (2009) L-Ornithine-l-aspartate in the management of hepatic encephalopathy: a meta-analysis. J Gastroenterol Hepatol 24: 9–14. [crossref]
  14. Hu Weiand Tang SH (2012) Efficacy of L-ornithine-L-aspartate in the Treatment of Hepatic Encephalopathy: A Systematic Review. Chin J Evidence-based Med (12): 799–803. (article in Chinese)
  15. Bai M, Yang Z, Qi X, Fan D, Han G (2013) L-ornithine-l-aspartate for hepatic encephalopathy in patients with cirrhosis: a meta-analysis of randomized controlled trials. J Gastroenterol Hepatol 28: 783–92. [crossref]
  16. Goh ET, Stokes CS, Vilstrup H, Gluud LL, Morgan MY (2017) L-ornithine L-aspartate for hepatic encephalopathy: a systematic review with meta-analyses of randomised controlled trials. J Hepatol 66: 131 (abstract)
  17. Goh ET, Stokes CS, Sidhu SS, Vilstrup H, Gluud LL et.al (2018) L-ornithine L-aspartate for prevention and treatment of hepatic encephalopathy in people with cirrhosis. Cochrane Database Syst Rev 15: 5. [crossref]
  18. Butterworth RF, Kircheis G, Hilger N, McPhail MJW (2018) Efficacy of l-ornithinel-aspartate for the treatment of hepatic encephalopathy and hyperammonemia incirrhosis: systematic review and meta-analysis of randomized controlled trials. J Clin Exp Hepatol 8: 301–13. [crossref]
  19. Dhiman RK, Thumburu KK, Verma N, Chopra M, Rathi S et.al (2019) Indian National Association for Study of Liver (INASL) Hepatic Encephalopathy Study Group (IHESG). Comparative Efficacy of Treatment Options for Minimal Hepatic Encephalopathy: A Systematic Review & Network Meta-analysis. Clin Gastroenterol Hepatol  19: 30969–3.
  20. Higgins JPT, Green S (2011) Cochrane Handbook for Systematic Review of Interventions Version 5.1.0 [updated March 2011]. The Cochrane Collaboration.
  21. Butterworth RF (2019) Beneficial effects of L-ornithine L-aspartate for prevention of overt hepatic encephalopathy in patients with cirrhosis: a systematic review with meta-analysis. Metab Brain Dis [crossref]
  22. Zacharias HD, Zacharias AP, Gluud LL, Morgan MY (2019) Pharmacotherapies that specifically target ammonia for the prevention and treatment of hepatic encephalopathy in adults with cirrhosis. Cochrane Database Syst Rev 6. [crossref]
  23. Zhu GQ, Shi KQ, Huang S, Wang LR, Lin YQ et.al (2015) Systematic review with network meta-analysis: the comparative effectiveness and safety of interventions in patients with overt hepatic encephalopathy. Aliment Pharmacol Ther 41: 624–35. [crossref]

Vegetation in Semi-Arid Areas as a Direct Meso and Macro Climatic Factor: First Evidence of Duplicate Climate Protective Effect of Large Scale Afforestation?

Abstract

Management of climate via vegetation mainly focuses on the CO₂ sequestration activity of plants. Ecologists and Meteorologists so far agree that vegetation has an impact on micro and meso climatic level. Settlement of new vegetation on bare steppe ground over thousands of square km created within short time as seen in a “Great Green Wall” (GGW) – this still is a “new” engineering event, climatic evaluation of greening of entire regions is only starting. Large scale vegetation in semi-arid areas may have a role as direct meso – and macro climatic factor, developing over decades. Discrepant results are found in simulation models (afforestation related risk of heat in same or neighboring region) versus biophysical analysis of satellite data (warming effect of deforestation in dry climate). In trying to explain this discrepancy the reported effects of large scale afforestation in the Chinese GGW on regional and continental climate are reviewed, as reported for model regions sized a few thousand square km. Long term data showing a mitigating effect on wind, temperature and dryness, an important function of trees in breaking hot dry desert wind, a change to moderately humid climate and the critical minimum density of tree cover are reported. Potential errors underlying the simulation models are being discussed. We derive that the first signs of a potential direct meso and macroclimatic effect of additional vegetation in dry semi-arid and arid areas may become visible in the Chinese GGW, which would mean a duplicate climate mitigating effect here. As more and more afforestation areas of this GGW are established this effect is expected to develop in even larger regions during the next two decades.

Keywords

semi-arid, macro climatic, afforestation, CO₂ independent, climate protection, Great Green Wall

Introduction

There is an increasing interest in managing climate, globally. The topic of managing global climate by means of additional vegetation so far is focused mainly on the CO₂ sequestration activity of plants. Natural climate solution projects are aiming to gain a maximum amount of CO₂ fixation, therefore plantation projects were started preferably in regions where high amount of CO₂ can be sequestered within short time, ie where fast growth of trees is supported by humidity of the local climate. The direct climatic impact of vegetation observed in hot dry regions is: breaking of hot desert winds, cooling effect via evapotranspiration and shadow, increasing water storage capacity of the ground, introduction of a hydrate cycle, etc. Ecologists and Meteorologists agree in that direct effects of vegetation can be demonstrated on micro and meso climatic level. The reason for limiting it to a local and regional scale possibly is because the settlement of new tree vegetation over ten thousands of square km, developing, e.g. on bare steppe ground within short time as seen in the “Great Green Walls” (GGW)– this rarely happened before in human history, so there was no opportunity to observe a macro climatic impact. If afforestation of a huge area with desert-like climate and formerly very sparse vegetation has an impact on climate – how long would it take for such new „savannah plantation“ to really show an impact on the dominating semi-arid (almost desert like) climate?

Evidence of such effects of vegetation so far can only be shown indirectly from analysing the meteorological outcome of large scale deforestation, which is leading to weather extremes. If taking place on several continents at the same time (as is the case with tropical forests) such deforestations are expected to bear risk of global temperature rise [1]. Climatic evaluation of the newly existing large scale GGW in Northern China is only starting [2, 3]. This “North Shelterbelt Development Program” was built on the Southern edges of the Gobi and Taklamakan deserts, predominantly in semi-arid climate, an area measuring up to 4,800 km from West to East.

The oldest GGW was started in the early 1970s in Algeria (1,500 km), and the so far largest GGW is planned since 2005 in the South (Sahel) and North of the Sahara Desert. Today the idea is to create a network of vegetation areas over a territory of more than 7,500 km from coast to coast across the North African continent. It is coordinated by the African Union Commission [4, 5]. New large scale afforestation in hot dry climate needs several decades to get established, vegetation here may directly reduce ground temperature, cause regularity of precipitation and humidity of soil and air. Additional evidence of trees and shrubs in semi-arid areas to have a possible cooling effect on surface temperature is coming from the biophysical investigation of vegetation changes on the energy balance in a global context [6]. On the other hand, two studies simulating the impact of large scale afforestation in semi-arid climate are reviewed here which are finding a risk of surface temperature warming in the planted area or the neighboring regions. The warming trend typically found in simulations is connected to the expected changes in albedo. To better understand the discrepant finding I will review the first long-term real life climate data published for the Chinese GGW.

Review

Afforestation in dry climate – Biophysical analysis and Simulation models

Only recently it has become possible to evaluate the effects of vegetation changes on the energy balance in a global context by means of satellite data analysis. Duveiller et al. [6] have shown that the conversion of forests into grassland or agricultural land in dry climate will lead to rise in mean land surface temperatures. The local effects of vegetation loss or land degradation are an increase in the reflected portion of the short wave radiation, and this was most significant in dry climate regions. The resulting emitted long wave radiation is higher in dry regions and lower in northern latitudes. In addition, vegetation loss will lead to strongly reduced latent heat stream, particularly in tropical climate.

„The type of vegetation covering the landscape has a direct influence on local climate through its control of water and energy fluxes. The albedo (brightness) of the vegetation cover will determine how much energy is reflected back into space as shortwave radiation. Its roughness determines how much mixing of air occurs between the atmosphere and the vegetation canopy. The depth and structure of its rooting system can determine how much soil moisture and groundwater might be tapped and thus how much heat can be dissipated through evapotranspiration or latent heat flux. The balance of all these surface properties determines the direct influence of vegetation on the surface energy budget and ultimately on the local temperature” [7]. It therefore seems that changes in surface properties resulting in reduced number of trees in regions with dry and warm climate can lead to a local warming effect. Can we derive from this finding that, vice versa plantation of trees on bare ground in dry climate will have a cooling effect on surface temperatures? The albedo changing effect of vegetation cover is a strong factor in current climate simulation models. Typically, these models are finding that albedo will be reduced by vegetation, i.e. in comparison with the highly reflective bare ground of steppe or desert, the reduced reflection of sun heat radiation will lead to warming of surface temperature via the non-reflected portion absorbed by vegetation.

Simulation of a Western African GGW [8] has investigated how a seamless vegetation cover with evergreen broad leafed plants in a several hundred km wide area (here called „Savannah“) in the South of the Sahel would impact the number of days with extreme hot temperature, since heat waves are becoming more frequent in some areas of the world and they could as well become a risk for man and agriculture here in the South of the Sahel. The simulation is finding that indeed the number of days with extremely hot temperature will increase over the Savannah region, whereas temperature reduction will be found in the „Guinea“ region in the South along the Ivory Coast and in the Sahel region in the North. The increase in days with hot temperature in the afforested „Savannah“ region would predominantly occur during the dry season. At the end of this article it is stated that further analysis work is needed due to some uncertainty factors in order to come to more robust conclusions but that afforestation would lead to increased risk of heat waves in the „Savannah“ and a reduced risk for regions of comparable size in the North and South of it. Another investigation has been conducted to simulate afforestation in the East of South Africa [9], and the results are similar: In the simulated scenario afforestation would lead to reduced albedo and an increase in surface temperature over the plantation area, as well as a certain cooling effect on the neighbouring regions. Some areas would become more dry, other areas of South Africa may get more precipitation than before. Therefore, afforestation could lead to unfavourable changes in local climate in unpredictable areas, which is why besides the positive biogeochemical impact of large scale afforestation also its possible biophysical effects needed to be considered. In trying to overcome the dilemma of the conflicting results, I will review the first real life climate data published for the world´s largest GGW in China, separated by their potential regional (meso climatic) and continental (macro climatic) effects.

Examples of direct meso climatic effects of vegetation in semi-arid climate

The Chinese state and part of its population have been tackling the “Northern Shelter Belt” project since the 1970’s by planting a reported 66 billion trees along the roads, ditches, ponds, and cultivated land ridges, with the aim of a total of 100 billion trees and shrubs planted by 2050.Today these activities are supported by increasingly sophisticated technology resulting in the (re-) greening of steppes and even sand deserts in a gigantic large scale, on an area of 4,800 x 1,500 km. By 2050 these measures are hoped to improve soil degradation on 40% of China´s total area [2, 3].  A detailed case study by Zhuang et al. [10] published in 2017 is based on long-term data from a ”show case“ region of 152,000 hectars (an area of about 50 x 30 km) in Northern Jiangsu. Some 132,600 hectares of the total ground had been desertified until the early 1950´s when afforestation with millions of trees was started here as one of the first regions in the fight against desertification. It is not reported but the proximity to the Yellow River may have made afforestation easier. A marked improvement of the regional climate data is reported: air humidity has increased, the number of days with dust winds is decreased and the formerly steppe landscape was transformed into a green patchwork of forests and agriculture. Reliable publications of detailed afforestation related climate parameters are still rare, therefore the findings are presented in more detail.

The authors claim that today, “the formerly extremely severe climate along the old course of the Yellow River has been fundamentally changed. The improved quality of the regional environment is verified by the greatly increased productivity and welfare of the people. The saline alkali soil has been treated, along with poverty, transforming a beggar’s hometown into a modern region, famous as a producer of food, fruits, vegetables and wood.“ [10]. Regional climate data for the last 66 years were documented by the Fengxian Meteorological Bureau. Data are showing a reduction in strong wind days per year by 80%, reduction in maximum wind speed from 26 to 11 m/sec and reduction of the average wind speed over the ground by 90%. The forested area has been expanded within 60 years, starting from 3% in the 1950´s to 36.9% in the 2010´s. This would have transformed the long term trend of sand storms and desertification into more humid climate in which catastrophic droughts have become rare, despite the underlying global warming mega trend. The local climate has benefitted from reduced temperature extremes, reduced strength and frequency of sand storms and more days with fog.

Precipitation data before / after afforestation are not presented in this paper. However, from 1958 to 1980 the average relative humidity in June had been between 55 and 80%, then during the last 30 years it has varied from 78 to 90%. The increase in relative humidity possibly would result from an increase in evapotranspiration of trees and shrubs and on the other hand from the markedly reduced frequency of strong winds and decreased average yearly wind speed. The number of foggy days per year in this region is reported to have increased from 10 to 20 days (1958 -1971), to 18 to 35 days (1972 – 2000), and 35 to 45 days (2001 – 2013). Before 1960 there were 1 to 22 days with hot dry wind per year, this value has gone down to 0 to 6 (1981 – 2005) and 0 to 3 per year (2005 – 2013). This finding is interesting as it is showing an important impact of vegetation on hot dry desert wind that had caused extreme temperatures in the past – and it contradicts the expected role of a reduced albedo that is to be assumed for an increase in vegetation coverage by 33%. Today this feature of hot dry desert winds seems to have mostly gone and a reduced average wind speed is caused by the additional vegetation. In China, as in many other countries a recent trend of warming and increase in droughts is found, as shown for the period from 1982 to 2011 in [7]. Despite this fact, Zhuang et al report that the June average temperatures have remained constant over the last 60 years in this Northern Jiangsu region. Given the global warming trend (with a reported increase of about 1.5 degrees for China during the last three decades) this arguably may be considered a net decrease of surface temperature.

The authors conclude that, “with constant application of reforestation for 50 years, the regional climate in the old course of Yellow River has improved greatly, from its former long term status as a region of sandstorms and desertification, into a region that can be considered as being intermediate between mesic and humid in weather, and with few natural disasters. Sandstorms, dry-hot wind and saline alkali soil have been eliminated at the root source, along with poverty of the local population.”[10]. The authors propose that, “even though a single or several plots of trees might be net consumers of water in arid and half arid region, millions of trees may have a ‘‘mass effect function on improving regional climate.’’

Furthermore, based on long term climate data a „critical mass“, i.e. a minimum number of trees per area required to find measurable climatic effects of vegetation was discovered. In the hostile semi-arid basic climate a reported 16% and higher tree coverage had led to the moderately sub humid conditions observed today. Less marked results so far are reported in another example. The arid Kubuqi desert is located in the Ordos prefecture of Inner Mongolia, an Autonomous Region in the Northwest of China. Here, a total area of almost 6,000 square km of sand desert has been greened. This achievement was sponsored by a private ecology and investment company, Elion Research Ltd. since 1988 [11, 12]. “Emerging private enterprises such as Elion have played an important role in desertification control and governance in the Kubuqi Desert with the support of local government in terms of policies, planning, and infrastructure construction” [12]. Along the south bank of the Yellow River, Elion has established shelter forest in a belt of 242 km length and 5 to 20 km wide, consisting of trees, bushes and grass. Kubuqi has a temperate continental arid monsoon climate (Köppen class BWk, desert climate), with a long cold winter and warm short summer. January is the coldest month with average of –11.7ºC, July is the hottest month with average of 22.1ºC [12].

In a newspaper article precipitation is reported to have increased during the last 30 years from 100 mm to more than 400 mm in 2018 in this part of the desert [11]. However, there is a constant risk for such reports to originate from biased source. A reliable report including meteorological long term data published by the United Nations (UNEP) in 2015 [12] has found only around 10 % increase in precipitation. The shape of the main tree plantation area is a stretched, rather narrow belt. Evapotranspiration is reported to be generally low due to the low temperatures in autumn and winter. Precipitation results published in [12] are between 260 and 280 mm from the 1960´s to the 2000´s, and 310 mm for the 2010´s decade.

As to sand storms, the UNEP report concludes: “The Kubuqi Project area displays a consistent greening trend that could have caused a decrease in dust storms. This is supported by evidence from the meteorological records at Hangjin Qi which indicated that the number of sandstorm days per year decreased dramatically after the 1970s. Although the decreasing trend was evident before the Kubuqi Project started it has continued until now.”

Days of sandstorm per year until 1985 was between 10 and 50, and since then has decreased to 0 to 8 days.

Annual air temperatures recorded at Hangjin Qi station seems to follow the continental trend as given in [7].

The UNEP report identifies a risk typical for large scale afforestation in semi-arid areas: “While there is currently some risk of overuse of the water table, that is… mitigated by the fact that high water use species, such as non-native vegetables and trees, are only a portion of the developed area, the remainder being mostly plants native to desert areas.” The report recommends “a thorough assessment of water resources before extending to new areas so that the risk of water table depletion can be managed in terms of planting the appropriate species at suitable densities for the local hydrological conditions” [12]. In summary, in both example regions which may belong to the most advanced areas of the Chinese GGW, a reduction in sand storms and events of strong wind can be found following afforestation. In addition, for Jiangsu region an increase in air humidity and constant temperatures over the last 6 decades are found which on basis of global warming trend could indicate a slight cooling effect resulting from afforestation. This may be evidence of direct effects of afforestation on meso climatic level, leading to mitigation of dryness, heat, wind and sand storms in semi-arid and arid climate. Regional transformation from semi-arid to now moderately humid climate was reported.

Direct macro climatic effect of vegetation

During the last three decades, increased drought severity has led to loss of biomass in China, particularly around the year 2000 [7]. This trend clearly will have impacted the Chinese GGW afforestation efforts but plantations may have recovered since then. However, significant increase of forested area in Northern China also has been confirmed for other regions of the GGW. In a study published in 2013 the forested area in the district of Yulin (Shaanxi province) was analysed by mapping afforestation and deforestation from 1974 to 2012. Here, the forested area grew from 14.8% (380,394 hectares) in 1974 to 43.9% (1,128,380 hectares) in 2010. This was determined in a validated evaluation of time series stacks taken by Landsat satellite [13]. The semi-arid continental climate here has an average annual precipitation as low as 400 mm, falling mostly in the hot months of July and August.

In the last century sand and dust from the Gobi and Taklamakan deserts have been reported to be blown over thousands of km, leading to regular heavy air pollution in the capital of Beijing, and even causing coloration of rain and surfaces in Korea and Japan. These dust storm events, so called “Yellow dragon”, probably have been worsened in the last century by deforestations and over use of vegetation and ground water in the climatically sensitive semi-arid Northern territories of China, thereby leading to desertification of wide areas. A publication of Feng Wan et al. (2013) is showing that the frequency of sand storms of different strength in China indeed has gone down since 1954. According to this study, until 2010 the last strong sand storm in Beijing has been registered in 1995 [2]. The reduction of these events has been connected by local meteorologists to the large scale fixation of sand dunes and steppes of Northern and Northwest China. Evidence is given in a study (2015) of time trends in vegetation index in the GGW region, showing that, when compared with adjacent regions the GGW has improved the vegetation index and effectively reduced dust storm intensity (frequency, visibility, duration) in Northern China [14]. The Normalized Vegetation Difference Index (NDVI) is a measure of green vegetation cover from satellite imagery. For this parameter time trends were analyzed together with rainfall and dust storm data from weather stations. An index of dust storm intensity was deployed that takes frequency, visibility, and duration of dust storm events into account. The study found that NDVI was not related to rainfall trends, whereas dust storm intensity was decreased, resulting from increase in NDVI.

An investigation published by the same author in 2016 [15] has analysed air pollution data as generated by 186 observational stations across China. Average NDVI values in the 20-km radius of the 186 stations for six selected years in the period from 1983 to 2003 were analysed. Tan concludes that sand storms and dust storm intensity had decreased markedly during this time period in the area of the GGW and that in parallel the vegetation had recovered here. Thus, reduction in sand and dust storm events seems to be the first and most obvious climatic change introduced by afforestation. It is mentioned in all studies on the subject and noticed on regional as well as on continental level.

Discussion

The biophysical analysis of satellite derived data by Duveiller et al. [6] is showing that in dry climate, when compared to any other form of vegetation, forests have a cooling effect on surface temperature. This finding is surprising and it may necessitate a correction of the existing albedo simulation models for this climate zone. The review of simulation results in contrast suggests that afforestation of steppes and desert bordering areas may lead to a rise in surface temperature and risk of extreme hot temperatures in the same or neighbouring regions.

The West African simulation study [8] is mentioning uncertainty factors to be considered, e.g., choice of simulation model, and definition of extreme heat. At least for the vegetation found naturally in this climate it is fair to say that it would not show dark green colour throughout the year: Leaves and bark of sclerophylls often show bright wax cover, white „hair“, spines, prickles or thorns reflecting the sun light, thereby protecting them from UV radiation. In the typical savannah landscape trees are not standing very close and the grass in between will show light yellow colour during the hot dry season, i.e. for 7 to 9 months of the year. During this time fresh green leaves will dry out and fall off, they typically do not exist on the local species during most of the year. Therefore it seems doubtful whether the standard used here (“evergreen broad leafed plants“) can be applied to simulations of semi-arid conditions. Any existing or newly developed savannah vegetation cover that is adapted to this climate would probably not present dark green colour during dry season thus have a lower effect on albedo most time of the year.

With more and more simulations and investigations being undertaken to analyse the climatic impact of trees and forests scientists are now heavily discussing the overall net contribution of afforestation on global warming. In this situation it may help to search for afforestation related real life (semi-arid) climate data. The dilemma being that for such experiment we would need 1. about 50 years of time to establish tree vegetation cover in semi-arid area, 2. perfect baseline regional climate data and 3. to come to a reliable conclusion the temperature rise of global warming trend over these decades is to be taken into account. Afforestation in the Chinese example areas more or less is those 50 years ahead. By using long term climate data collected in one and the same meteorological station an interesting regulation mechanism was found that may not be as predominant in simulation models [10]. In the Jiangsu region, an actual tree coverage as high as 36% (starting from 3%) led to significantly reduced wind speed so that days of hot dry desert wind and extreme temperature in this region are almost gone. Where did the heat go, has it led to warming of the neighbouring regions?

We do not know, but certainly part of the energy will have gone into evapotranspiration of the newly developed forests. In the context of a GGW we need to ”think big“, we should find similar, maybe weaker cooling trends in other parts of the gigantic large Chinese GGW. The example described in above is a simple cause-and-effect relationship but it seems to have large meso climatic effect. It is questionable whether simulation would have shown that the vegetational impact on wind speed would by far overweight the impact of reduced albedo in the investigated region – and probably to some degree in all surrounding regions that have been enriched with vegetation. Albedo change and reduction in wind speed – these are only two of the factors of the complex regional interaction between vegetation, ground and climate. Other single factors that speak against warming effect of afforestation in dry hot climate which seem difficult to analyse or simulate are:

  1. Shade: Shade reduces temperature, increases humidity, leading to constant soil moisture and thereby an increased uptake of rare precipitation. In this climate partial shadow may enable life, whereas absence of shadow does not. On a ground that is entirely dried out water can stay for long time without being taken up. During this time the majority of precipitation may already have run away in a wadi.
  2. Root system: Deep root penetration of the ground will give it structure that allows for infiltration and long term storage of precipitation in deeper zones of the ground, leading to rise of the ground water level. Strong main roots will break up soil compaction in deep ground, fibre roots will increase the water holding capacity of desert sand… All of which will contribute to the water cycle, thereby increasing the cooling effect via evapotranspiration. In this climate zone water is of ultimate importance as it dominates life here in a “all or nothing rule”.

Can these and other biophysical single factors related to afforestation be simulated appropriately, with their specific intensity and meaning in semi-arid regions? Today, where would we get reference data to underlie a realistic simulation, even if these were given for an area of ”only“ 1,500 square km, like the Jiangsu region in China? When in this climate it takes at least 4, 5 or more decades until such „test area“ is established? Probably it is not a simple task to simulate an overall cooling effect of new vegetation that may evolve to its full extent in nature only after 5 to 7 decades, as can be derived from review of dry climate ecological data [16].

Often questions around publication of data of the Chinese GGW are raised: Where do data come from, what is the source? Analysts may be over motivated to sell a positive outcome of such huge project leading to biased reporting of results. As shown in the Kubuqi example, true facts (increase in precipitation) can be mixed with “half truth” (100 mm instead 260 mm initial value, 400 mm instead of 310 mm averaged value today) which is disappointing as it may mask any helpful interpretation based on true data. The UNEP (2015) report in this respect seems trustworthy, doing only interpretation of long term data, gathered from a local weather station.

Likewise, climate data from the Jiangsu region do meet these criteria. They are also underlined by positive agro economical facts on the development from steppe land in the 1950´s to farming land and fruit garden today. The authors even complain that, because harvests here are so rich farmers would now start to cut trees on the field borders in order to gain more arable land, they see a risk that very soon such behaviour could bring back the old days of hot sand storms.

The Northern Jiangsu region seems to be a “show case” or “model” region: Its´ proximity to the Yellow River is likely to have enabled irrigation of young plants, maybe there is a high water table as in the example of Kubuqi where the stretched narrow green belt was built along the banks of Yellow River. Here a high water table in a few meters depth is reported which clearly has made afforestation easier. Other regions of the Chinese GGW may not have this luxury. Their development into a state of 16, 20 or more percent tree cover when transition to sub-humid climate can be expected (as in Jiangsu) – this is likely to take more years here.

In this review we do not cover the question of which kind of species or vegetation to be chosen for which climate situation. Reports of the Chinese GGW make clear that also plantation of grassland and shrubs is part of the afforestation campaign. The high mortality rate of trees in this climate and a preferably lower water consumption rate of grassland are typical points of criticism of scientists [17]. Today China looks back on three generations of large scale planting efforts, and correction of some of the ecological parameters has been and will need to be done.

Any improvement of climate parameters may only develop over years and decades, hand in hand with the establishment of the new vegetation. Such improvement likely will be counteracted by the effects of global warming. It is therefore difficult to measure any balancing climate effect of new vegetation since these two activities minimize each other. In addition, the larger the region being analysed the more difficult it seems to relate any change in climate parameters to afforestation activity. Long term investigations over the next decades will show whether a still growing new vegetation cover in semi-arid Northern China, besides sand storm events also will modify temperature and humidity on a continental level, similar to the reports on regional level.

Conclusion

It is surprising that we may be able to already find meso and macro climatic effects of vegetation only 50 years after the first plantations were started. In comparison to afforestation in humid climate, newly planted vegetation in semi-arid climate is expected to need significantly more time to take root and get established. Based on semi-arid ecological observations it may take up to 70 years until new vegetation in steppes is well established [16] and only then would also have developed its´ full climatic potential for increased deposition of precipitation in the ground, for the activation of hydrate cycle, formation of clouds, reduction of wind speed, and stabilized surface temperatures. Similarly, a recent report from a Chinese science journalist indicates that it is expected to take another 20 years until we will see the full spectrum of positive results from the Chinese GGW that was started in 1978 (“France 24”, online news 2018). We need to „think big“ in terms of geography – and time. The ability of such plantation to develop, spread and expand further, this certainly can be used as a measure of persistence and success of semi-arid afforestation.

Striking discrepancy was found between the theoretical impact of albedo changes outweighing afforestation results in simulation studies when compared to the importance of wind breaking activity of vegetation on the border of deserts, as seen in real life. The difficult afforestation of steppes and desert border regions may be of high value, functioning as a „vegetational climate barrier“, in addition to the climate protective effect via CO₂ fixation. Here the desert climate parameters are being controlled, vegetation here is buffering the climatic impact of deserts on their adjacent regions.

The first results from Jiangsu region with a size of about 30 x 50 km are showing a threshold with 16 to 20 % of minimum tree cover that is leading to beneficial regional climate changes, i.e. an increase in humidity that is enabling agricultural production in an area dominated by hostile semi-arid climate before. Especially in semi-arid and arid climate it seems obvious that vegetation should have a minimum density over a larger area, a certain minimum percentage in order to show climatic impact and to support or enable agriculture via humidity and precipitation induced by the additional vegetation.

Current natural climate solution projects are focused on maximum fixation of CO₂ amounts, consequently plantation projects were supported preferably in regions where high amount of CO₂ can be sequestered within short time, i.e. where fast growth of trees is supported by humidity of the local climate. In the semi-arid climate of desert border regions however, viability of vegetation depends on a certain regularity of precipitation, additional vegetation may create a duplicate climate mitigating effect, leading to additional humidity and reduced surface temperatures on formerly bare ground.

What if many or most of the desert bordering regions and semi-arid areas with signs of desertification, globally are considered as GGW candidates, getting re-greened in order to maintain soil fertility and a balanced regional and continental climate? Regions in question for respective activities are the Sahel, South Africa, the entire region from Syria to Pakistan, parts of India, and Australia. GGWs and networks of existing and new vegetation in desert bordering areas may be stabilizing in many regards, leading to a more balanced climate regionally and perhaps, globally – in addition to the benefit for agriculture and economy.

Acknowledgement

I would like to thank Professor Dr. Klaus Becker, University of Hohenheim, Germany for all helpful feedback and discussion of the topic.

References

  1. Sven Ploeger, Frank Boettcher: Klimafakten“, Westend Verlag GmbH, Frankfurt (2013). ISBN 978-3-86489-048-2. Pg No: 124–125.
  2. China’s ‘Great Green Wall’ Fights Expanding Desert by Alexandra Petri E (2017) National Geographic, Apr 21.
  3. Feng Wan, Xubin Pan, Dongfang Wang, ChongyangShen, Qi Lu (2013) Combating desertification in China: Past, present and future“. Land Use Policy 31: 311–313.
  4. World leaders renew commitment to strengthen climate resilience through Africa’s Great Green Wall“. Article based on The African Union Commission Press Release, Paris, France, 02 December 2015. In: The African Union, Link: http://www.au.int/en/
  5. Eduardo Mansur in Great Green Wall’ initiative offers unique opportunity to combat climate change in Africa. UN agency. 17 November 2016. Link: http://www.un.org/sustainabledevelopment/blog/2016/11/great-green-wall-Ca-un-agency/
  6. Gregory Duveiller, Giovanni Forzieri, Eddy Robertson, Wei Li, Goran Georgievski, et al. (2018) Biophysics and vegetation cover change: a process-based evaluation framework for confronting land surface models with satellite observations. Earth Syst Sci Data 10: 1265-1279, https://doi.org/10.5194/essd-10-1265-2018
  7. WAD – World Atlas of Desertification, European Commission, Joint Research Center Update 21.11.2018, Link: https://wad.jrc.ec.europa.eu/
  8. Odoulami RC, Abiodun BJ, Ajayi AE, Diasso UJ, Saley MM (2017) Potential impacts of forestation on heatwaves over West Africa in the future. Ecological Engineering 102: 546–556.
  9. Myra Naik, Babatunde J (2016) Potential impacts of forestation on future climate change in Southern Africa”. Int. Journal of Climatology 36: 4560–4576.
  10. Jia-Yao Zhuang, Jin-Chi Zhang, Yangrong Yang, Bo Zhang, Juanjuan Li (2017) Effect of forest shelter-belt as a regional climate improver along the old course of the Yellow River, China. AgroforestSyst 91: 393–401.
  11. Li Yang: Kubuqi a successful example of desert greening.China Daily, Updated: 2018-08-06, 07:39h.
  12. UNEP: Review of the Kubuqi Ecological Restoration Project: A Desert Green Economy Pilot Initiative.” 2015. United Nations Environment Programme, Nairobi.
  13. Liangyun Liu,Huan Tang, Peter Caccetta, Eric A. Lehmann, Yong Hu,Xiaoliang Wu (2013) Mapping afforestation and deforestation from 1974 to 2012 using Landsat time-series stacks in Yulin District, a key region of the Three-North Shelter region, China Environ Monit Assess. 185: 9949–9965.
  14. Minghong Tan, Xiubin Li (2015) Does the Green Great Wall effectively decrease dust storm intensity in China? A study based on NOAA NDVI and weather station data. Land Use Policy 43: 42–47.
  15. Minghong Tan (2016) Exploring the relationship between vegetation and dust-storm intensity (DSI) in China. Journal of Geographical Science 26: 387–396.
  16. Lorenz Huebner (2019) Der Gruene Rettungsring. MitvernetzterSteppenbegruenung global der Klimakrisebegegnen”.OekomVerlag, Munich, Germany.
  17. Alexandra E. Petri (2017) China’s ‘Great Green Wall’ Fights Expanding Desert”. National Geographic Link: https://news.nationalgeographic.com/ 2017/04/china-great-green-wall-gobi-tengger desertification/

Incidence and risk factors associated with cervical cancer in sub-Saharan Africa: A systematic review

DOI: 10.31038/AWHC.2020311

Abstract

Cervical cancer is the second most common leading cause of cancer death among women worldwide. Annually, ≥ 300,000 women die of cervical cancer and the majority of these deaths occur in developing regions of the world including sub-Sahara Africa. Human papillomavirus (HPV) is necessary but not a sufficient cause of cervical cancer. This review paper evaluated risk factors associated with cervical cancer in sub-Saharan Africa, using recent epidemiological studies. The main risk factors associated with cervical cancer in the sub-Saharan African women were; infection with high-risk HPV subtypes, HIV infection, socio-economic factors, age at first sexual intercourse, multiple sexual partners, and long-term use of oral contraceptives. Multi-parity, early pregnancies, and cigarette smoking are some of the risk factors associated with an increased risk of cervical cancer in sub-Saharan Africa. In addition, candidate gene studies have identified a number of single nucleotide polymorphisms mainly within the immune response genes to be associated with cervical cancer risk. Recently, dysbiosis of the cervical microbiome has been associated with cervical cancer risk in sub-Saharan African women.

Keywords

Cervical cancer, Incidence, Sub-Saharan Africa, HPV, Risk Factors

Introduction

Cervical cancer is the second most common leading cause of cancer death among women worldwide [1]. More than 300,000 cervical cancer deaths are reported annually and the majority of these deaths are from developing regions of the world. Squamous cell carcinoma (SCC) and adenocarcinoma (ADC) are the main histological types of cervical cancer [2,3]. SCC begins in epithelial cells of the ectocervix while ADC develops in the glandular cells that line the endocervix [4]. Approximately 80% and 20% of all cervical cancers are SCC and ADC, respectively [5]. ADC is more aggressive and frequently have distant metastases. Patients with ADC tend to have lower five-year survival rates and require an alternative approach to treatment than those with SCC [6]. This review paper evaluates the incidence and risk factors associated with cervical cancer in sub-Saharan Africa, using recent evidence from epidemiological studies.

Incidence of cervical cancer

The incidence of cervical cancer has been decreasing steadily for the past three decades in industrialized regions of the world [7]. However, in developing regions of the world especially in sub-Saharan Africa, the incidence of cervical cancer is increasing at an alarming rate [8]. The age-standardized incidence rate (ASIR) of cervical cancer in sub-Saharan Africa was estimated to be 34.9/100, 000 women [1]. Moreover, ASIR of cervical cancer varies greatly within sub-Saharan Africa, with ASIRs of 43.4/100, 000 women reported in southern Africa, 40.1/100, 000 women in eastern Africa, 29.6/100, 000 women in western Africa, and 26.8/100, 000 women in middle Africa [1], (Figure 1). According to the global cancer statistics of 2018, Eswatini has the highest incidence of cervical cancer followed by Malawi. The ASIRs of cervical cancer in Eswatini and Malawi are 75.3/100, 000 and 72.9/100, 000 women, respectively. Moreover, it is estimated that in the absence of any intervention, nearly 16.5 million cervical cancer cases will occur in sub-Saharan Africa in the next five decades [9].

Risk factors for cervical cancer

1. Human papillomavirus (HPV) infection

HPV is necessary but not sufficient cause of cervical cancer [10]. Approximately 90% of cervical cancers are attributed to HPV infection [11]. HPV, a small, non-enveloped, double-stranded circular DNA viruses belong to the Papovaviridae family [12]. There are ≥150 HPV subtypes that have been identified and characterized so far. These subtypes are categorized into high and low-risk according to their ability to cause malignant tumours. The high-risk HPV subtypes include 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68, 69, 73, and 82 [13]. Within this category, HPV subtypes 16 and 18 are the most oncogenic and contribute ≥ 70% of all cervical cancer cases [14].

Over 90% of HPV is cleared by the immune system within two years after infection [15]. However, a small proportion of infections especially those with high-risk HPV subtypes can persist and progress to cervical cancer. HPV encodes eight early viral regulatory protein (E1 to E8) and two late structural proteins (L1 and L2), which are crucial for cervical carcinogenesis [16–18]. The E1 and E2 are required for viral DNA replication. The E2 suppresses E6 and E7 viral oncoprotein, E4 and E5 help viral assembly, whereas L1 and L2 are involved in capsid formation [19]. HPV usually integrate its DNA into the human genome for replication. However, the integration of HPV into the human DNA disrupts the E2 functionality, thus resulting in a higher expression of E6 and E7 oncoprotein [20]. These oncoproteins invade the host immune system, deregulate the cell cycle control and apoptosis, thus allowing viral persistence. Dysregulation of the cell cycle and apoptosis lead to cellular transformation and immortalization, which is an important step in cervical tumorigenesis [19]. Specifically, E6 bind to tumour suppressor gene (TP53) and prevents apoptosis, whilst E7 oncoprotein promotes cellular proliferation and differentiation [21].

AWHC 2020-301_Abram Bunya Kamiza_F1

Figure 1. Age-standardized incidence rate of cervical cancer in sub-Saharan Africa. Adapted from Global cancer statistics 2018, International Agency for Research on Cancer, World Health Organization.

A retrospective study from 38 countries in North America, Latin America, Caribbean, Europe, Africa, Asia, and Oceania revealed that ≥ 85% of cervical cancer tissues were HPV positive [11]. In addition, 70% of cervical cancer cases were reported to be caused by HPV subtype 16 and 18 [22]. Studies have suggested that in addition to high-risk HPV subtypes been associated with cervical cancer, certain low-risk HPV subtypes such as subtype 6 and 11 also play a crucial role in cervical carcinogenesis [23–25]. However, these low-risk HPV subtypes are commonly associated with benign genital warts. Epidemiological studies have confirmed the direct role of several HPV subtypes in the development of cervical cancer [26,27]. Persistent infection with high-risk HPV subtypes has also been implicated in other cancers including that of the anus, penis, vulva, vagina, and oropharynx [10,28]. These findings suggest that HPV is not only associated with cervical cancer but also other cancers.

2. Human immunodeficiency virus (HIV) infection

HIV exacerbates the risk of cervical cancer. Population-based studies have reported that HIV-positive women are more likely to develop cervical cancer than HIV-negative women [29,30]. In Senegal, HIV-positive women were 2.55, (95% CI 1.69–3.86) times more likely to progress from HPV infection to cervical cancer than HIV-negative women [31]. A case-control in Eswatini reported that HIV positive women were 5.24 times increased risk of cervical cancer than HIV negative women [32]. The increased risk of cervical cancer among HIV-positive women is particularly important in sub-Saharan Africa, where HIV infection is endemic. In Rwanda, Singh et al. reported a higher prevalence of high-risk HPV subtypes in HIV-positive women than in HIV-negative women [33]. In Zambia, HIV-positive individuals were two-timed more likely to be co-infected with high-risk HPV subtypes than HIV-negative individuals [34]. In Zimbabwe and South Africa, HIV-positive women were more likely to have abnormal cervical cytology than HIV-negative women [35,36]. A number of studies have indicated that HIV infection suppresses the immune system’s ability to clear the HPV infection [37–39], leading to persistent infection, which subsequently leads to cervical abnormalities and cancer. Moreover, HIV infection significantly decreases cervical cancer survival among HIV-positive women in Botswana [40].

3. Socio-economic status

Low socioeconomic status (SES) has been associated with an increased risk of cervical cancer in studies from both developing and developed countries [41–43]. A case-control study in the United States reported a 1.8-fold increased risk of cervical cancer among women who reside in poor counties in Ohio compared to those who reside in affluent counties [42]. El-moselhy et al. reported that women with low education level, unskilled, and reside in rural areas in Egypt were more likely to develop cervical cancer than those with high SES [43]. In Tanzania, women with no formal education were 4.30, (95% CI 3.50–5.31) increased the risk of cervical cancer compared to women with high education level [44]. Moreover, women with low SES were 2.3-fold more likely to die from cervical cancer compared to those with high SES [42]. Differences in SES as defined by education, occupation, and annual income play a major role in disparities in the incidence and mortality of cervical cancer. Women with low SES tend to engage in risky sexual behaviour like prostitution [45], which increases the risk of contracting sexually transmitted diseases (STDs) like HPV and HIV, which are important risk factors of cervical cancer. Moreover, women with low SES tend to lack health-seeking behavior [46], hence they are less likely to participate in cancer screening programmes.

4. Age at first sexual intercourse

Early age at first sexual intercourse is associated with risky sexual behaviour like having unprotected sex and multiple sexual partners, which are important risk factors of HPV and HIV [47]. A number of studies have reported an increased risk of cervical cancer with an early age at first sexual intercourse [48–50]. In Nigeria, women with an early onset of sexual intercourse ≤17 years were 3.7-fold increased risk of cervical cancer compared to those aged ≥ 18 years old [49]. A case-control study in Ethiopia indicated that women who experience sexual intercourse earlier than 15 years were 6.7-times more likely to develop cervical cancer than women who experience sexual intercourse between the ages of 21–25 years [50]. Compared with women with age at first sexual intercourse of ≥18 years, the odds ratio of developing cervical cancer was 1.90 and 2.60 among women with age at first sexual intercourse between the ages of 16–17 and <15 years old, respectively [51]. Previous studies have suggested that immature cervix is susceptible to high-risk HPV subtypes, which lead to persistent HPV infection and subsequently increased the risk of cervical cancer among young women [52].

5. Multiple sexual partners

Sexual activities are the main risk factors of HPV infection especially among those with multiple sexual partners [32,50]. Kassa et al. reported a 5.86-fold increased risk of cervical cancer among women with multiple sexual partners in Ethiopia [50]. In Eswatini, Jolly et al. reported an odds ratio 3.00, (95% CI 1.02–8.85) of developing cervical cancer among women with multiple sexual partners after adjusting for age at first sexual intercourse [32]. Moreover, a meta-analysis study suggested that having multiple sexual partners, with or without HPV infection, is an important risk factor of cervical cancer among sexually active women [53].

6. Multi-parity and early pregnancy

Multi-parity has been associated with an increased risk of cervical cancer [46,54]. Women who engage in early sexual intercourse may become pregnant at a young age and are more likely to be parous later in life [55]. Early pregnancies have been associated with an increased risk of cervical cancer [49]. The increased risk of cervical cancer among women with early pregnancies may be due to cervical trauma experienced during early childbearing or by high parity births [55]. A pooled analysis of eight case-control studies indicated that women who were parous at a young age were more likely to develop cervical cancer later in life [56]. Louie et al. suggested that the increased risk of cervical cancer among highly parous women may be attributed to sexual and reproductive events occurring at a young age [55].

7. Oral contraceptive use

Long-term use of oral contraceptives has been associated with cervical cancer risk [50,57]. In Ethiopia and Kenya, women with long-term use of oral contraceptives were associated with an increased risk of cervical cancer compared to women who do not use oral contraceptives [50,57]. A meta-analysis study of 28 case-control studies concluded that long-term use of oral contraceptive is an important risk factor of cervical cancer [58]. Moreover, an animal model study indicated that mouse treated with longer duration of estrogen developed cervical cancer than mouse treated with short duration of estrogen [59]. Interestingly, the incidence of cervical cancer has been found to decline over time as women stopped using oral contraceptives [60,61]. These findings suggest that long-term use of oral contraceptives is an important risk factor of cervical cancer especially among women of reproductive age.

8. Cigarette smoking

While cigarette smoking is commonly associated with lung cancer, it also plays a crucial role in carcinogenesis of many other cancers, including cervical cancer [62]. The International Agency for Research on Cancer classified tobacco as a group one carcinogen. A pooled analysis study revealed an increased risk of cervical cancer in current smokers as compared to non-smokers after adjusting for HPV infection and other environmental factors [63]. Min et al. showed that the risk of cervical cancer increased not only in women who smoke but also in women who are exposed to second-hand smoke [64]. The biological mechanism that underlies the increased risk of cervical cancer among women who smoke is not completely understood. However, studies have suggested that smoking inhibits the clearance of HPV infection by the immune system [65,66]. Surprisingly, the association between cigarette smoking and cervical cancer is stronger in SCC than in ADC [67]. The increased risk of SCC among women who smoke is not fully understood as it has rarely been investigated. However, quitting cigarette smoking has been reported to be associated with a decreased risk of cervical cancer [68]. Roura et al. reported a 2-fold decreased risk of developing cervical cancer among women who quit cigarette smoking.

9. Host genetic factors

Approximately 1% of women with chronic HPV infection progress to cervical cancer [69]. Magnuson et al. estimated that 27% of all cervical cancers are attributed to host genetic factors [70]. Studies have identified a number of single nucleotide polymorphisms (SNPs) mainly within the immune response genes to be associated with cervical cancer [71–74]. In Tunisia, a case-control study identified three SNPs (rs1800871, rs1800872, and rs3024490) within IL10 to be associated with an increased risk of cervical cancer [71]. In South Africa, CCR2-V64L G>A was associated with an increased risk of cervical cancer [72]. Zida et al. and Ben et al. identified TNF-α-308G>A and HLA-DRB1*15 and DQB1*06 to be associated with cervical carcinogenesis among HPV-negative women in Tunisia [73,74]. Apart from the immune response genes been heavily associated with cervical cancer, TP53 has also been implicated in cervical tumorigenesis. A candidate gene study in the black South African population indicated that TP53 rs1042522 SNP is associated with cervical cancer in HPV-negative women [75]. This finding reveals the direct role of host genetic factors in the aetiology of cervical cancer. However, the association between host genetic factors and cervical cancer has rarely been investigated in sub-Saharan Africa. Hence, more genetic studies with larger sample sizes and probably using genome-wide approaches are needed in sub-Saharan Africa to fully understand the aetiology of cervical cancer.

10. Cervical microbiome

Dysbiosis of the cervical microbiome has been associated with cervical cancer risk [76–78]. In Tanzania, Klein et al. reported that Staphylococcus, Pseudomonadales and Mycoplasmatales species were associated with high-grade squamous intraepithelial lesions in HIV-positive women [76]. Curty et al. found Gardnerella, Aerococcus, Schlegelella, Moryella, and Bifidobacterium to be associated with cervical lesions [77]. Moreover, a case-control study by Oh et al.
reported that Atopobium vaginae, Gardnerella vaginalis, and Lactobacillus iners were associated with an increased risk of cervical cancer [78]. Vagina and ectocervix are normally colonized by Lactobacillus species, which inhibit the growth of other bacterial species [79]. Inhibition of these bacteria species is crucial in maintaining the cervical epithelial barrier to HPV entry. However, reduction in the number of Lactobacillus species, result in colonization of cervical epithelium by other bacteria species [80]. These bacterial species produce enzymes and metabolites that compromise the cervical epithelium barrier [81], thus facilitating HPV entry into basal keratinocytes. In Kenya, bacterial vaginosis, trichomonas vaginosis, and Candida species were associated with high-risk HPV infection [82], which is an important risk factor of cervical cancer. Moreover, fungal and some of the bacterial species have been reported to enable HPV persistent, thus leading to cervical cancer [83].

Prevention and screening

1. HPV vaccination

HPV vaccination is becoming the primary prevention of cervical cancer and other HPV-associated cancers. Currently, the Food and Drug Administration approved three HPV vaccines including Gardasil 9, Gardasil, and Cervarix [84]. Gardasil 9 is a nanovalent vaccine produced by Merck [85]. This vaccine target nine HPV subtypes, seven of which are high-risk (16, 18, 31, 33, 45, 52 and 58) and two of which are low-risk (6 and 11). This vaccine target HPV subtypes that cause ≥ 90% of HPV-associated cancers worldwide [86]. Gardasil (Merck and Kenilworth) is a quadrivalent vaccine, thus targeting two high-risk subtypes (16 and 18) and two low-risk subtypes (6 and 11), and covering ≥ 80% of HPV-associated cancers [87]. Cervarix is a bivalent HPV vaccine produced by GlaxoSmithKline, targeting two high-risk HPV subtypes 16 and 18, which contribute 70% of cervical cancer worldwide [87].

However, these vaccines cannot prevent pre-existing infections and are administered to pre-adolescent girls between the ages of 9–15 years [84]. Uptake of these vaccines is low in developing countries, especially in sub-Saharan Africa [88]. However, most countries are now implementing HPV vaccination in school-going children. It is estimated that ≥ 6.7 million cervical cancer cases could be prevented if HPV vaccination coverage is scaled up to 80–100% globally by the year 2020 [9]. However, it will take several decades in sub-Saharan Africa to see the impact of HPV vaccination.

2. Pap smear test

Pap smear is a screening test used to check cervical lesions. It is usually performed in women of reproductive age and who are sexually active [89]. Pap smear can detect early cervical dysplasia in its earliest form. Once cervical abnormalities are detected, the best way is to treat the precancerous lesions before they can fully develop into cancer. Countries that have successfully implemented cervical cancer screening have also significantly reduced both the incidence and mortality of cervical cancer, especially SCC [90,91]. The HPV DNA test has also been recommended to be included in cervical cancer screening package among women of reproductive age [89]. Cervical cytology together with HPV DNA test has higher sensitivity than screening with Pap smear alone [92]. A recent study suggested that rapid scale-up of HPV vaccination and screening from 2020 onwards will rapidly decrease the incidence and mortality of cervical cancer in the next five decades [9]. However, cervical cancer screening coverage is still low in sub-Saharan Africa [93], and there is a need for rapid scale-up to avert the high incidence and mortality of cervical cancer.

3. Visual inspection with acetic acid (VIA)

VIA is an alternative cervical cancer screening method viable in sub-Saharan Africa, as it is cheap, easy to use, does not require a physician or pathologist to perform, and tend to have shorter turn-around time than Pap smear [94]. In VIA, about 5% acetic acid (vinegar) is applied to the cervix and then visualized with a lamp. The precancerous lesions on the cervix normally turn white when combined with acetic acid whilst normal cervix do not change colour [95]. A number of studies in sub-Saharan Africa have indicated that VIA has a higher sensitivity than Pap smear [96–99]. Specifically, VIA has a high sensitivity for SCC which contribute ≥ 80% of cervical cancers in sub-Saharan Africa [97]. However, previous studies have indicated that VIA tends to have lower specificity than Pap smear [96–98]. Nonetheless, VIA is comparable to Pap smear and the World Health Organization recommended VIA as a primary cervical cancer screening method in developing countries, where pathology laboratories are limited. The low cervical cancer screening rate in sub-Saharan Africa may be attributed to inadequate funding, lack of awareness campaign, lack of health-seeking behaviour, low SES, and long-distance to access healthcare facility [100]. Cervical cancer can also be prevented by having safe sex, monogamous relationship and adopting a healthy lifestyle like quitting cigarette smoking, alcohol consumption and engaging in regular physical activity.

Summary and conclusion

The incidence of cervical cancer is highest in sub-Saharan Africa. Epidemiological studies have indicated that infection with high-risk HPV subtypes is crucial in the carcinogenesis of cervical cancer. Apart from HPV infection, HIV, SES, age at first sexual intercourse, multiple sexual partners, oral contraceptive use, multi-parity, early pregnancies, cigarette smoking, host genetic factors, and dysbiosis of the cervical microbiome are also important risk factors associated with cervical cancer in sub-Saharan Africa. However, cervical cancer can be prevented by HPV vaccination and early detection through screening. Gardasil and Cervarix are two HPV vaccines that are currently used to prevent cervical cancer and other HPV-associated cancers in sub-Saharan Africa. Scaling up HPV vaccination and decentralization of cervical cancer screening programmes from tertiary-level to primary-level care is crucial in preventing the incidence and mortality of cervical cancer in sub-Saharan Africa. Moreover, future cervical cancer prevention programmes should include other risk factors associated with the disease.

Funding: None.

Conflicts of Interest: None

References

  1. Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, et al. (2018) Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA: A Cancer Journal for Clinicians 68: 394–424. [Crossref]
  2. Chaturvedi AK, Kleinerman RA, Hildesheim A, Gilbert ES, Storm H, et al. (2009) Second Cancers After Squamous Cell Carcinoma and Adenocarcinoma of the Cervix. J Clin Oncol 27: 967–973.
  3. Marth C, Landoni F, Mahner S, McCormack M, Gonzalez-Martin A, et al. (2018) Cervical cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 29. [Crossref]
  4. Silverberg SGM, Loffe OBM (2003) Pathology of Cervical Cancer. Cancer J 9: 335–347. [Crossref]
  5. Wang SS, Sherman ME, Hildesheim A, Lacey JV, Devesa S (2004) Cervical adenocarcinoma and squamous cell carcinoma incidence trends among white women and black women in the United States for 1976–2000. Cancer 100: 1035–1044. [Crossref]
  6. Yokoi E, Mabuchi S, Takahashi R, Matsumoto Y, Kuroda H, et al. (2017) Impact of histological subtype on survival in patients with locally advanced cervical cancer that were treated with definitive radiotherapy: adenocarcinoma/adenosquamous carcinoma versus squamous cell carcinoma. J Gynecol Oncol 28. [Crossref]
  7. Baldur-Felskov B, Munk C, Nielsen TSS, Dehlendorff C, Kirschner B, et al. (2015) Trends in the incidence of cervical cancer and severe precancerous lesions in Denmark, 1997–2012. Cancer Causes Control 26: 1105–1116. [Crossref]
  8. Torre LA, Islami F, Siegel RL, Ward EM, Jemal A. (2017) Global Cancer in Women: Burden and Trends. Cancer Epidemiol Biomarkers Prev 26: 444–457. [Crossref]
  9. Simms KT, Steinberg J, Caruana M, Smith MA, Lew J-B, et al. (2019) Impact of scaled up human papillomavirus vaccination and cervical screening and the potential for global elimination of cervical cancer in 181 countries, 2020–99: a modelling study. Lancet Oncol 20: 394–407.
  10. Walboomers JM, Jacobs MV, Manos MM, Bosch FX, Kummer JA, et al. (1999) Human papillomavirus is a necessary cause of invasive cervical cancer worldwide. J Pathol 189: 12–19. [Crossref]
  11. De Sanjose S, Quint WG, Alemany L, Geraets DT, Klaustermeier JE, et al. (2010) Human papillomavirus genotype attribution in invasive cervical cancer: a retrospective cross-sectional worldwide study. Lancet Oncol 11: 1048–1056. [Crossref]
  12. Tjalma WA. (2006) Cervical cancer and prevention by vaccination: results from recent trials. Ann Oncol 17: 217–223. [Crossref]
  13. Muñoz N, Bosch FX, de Sanjosé S, Herrero R, Castellsagué X, et al. (2003) Epidemiologic classification of human papillomavirus types associated with cervical cancer. N Engl J Med 348: 518–527. [Crossref]
  14. Smith JS, Lindsay L, Hoots B, Keys J, Franceschi S, et al. (2007) Human papillomavirus type distribution in invasive cervical cancer and high-grade cervical lesions: a meta-analysis update. Int J Cancer 121: 621–632. [Crossref]
  15. Ho GY, Bierman R, Beardsley L, Chang CJ, Burk RD (1998) Natural history of cervicovaginal papillomavirus infection in young women. N Engl J Med 338: 423–428. [Crossref]
  16. McBride AA (2017) Oncogenic human papillomaviruses. Philos Trans R Soc Lond B Biol Sci 372.
  17. Chen J (2015) Signaling pathways in HPV-associated cancers and therapeutic implications: Signaling pathways in HPV-associated cancers. Reviews in Medical Virology 25: 24–53. [Crossref]
  18. Yugawa T, Kiyono T (2009) Molecular mechanisms of cervical carcinogenesis by high-risk human papillomaviruses: novel functions of E6 and E7 oncoproteins. Reviews in Medical Virology 19: 97–113. [Crossref]
  19. Senba M, Mori N (2012) Mechanisms of virus immune evasion lead to development from chronic inflammation to cancer formation associated with human papillomavirus infection. Oncol Rev 6. [Crossref]
  20. Williams VM, Filippova M, Soto U, Duerksen-Hughes PJ (2011) HPV-DNA integration and carcinogenesis: putative roles for inflammation and oxidative stress. Future Virol 6: 45–57.
  21. Tomaić V (2016) Functional Roles of E6 and E7 Oncoproteins in HPV-Induced Malignancies at Diverse Anatomical Sites. Cancers (Basel) 8. [Crossref]
  22. Gul S, Murad S, Javed A (2015) Prevalence of High risk Human Papillomavirus in cervical dysplasia and cancer samples from twin cities in Pakistan. International Journal of Infectious Diseases 34: 14–19. [Crossref]
  23. Burd EM (2003) Human Papillomavirus and Cervical Cancer. Clin Microbiol Rev 16: 1–17.
  24. Bonello K, Blundell R (2016) The Role of the Human Papillomavirus (HPV) in Cervical Cancer: A Review about HPV-Induced Carcinogenesis and Its Epidemiology, Diagnosis, Management and Prevention. International Journal of Medical Students 4: 26–32.
  25. Hoory T, Monie A, Gravitt P, Wu TC (2008) Molecular Epidemiology of Human Papillomavirus. Journal of the Formosan Medical Association 107: 198–217. [Crossref]
  26. Furumoto H, Irahara M (2002) Human papilloma virus (HPV) and cervical cancer. J Med Invest 49: 124–133.
  27. Ghittoni R, Accardi R, Chiocca S, Tommasino M (2015) Role of human papillomaviruses in carcinogenesis. Ecancermedicalscience 9: 526. [Crossref]
  28. Van der Marel J, Berkhof J, Ordi J, Torné A, Del Pino M, et al. (2015) Attributing oncogenic human papillomavirus genotypes to high-grade cervical neoplasia: which type causes the lesion? Am J Surg Pathol 39: 496–504. [Crossref]
  29. Engels EA, Pfeiffer RM, Goedert JJ, Virgo P, McNeel TS, et al. (2006) Trends in cancer risk among people with AIDS in the United States 1980–2002. AIDS 20: 1645–1654. [Crossref]
  30. Chaturvedi AK, Madeleine MM, Biggar RJ, Engels EA (2009) Risk of human papillomavirus-associated cancers among persons with AIDS. J Natl Cancer Inst 101: 1120–1130. [Crossref]
  31. Whitham HK, Hawes SE, Chu H, Oakes JM, Lifson AR, et al. (2017) A Comparison of the Natural History of HPV Infection and Cervical Abnormalities among HIV-Positive and HIV-Negative Women in Senegal, Africa. Cancer Epidemiol Biomarkers Prev 26: 886–894. [Crossref]
  32. Jolly PE, Mthethwa-Hleta S, Padilla LA, Pettis J, Winston S, et al. (2017) Screening, prevalence, and risk factors for cervical lesions among HIV positive and HIV negative women in Swaziland. BMC Public Health 17: 218. [Crossref]
  33. Singh DK, Anastos K, Hoover DR, Burk RD, Shi Q, et al. (2009) Human papillomavirus infection and cervical cytology in HIV-infected and HIV-uninfected Rwandan women. J Infect Dis 199: 1851–1861. [Crossref]
  34. Ng’andwe C, Lowe JJ, Richards PJ, Hause L, Wood C, et al. (2007) The distribution of sexually-transmitted Human Papillomaviruses in HIV positive and negative patients in Zambia, Africa. BMC Infect Dis 7: 77. [Crossref]
  35. Chirenje ZM, Loeb L, Mwale M, Nyamapfeni P, Kamba M, et al. (2002) Association of cervical SIL and HIV-1 infection among Zimbabwean women in an HIV/STI prevention study. Int J STD AIDS 13: 765–768.
  36. Moodley JR, Constant D, Hoffman M, Salimo A, Allan B, et al. (2009) Human papillomavirus prevalence, viral load and pre-cancerous lesions of the cervix in women initiating highly active antiretroviral therapy in South Africa: a cross-sectional study. BMC Cancer 9: 275. [Crossref]
  37. Looker KJ, Rönn MM, Brock PM, Brisson M, Drolet M, et al. (2018) Evidence of synergistic relationships between HIV and Human Papillomavirus (HPV): systematic reviews and meta-analyses of longitudinal studies of HPV acquisition and clearance by HIV status, and of HIV acquisition by HPV status. J Int AIDS Soc 21. [Crossref]
  38. Williamson AL (2015) The Interaction between Human Immunodeficiency Virus and Human Papillomaviruses in Heterosexuals in Africa. J Clin Med 4: 579–592. [Crossref]
  39. Kelly HA, Sawadogo B, Chikandiwa A, Segondy M, Gilham C, et al. (2017) Epidemiology of high-risk human papillomavirus and cervical lesions in African women living with HIV/AIDS: effect of anti-retroviral therapy. AIDS 31: 273–285. [Crossref]
  40. Dryden-Peterson S, Bvochora-Nsingo M, Suneja G, Efstathiou JA, Grover S, et al. (2016) HIV Infection and Survival Among Women With Cervical Cancer. J Clin Oncol 34: 3749–3757.
  41. Irimie S, Vlad M, Mirestean IM, Balacescu O, Rus M, et al. (2011) Risk Factors in a Sample of Patients with Advanced Cervical Cancer. Applied Medical Informatics 29: 1–10.
  42. Kollman J (2018) Poverty and Cancer Disparities in Ohio. Prev Chronic Dis 15.
  43. Ea E-M, Hm B, Sa A (2016) Cervical Cancer: Sociodemographic and Clinical Risk Factors among Adult Egyptian Females. Journal of Oncology Research and Treatment 1: 1–7.
  44. Kahesa C, Kjaer SK, Ngoma T, Mwaiselage J, Dartell M, et al. (2012) Risk factors for VIA positivity and determinants of screening attendances in Dar es Salaam, Tanzania. BMC Public Health 12: 1055. [Crossref]
  45. DINKELMAN T, LAM D, LEIBBRANDT M (2008) LINKING POVERTY AND INCOME SHOCKS TO RISKY SEXUAL BEHAVIOUR. S Afr J Econ 76: 52–74.
  46. Mebratie AD, Poel EV de, Yilma Z, Abebaw D, Alemu G, et al. (2014) Healthcare-seeking behaviour in rural Ethiopia: evidence from clinical vignettes. BMJ Open 4.
  47. Zhang R, Shi TY, Ren Y, Lu H, Wei Z-H, et al. (2013) Risk factors for human papillomavirus infection in Shanghai suburbs: a population-based study with 10,000 women. J Clin Virol 58: 144–148. [Crossref]
  48. Adewuyi SA, Shittu SO, Rafindadi AH (2008) Sociodemographic and clinicopathologic characterization of cervical cancers in northern Nigeria. Eur J Gynaecol Oncol 29: 61–64. [Crossref]
  49. Ogunbowale T, Lawoyin TO (2008) Cervical cancer risk factors and predictors of cervical dysplasia among women in south-west Nigeria. Aust J Rural Health 16: 338–342. [Crossref]
  50. Kassa RT (2018) Risk factors associated with precancerous cervical lesion among women screened at Marie Stops Ethiopia, Adama town, Ethiopia 2017: a case control study. BMC Res Notes 11: 145. [Crossref]
  51. Williams MA, Kenya PR, Mati JK, Thomas DB (1994) Risk factors for invasive cervical cancer in Kenyan women. Int J Epidemiol 23: 906–912. [Crossref]
  52. Moscicki AB, Winkler B, Irwin CE, Schachter J (1989) Differences in biologic maturation, sexual behavior, and sexually transmitted disease between adolescents with and without cervical intraepithelial neoplasia. The Journal of Pediatrics 115: 487–493. [Crossref]
  53. Liu ZC, Liu WD, Liu YH, Ye XH, Chen SD (2015) Multiple Sexual Partners as a Potential Independent Risk Factor for Cervical Cancer: a Meta-analysis of Epidemiological Studies. Asian Pac J Cancer Prev 16: 3893–3900. [Crossref]
  54. Bezabih M, Tessema F, Sengi H, Deribew A (2015) Risk Factors Associated with Invasive Cervical Carcinoma among Women Attending Jimma University Specialized Hospital, Southwest Ethiopia: A Case Control Study. Ethiop J Health Sci 25: 345–352.
  55. Louie KS, de Sanjose S, Diaz M, Castellsagué X, Herrero R, et al. (2009) Early age at first sexual intercourse and early pregnancy are risk factors for cervical cancer in developing countries. Br J Cancer 100: 1191–1197. [Crossref]
  56. Muñoz N, Franceschi S, Bosetti C, Moreno V, Herrero R, et al. (2002) Role of parity and human papillomavirus in cervical cancer: the IARC multicentric case-control study. The Lancet 359: 1093–1101. [Crossref]
  57. Soh J, Rositch AF, Koutsky L, Guthrie BL, Choi RY, et al. (2014) Individual and partner risk factors associated with abnormal cervical cytology among women in HIV-discordant relationships. Int J STD AIDS 25: 315–324. [Crossref]
  58. Smith JS, Green J, Berrington de Gonzalez A, Appleby P, Peto J, et al. (2003) Cervical cancer and use of hormonal contraceptives: a systematic review. Lancet 361: 1159–1167. [Crossref]
  59. Brake T, Lambert PF (2005) Estrogen contributes to the onset, persistence, and malignant progression of cervical cancer in a human papillomavirus-transgenic mouse model. Proc Natl Acad Sci USA 102: 2490–2495. [Crossref]
  60. Bayo S, Bosch FX, de Sanjosé S, Muñoz N, Combita AL, et al. (2002) Risk factors of invasive cervical cancer in Mali. Int J Epidemiol 31: 202–209. [Crossref]
  61. Muwonge R, Ngo Mbus L, Ngoma T, Gombe Mbalawa C, Dolo A, et al. (2016) Socio-demographic and reproductive determinants of cervical neoplasia in seven sub-Sahara African countries. Cancer Causes Control 27: 1437–1446. [Crossref]
  62. Fonseca-Moutinho JA (2011) Smoking and Cervical Cancer. ISRN Obstet Gynecol 2011.
  63. Plummer M, Herrero R, Franceschi S, Meijer CJLM, Snijders P, et al. (2003) Smoking and cervical cancer: pooled analysis of the IARC multi-centric case–control study. Cancer Causes Control 14: 805–814. [Crossref]
  64. Min KJ, Lee JK, So KA, Kim MK (2018) Association Between Passive Smoking and the Risk of Cervical Intraepithelial Neoplasia 1 in Korean Women. J Epidemiol 28: 48–53. [Crossref]
  65. Giuliano AR, Sedjo RL, Roe DJ, Harri R, Baldwi S, et al. (2002) Clearance of oncogenic human papillomavirus (HPV) infection: effect of smoking (United States). Cancer Causes Control 13: 839–846.  [Crossref]
  66. Koshiol J, Schroeder J, Jamieson DJ, Marshall SW, Duerr A, et al. (2006) Smoking and time to clearance of human papillomavirus infection in HIV-seropositive and HIV-seronegative women. Am J Epidemiol 164: 176–183. [Crossref]
  67. Berrington de González A, Sweetland S, Green J (2004) Comparison of risk factors for squamous cell and adenocarcinomas of the cervix: a meta-analysis. Br J Cancer 90: 1787–1791. [Crossref]
  68. Roura E, Castellsagué X, Pawlita M, Travier N, Waterboer T, et al. (2014) Smoking as a major risk factor for cervical cancer and pre-cancer: Results from the EPIC cohort. International Journal of Cancer 135: 453–466. [Crossref]
  69. Xu H-H, Zhang X, Zheng H-H, Han Q-Y, Lin A-F, et al. (2018) Association of HLA-G 3′ UTR polymorphism and expression with the progression of cervical lesions in human papillomavirus 18 infections. Infect Agent Cancer 13: 42. [Crossref]
  70. Magnusson PKE, Lichtenstein P, Gyllensten UB (2000) Heritability of cervical tumours. International Journal of Cancer 88: 698–701. [Crossref]
  71. Zidi S, Gazouani E, Stayoussef M, Mezlini A, Ahmed SK, et al. (2015) IL-10 gene promoter and intron polymorphisms as genetic biomarkers of cervical cancer susceptibility among Tunisians. Cytokine 76: 343–347. [Crossref]
  72. Chatterjee K, Dandara C, Hoffman M, Williamson AL (2010) CCR2-V64I polymorphism is associated with increased risk of cervical cancer but not with HPV infection or pre-cancerous lesions in African women. BMC Cancer 10: 278. [Crossref]
  73. Zidi S, Stayoussef M, Zouidi F, Benali S, Gazouani E, et al. (2015) Tumor Necrosis Factor Alpha (-238 / -308) and TNFRII-VNTR (-322) Polymorphisms as Genetic Biomarkers of Susceptibility to Develop Cervical Cancer Among Tunisians. Pathol Oncol Res 21: 339–345.
  74. Ben Othmane Y, Ghazouani E, Mezlini A, Lagha A, Raïs M, et al. (2012) HLA class II susceptibility to cervical cancer among Tunisian women. Bull Cancer 99: 81–86. [Crossref]
  75. Pegoraro RJ, Rom L, Lanning PA, Moodley M, Naiker S, et al. (2002) P53 codon 72 polymorphism and human papillomavirus type in relation to cervical cancer in South African women. Int J Gynecol Cancer 12: 383–388. [Crossref]
  76. Klein C, Gonzalez D, Samwel K, Kahesa C, Mwaiselage J, et al. (2019) Relationship between the Cervical Microbiome, HIV Status, and Precancerous Lesions. MBio 10. [Crossref]
  77. Curty G, Costa RL, Siqueira JD, Meyrelles AI, Machado ES, et al. (2017) Analysis of the cervical microbiome and potential biomarkers from postpartum HIV-positive women displaying cervical intraepithelial lesions. Sci Rep 7.
  78. Oh HY, Kim BS, Seo SS, Kong JS, Lee JK, et al. (2015) The association of uterine cervical microbiota with an increased risk for cervical intraepithelial neoplasia in Korea. Clin Microbiol Infect 21: 674. [Crossref]
  79. Witkin SS, Linhares IM (2017) Why do lactobacilli dominate the human vaginal microbiota? BJOG: An International Journal of Obstetrics & Gynaecology 124: 606–611. [Crossref]
  80. Amabebe E, Anumba DOC (2018) The Vaginal Microenvironment: The Physiologic Role of Lactobacilli. Front Med (Lausanne) 5: 181. [Crossref]
  81. Mitra A, MacIntyre DA, Marchesi JR, Lee YS, Bennett PR, et al. (2016) The vaginal microbiota, human papillomavirus infection and cervical intraepithelial neoplasia: what do we know and where are we going next? Microbiome 4: 58.
  82. Menon S, Broeck DV, Rossi R, Ogbe E, Harmon S, et al. (2016) Associations Between Vaginal Infections and Potential High-risk and High-risk Human Papillomavirus Genotypes in Female Sex Workers in Western Kenya. Clin Ther 38: 2567–2577. [Crossref]
  83. Uren A, Fallen S, Yuan H, Usubütün A, Küçükali T, et al. (2005) Activation of the canonical Wnt pathway during genital keratinocyte transformation: a model for cervical cancer progression. Cancer Res 65: 6199–6206. [Crossref]
  84. Harper DM, DeMars LR (2017) HPV vaccines – A review of the first decade. Gynecologic Oncology 146: 196–204. [Crossref]
  85. Zhang Z, Zhang J, Xia N, Zhao Q (2017) Expanded strain coverage for a highly successful public health tool: Prophylactic 9-valent human papillomavirus vaccine. Hum Vaccin Immunother 13: 2280–2291.
  86. Serrano B, Alemany L, Tous S, Bruni L, Clifford GM, et al. (2012) Potential impact of a nine-valent vaccine in human papillomavirus related cervical disease. Infect Agents Cancer 7: 38. [Crossref]
  87. Gattoc L, Nair N, Ault K (2013) Human Papillomavirus Vaccination. Obstet Gynecol Clin North Am 40: 177–197.
  88. Bruni L, Diaz M, Barrionuevo-Rosas L, Herrero R, Bray F, et al. (2016) Global estimates of human papillomavirus vaccination coverage by region and income level: a pooled analysis. Lancet Glob Health 4: 453–463. [Crossref]
  89. Jeronimo J, Castle PE, Temin S, Denny L, Gupta V, et al. (2016) Secondary Prevention of Cervical Cancer: ASCO Resource-Stratified Clinical Practice Guideline. JGO 3: 635–657. [Crossref]
  90. Chiang YC, Chen YY, Hsieh SF, Chiang CJ, You SL, et al. (2017) Screening frequency and histologic type influence the efficacy of cervical cancer screening: A nationwide cohort study. Taiwanese Journal of Obstetrics and Gynecology 56: 442–448. [Crossref]
  91. Murillo R, Herrero R, Sierra MS, Forman D (2016) Cervical cancer in Central and South America: Burden of disease and status of disease control. Cancer Epidemiology 44: 121–130. [Crossref]
  92. Moy LM, Zhao FH, Li LY, Ma JF, Zhang QM, et al. (2010) Human papillomavirus testing and cervical cytology in primary screening for cervical cancer among women in rural China: Comparison of sensitivity, specificity, and frequency of referral. International Journal of Cancer 127: 646–656. [Crossref]
  93. Gakidou E, Nordhagen S, Obermeyer Z (2008) Coverage of cervical cancer screening in 57 countries: low average levels and large inequalities. PLoS Med 5: 132. [Crossref]
  94. Saleh HS (2014) Can visual inspection with acetic acid be used as an alternative to Pap smear in screening cervical cancer? Middle East Fertility Society Journal 19: 187–191.
  95. Kavita SN, Shefali M (2010) Visual inspection of cervix with acetic acid (VIA) in early diagnosis of cervical intraepithelial neoplasia (CIN) and early cancer cervix. J Obstet Gynaecol India 60: 55–60.
  96. Doh AS, Nkele NN, Achu P, Essimbi F, Essame O, et al. (2005) Visual inspection with acetic acid and cytology as screening methods for cervical lesions in Cameroon. International Journal of Gynecology & Obstetrics 89: 167–173. [Crossref]
  97. Goel A, Gandhi G, Batra S, Bhambhani S, Zutshi V, et al. (2005) Visual inspection of the cervix with acetic acid for cervical intraepithelial lesions. Int J Gynaecol Obstet 88: 25–30. [Crossref]
  98. Ardahan M, Temel AB (2011) Visual inspection with acetic acid in cervical cancer screening. Cancer Nurs 34: 158–163.
  99. Arbyn M, Sankaranarayanan R, Muwonge R, Keita N, Dolo A, et al. (2008) Pooled analysis of the accuracy of five cervical cancer screening tests assessed in eleven studies in Africa and India. Int J Cancer 123: 153–160. [Crossref]
  100. Birhanu Z, Abdissa A, Belachew T, Deribew A, Segni H, et al. (2012) Health seeking behavior for cervical cancer in Ethiopia: a qualitative study. International Journal for Equity in Health 11: 83. [Crossref]

Occupational Performance of Children and Adolescents with Mucopolysaccharidosis Using Assistive Technologies

Abstract

Mucopolysaccharidoses (MPS) are a specific group of genetic diseases in which due to the accumulation of glycosaminoglycans (GAGs) in different organs and tissues, causes multisystemic changes that compromise the functionality and occupational performance of individuals. Occupational performance, understood as the participation and execution of activities of daily living, may be favoured using Assistive Technology (AT). Since there are no studies reporting the influence of AT on the occupational performance of children and adolescents with MPS, the objective of this study was to evaluate the occupational performance in self-care activities, based on the use of low-cost AT in children and adolescents with Mucopolysaccharidosis. Six individuals with MPS types I, IV-A and VI, aged 9 to 16 years participated. The instruments used for data collection were the Pediatric Disability Assessment Inventory (PEDI) – self-care area only, and the Canadian Occupational Performance Measure (COPM). The results showed that the tasks that presented the greatest disabilities in the performance are the areas of dressing, personal hygiene and bath. Thus, TA resources were made for five activities related to dressing and one for personal hygiene. After the use of AT, there was a positive and significant change in occupational performance and satisfaction of these individuals. Thus, the use of AT can significantly improve the occupational performance of this population.

Keywords

Adolescent, Assistive Technology, Child, Mucopolysaccharidosis, Occupational Performance, Self-Care Activities

Introduction

Mucopolysaccharidoses (MPS) are rare diseases, characterized by genetically determined metabolic errors, which are part of the Lysosomal Deposit Disease group. In these diseases there is accumulation of substrates that are normally degraded in lysosomes, and in MPS, deficiencies of specific enzymes lead to the accumulation of glycosaminoglycans (GAGs), resulting in a series of signs and symptoms, which together bring systemic impairment [1–3]. There is no cure for this group of diseases, and the current treatment is aimed at delaying its progress. Even with treatments, progression is nonetheless long-term, and changes in body structures and functions (joint stiffness, decreased range of motion, joint laxity, claw hand) result in limited functionality in the areas of occupational performance, especially in self-care tasks – related to dressing, personal hygiene and food [4].

Occupational performance is understood as the ability to perform routines and perform roles and tasks, involving the areas of self-care, productivity and leisure, being influenced by the factors of the individual, their skills and the context in which they are inserted [5]. Thus, for individuals with some form of physical limitation, occupational therapists may use Assistive Technology (AT) as an effort to enable improved independence and occupational performance, to the extent that limitations can be overcome through adaptations and use of ATs.

Assistive Technology allows a person with a limitation to perform activities and tasks more independently, and can be characterized as technology of high complexity (high cost – with electronic components) or low complexity (low cost), the latter being designed from everyday easily accessible materials that can often be made from materials available at home, in the office, at school or in the hospital. This type of AT is something that can be done right away to meet the needs of those who need it, with the resources at hand [7–9]. However, there are no studies linking the use of AT and MPS. Thus, this study aims to evaluate occupational performance in self-care activities, based on the use of low-cost assistive technology in children and adolescents with Mucopolysaccharidoses.

Methods

This is a prospective and descriptive longitudinal quantitative research, conducted at the outpatient infusion and enzyme replacement therapy center of a reference Hospital for the treatment of rare diseases, located in Rio de Janeiro – Brazil. Participated in the study: Six children and adolescents of both sexes between 9 years and 6 months and 16 years and 4 months of age, with type I, IV-A and VI MPS, with biochemical diagnosis of MPS that are treated with enzyme replacement in the institution’s medical genetics department. Were excluded from this research: Individuals with type III MPS because of neurological impairment; children and adolescents who had severe cognitive and / or motor impairment that prevented them from responding to assessments; and children and adolescents who reached the maximum PEDI score. For data collection, the Pediatric Disability Assessment Inventory – PEDI was used, only Part I – Child Abilities, which reports on the child’s functional abilities to perform daily activities and tasks and on the self-care scale [10] and, then, the Canadian Occupational Performance Measure – COPM was applied.

The PEDI was applied through a structured interview with children and adolescents, lasting on average 30 to 40 minutes, where it was identified if individuals can perform certain activities. The COPM was administered in around 10–15 minutes, with participants identifying issues related to their occupational performance related to the activities contained in PEDI. They chose the activities that were meaningful to them, quantifying the degree of satisfaction and importance they attributed to each of the activities. At the end of the application of the instruments, it was made a survey from the chosen activities (the activity that obtained the highest importance score in the COPM) and the possible assistive technology resources to be incorporated in the intervention process of the activity that gained the most quantification, by the participants, including from creating and building a low-cost TA resource to providing guidance to follow during activities performance. With the AT done, its use was trained with the participants and the responsible person accompanying them by the main researcher and after the participant’s minimum 2 weeks of AT use, the COPM was reapplied to assess if there were changes in occupational performance with the aid of the AT. This reapplication was made by a blinded evaluator who had no prior knowledge of previous results.

The COPM was created as an outcome measure, therefore, the total scores of the initial moment and the moment of re-evaluation were used with the objective of comparing the occurrence or not of changes in occupational performance and satisfaction, so it could be proved the effectiveness of an approach or intervention – in this case, the use of Assistive Technology. These changes were calculated by subtracting the evaluation values from the re-evaluation values, both for performance and satisfaction. The participants’ scores were not compared with each other, as COPM is an individual measure. With the completion of research data collection, the assistive technology resource made and/or adapted for each participant remained the same for continuous use. This study is part of a project approved by the Research Ethics Committee of the research site, under the number 1.827.932, valid until 31/10/2021, complying with the ethical principles in accordance with resolution 466/2012, and all participants were informed about the study, objectives, benefits and risks.

Results

From PEDI results we observed impacts on occupational performance, which consequently affects the ability to perform self-care tasks, especially in dressing, personal hygiene and bathing activities, as can be seen in Table 1. The changes in self-care activities observed from PEDI, participants chose the activities that were most significant through COPM, adding a value about it, to quantify its importance in performing it on a daily basis or wanting to execute it. Table 2 shows the chosen activities, the degree of importance and the AT made. It is noted that the activities varied, related to dressing or personal hygiene.

Table 1. Affected items grouped by tasks performed in PEDI self-care.

Participant

ITEMS AFFECTED

Feeding (14)*

Personal hygiene (14)*

Bathing (10)*

Dressing (20)*

Toilet use (5)*

Sphincter control (10)*

1

12

2

2

2

5

2

3

2

2

1

12

1

4

5

11

5

4

9

6

2

4

3

12

2

*:  Number of items contained in each self-care task according to PEDI.

Table 2. Description of activities, importance given by participants – COPM and AT made

Participant

MPS

Activities chosen at COPM

Grau de importância

AT

1

II

Put on socks

9

Sock on Applicator

2

IV-A

Brush hair

9

Hair brush with L-form

3

IV-A

Remove socks

8

Stretch cable to remove socks

4

VI

Put on socks

10

Sock on Applicator

5

VI

Wear lower end (buttoning and zipper handling)

9

Buttoning

6

VI

Dress upper and lower extremity (buttoning and zipper handling)

8

Buttoning

After making and training the ATs, Table 3 presents the changes in occupational performance and satisfaction in performing the selected tasks. The improvement of these two parameters was observed throughout the sample. However, it was observed that it was not possible to infer changes in two cases (participant 4 and participant 6), because they did not use the AT after training: participant 4 started training at home, but didn’t feel willing to keep using the AT, preferring that his mother did the activity for him; and participant 6, did not use, because he did not wear clothes that have button or zipper at home, only using to go out and preferring that his mother performed the activity.

Table 3. Importance / Performance / Satisfaction Relationship – Before and after the application of AT and observed changes

Participant/ MPS

Activity

Importance

Initial Evaluation

Revaluation

Change

Performance 1

Satisfaction 1

Performance  2

Satisfaction  2

Performance

Satisfaction

1 (type II)

Put on socks

9

2

2

5

8

3

6

2 (type  IV)

Brush hair

9

5

3

10

10

5

7

3 (type  IV)

Remove socks

8

2

4

4

7

2

3

4 (type  VI)

Put on socks

10

1

5

*

*

*

*

5 (type  VI)

buttoning and zipper handling

9

2

5

10

10

8

5

6 (type VI)

buttoning and zipper handling

8

3

5

*

*

*

*

Note: *: Data were not obtained as the participant reported not using the AT

Discussion

Children and adolescents with MPS, the limitation of mobility caused by the accumulation of glycosaminoglycans in tissues and joints, causes a loss in the ability to perform occupational activities, especially related to activities of daily living (ADLs), especially those requiring fine movements (eg: buttoning) or of large amplitudes (brush hair) [11–15]. It is widely discussed in the literature that progressive musculoskeletal impairment, found regardless of the type of MPS, impacts occupational performance. Studies show that joint stiffness, common in MPS, and even MPS IV-A-specific ligament laxity and muscle weakness, as well as carpal tunnel syndrome and Dupuytren’s contractures, all contribute to important limitation in self-care activities such as eating, dressing and personal hygiene [14, 16,17,18]. From the knowledge of body structure and function deficiencies related to self-care activities, it is possible to establish intervention priorities and select better strategies to be used, in order to enhance occupational performance. Among the intervention strategies, AT is a possibility of occupational therapist resource for the promotion of functionality [10].

Although the entire sample showed impairment in the area of dressing, the choices of tasks for making the AT were diverse and did not show a pattern by MPS type. This is because each individual sees itself in a way, and different activities may be a priority for one but not to the other. The activities that a person chooses to engage in are full of meaning and purpose and are related to their roles and how they relate to the world/environment [19], and therefore each individual attaches meaning and importance to each task of your day to day, like doing one activity is more important than performing another. With the application of COPM, besides allowing the choices of self-care activities that are significant for individuals, it was possible to measure the importance of the activity and quantify its performance and satisfaction. This is because according to the COPM theory was developed occupational performance is viewed as a subjective individual experience [20].

As much as it is not possible to make inferences between participants and their scores, it is possible to say that in the initial assessment of occupational performance, the average among participants was 2.5 points and in the revaluation, an improvement of the results was observed with an average of 7,25 points (minimum value of 4 and maximum of 10) There was also some improvement in the performance rate of activities, in the initial rating the group average was 4 (minimum 2 and maximum of 5) and in the revaluation the average value was 8.75 points (minimum 7 and maximum of 10). According to Carswell (2004), the variation found from 2 or more points in the COPM can be considered a clinically significant intervention [21]. That said, there was an improvement in the occupational performance of individuals with MPS, based on assistive technology, thus seeking to increase the independence of these individuals.

With these changes presented in a significant way,  it is possible to suggest that the higher the performance in performing self-care activities, the better the satisfaction in performing it, as seen in the work of Mildner et al., 2017, where the use of AT was described as significant in another health condition [22]. According to Persson et al. (2014) changes in occupational performance are associated with changes in psychosocial functioning and psychological well-being of individuals [23]. Regarding the non-use or abandonment of AT devices by users (occurred with two participants), Costa and collaborators (2015) conducted a literature review on the reasons that led individuals to abandon their resources. The most quoted factors were: problems with the user’s physical state; lack of information and training from both professionals and users; pain; functional limitations; preference for another resource or use of remaining capacities [24]. Among the factors mentioned, only the “preference of using remaining capacities” was found in this paper. In addition to this factor it was also quoted “lack of user motivation” and “lack of device functionality”.

Regarding AT, social acceptance is an important variable that permeates the decision of the user or his family to use the resource, because even if a certain resource improves the quality of life and occupational performance, but represents a negative social connotation and stigmatizing, the user tends to abandon it. If there is no support or encouragement from family members or if the device is viewed as a validation of being sick/being different (by the individual or family members) the chances of abandonment may be high [24–26].

Conclusion

AT has become an importante occupation therapeutic resource for children and adolescentes with problems in performing activities of daily living, such as MPS, increasing their autonomy and personal satisfaction. Thus, we highlight the importance of investing in future research in AT field focusing on occupational performance, especially self-care of individuals with MPS to then guide the intervention and occupational therapeutic care.

References

  1. Guarany NR, Schwartz IVD, Guarany FC, Giugliani R (2012) Functional capacity evaluation of patients with Mucopolysaccharidosis. J Pediatr Rehabil Med  1: 37–49.
  2. Nussbaum RL, Mcinnes RR, Willard HF (2008) Thompson e Thompson Genética médica, 7º edição. Saunders, Elsevier.
  3. Schwart, IVD, Boy R (2011) As doenças lisossômicas e tratamento das mucopolissacaridoses. Rev do Hosp Univ Ped Ernest 2.
  4. Silva MCA, Horovitz DDG, Ribeiro CTM (2015) Desempenho ocupacional de crianças e adolescentes com mucopolissacaridose de uma instituição de saúde do município do Rio de Janeiro [dissertação de mestrado]. Rio de Janeiro.
  5. Magalhães LC, Magalhães LV, Cardoso, AA (2009) Medida Canadense de Desempenho Ocupacional – COPM. Belo Horizonte: Editora UFMG.
  6. Barata-Assad DA, Elui VMC (2010) Limitações no desempenho ocupacional de indivíduos portadores de hemofilia em centro regional de hemoterapia de Ribeiro Preto, Brasil. Rev. Ter. Ocup. São Paulo 3: 198–206.
  7. Anson D. (2004) Tecnologia assistiva. In: Pedretti LW, Early MB. Terapia Ocupacional: Capacidades práticas para as disfunções físicas. Quinta edição. São Paulo: Roca P. 276–296
  8. Rodrigues AC (2008) Reabilitação: Tecnologia Assistiva. In: Rodrigues, AC. Reabilitação. Práticas inclusivas e estratégias para a ação.  São Paulo: Livraria e Editora Andreoli p. 39–41.
  9. Sfredo Y, Silva RCR. (2013) Terapia Ocupacional e o uso de tecnologia assistiva como recurso terapêutico na artrogripose. Cad Ter Ocup. UFSCar 3: 479 – 491.
  10. Mancini, MC (2005) Inventário de Avaliação Pediátrica de Incapacidade (PEDI): Manual da versão brasileira adaptada. Belo Horizonte; UFMG.
  11. Rocha JSM, Bonorandi AD, Oliveira LS, Silva MNS, Silva, VF (2012) Avaliação do desempenho motor em crianças com mucopolissacaridose II. Cad Ter Ocup UFSCar 2012 20(3): 403–12.
  12. Amaral IABS, Filho RLO; Neto JAR, Reis MCS. Avaliação da capacidade funcional de adolescentes portadores de Mucopolissacaridose do tipo II. Cad Bras Ter Ocup, São Carlos. 2017; 25(2): 297–303.
  13. Schwart, IVD; Boy, R. (2011) Às doenças lisossômicas e tratamento das mucopolissacaridoses. Rev do Hosp Univ Ped Ernest 2.
  14. Santos AC, Azevedo ACMM, Fagondes S, Burin MG, Giugliani R, Schwartz IVD (2008) Mucopolysaccharidosis type VI (Maroteaux-Lamy syndrome): assessment of joint mobility and grip and pinch strength. Jorn de Ped 2: 130–5.
  15. Pinto LLC, Schwartz IVD, Puga ACS, Vieira TA, Munoz MVR, Giugliani R, et al. (2006) Prospective study of 11 Brazilian patients with mucopolysaccharidosis II. Jornal de Ped 4: 273–8
  16. Vieira TA, Giugliani R, Schwartz I (2007) História natural das mucopolissacaridoses: Uma investigação da trajetória dos pacientes desde o nascimento até o diagnóstico. [dissertação de mestrado] [online]. Universidade Federal do Rio Grande do Sul, Porto Alegre.
  17. Viapina M, Burin MG, Wilke M, Schwartz IVD (2011) Síndrome de Morquio – Mucopolissacaridose IV-A. Serviço de Genética Médica – Hospital de Clínicas de Porto Alegre.
  18. Azevedo ACMM, Giugliani R (2004) Estudo clínico e bioquímico de 28 pacientes com MPS tipo VI. [Dissertação de mestrado]. Universidade Federal do Rio Grande do Sul; Porto Alegre.
  19. Pelosi, MB (2009) Tecnologias em comunicação alternativa sob o enfoque da terapia ocupacional. In: Deliberato D.; Gonçalves MJ; Macedo EC (Org.). Comunicação alternativa: teoria, prática, tecnologias e pesquisa. São Paulo: Memnon Edições Científicasp 163–173.
  20. Andolfato C, Mariotti MC (2009) Avaliação do paciente em hemodiálise por meio da medida canadense de desempenho ocupacional. Rev Ter Ocup Univ São Paulo 1: 1–7.
  21. Carswell A, Mccoll MA, Baptiste S, Law M, Polatajko HL, Pollock N (2004) The Canadian occupational performance measure: a research and clinical literature review. Can Jour Occup Ther 4: 210–222.
  22. Mildner AR, Ponte AS, Pommerehn J, Estivalet KM, Duarte BSL, Delboni MCC. Desempenho ocupacional de pessoas hemiplégicas pós-avc a partir do uso de tecnologias assistivas.
  23. Persson E (2014) Occupational performance and factors associated with outcomes in patients participating in a musculoskeletal pain rehabilitation programme. J Rehabil Med. Uppsala 46: 546–552.
  24. Costa CR, Ferreira FMRM, Bortolus MV, Carvalho MGR (2015) Dispositivos de tecnologia assistiva: fatores relacionados ao abandono. Cad. Ter. Ocup. UFSCar, São Carlos 3: 611–624.
  25. Kruger, JM; Ferreira, AR (2013) Aplicação da Tecnologia Assistiva para o desenvolvimento de uma classe ajustável para cadeirantes. Iberoamerican Journal of Industrial Engineering. Florianópolis 9: 43–69.
  26. Zelia ZLC, Bittencourt DC, Cheraid RC, Montilha, Elisabete RF (2016) Expectativas quanto ao uso de tecnologia assistiva. Journal of Research in Special Educational Needs 1: 492–496

Thoughts at a White Coat Ceremony

 

The first documented White Coat Ceremony was held 10 years after I entered medical school. Dr. Arnold P. Gold held his first White Coat Ceremony four years after that [1]. White Coat Ceremonies have spread throughout US medical schools and even internationally [2,3], largely through the support of the foundation established by Dr. Gold, his family and his colleagues [3]. I confess that when I first heard of these events sometime in the mid to late 1990s, the idea of presenting a white coat to entering medical students in a ceremony so that they would understand that they are beginning their entry into a profession, reminded me of an old Monty Python sketch. A middle-aged man with spectacles (not unlike me) goes into an employment office and asks if there are any job openings for a lion tamer. When asked about his qualifications, he pulls out a pith helmet and says, “I’ve got the hat”.

After I began attending White Coat Ceremonies in 2011, I realized my flippant initial reaction was unjust. I have come to appreciate White Coat Ceremonies as an opportunity for helping new students understand and embrace the values of the medical profession, with the white coat as a symbol of those values. Of course, the holistic admissions practices of most medical schools, at least in the US, aim to ensure that matriculated students possess many of the underlying humanistic qualities desired in physicians; and certainly, the students should understand that ultimately what makes one a physician is not the white coat but the person who is inside it.

However, even the apparently innocuous activity of the White Coat Ceremony has generated controversy. There was always some debate about the timing of the ceremony in the process of education: some schools would hold their ceremony at matriculation, while others might schedule it at the point in the curriculum where students shift from their preclinical studies to working in the clinics and wards. As earlier clinical exposure becomes more common, it is likely that White Coat Ceremonies held in the end of the second year of medical school will shift earlier in the educational process. More significant controversies revolve around the purpose and symbolism of the White Coat Ceremony itself.

For Dr. Arnold Gold, it seems clear that there was no intrinsic conflict between “humanism” and medical “professionalism” and the White Coat Ceremony represented both [3]. This perspective was certainly that held by physicians of his generation [4], and certainly is an aspirational goal even now. Even early in their history, White Coat Ceremonies were recognized as a tool for inculcating and teaching professionalism [5]. More recent commentators have argued that humanism, defined by values that are egalitarian and universal, has become distinct from professionalism, which may be parochial and culturally determined, and to at least some degree, self-interested [6]. It has also been suggested that the White Coat Ceremony is a defensive action by the medical profession, symbolizing a claim of entitlement in a world where physician leadership of healthcare is challenged [7]. Perhaps reflecting these perceived conflicts is a model in which a “profession-entry” ceremony is held early in the first year followed by a later “humanistic” ceremony including individual statements of values, a high level of student engagement, and artistic performances [2]. Most White Coat Ceremonies include recitation of some sort of commitment or oath: the meaning and appropriateness of such recitations has also been debated [8,9].

The widely discussed issue of physician burnout engages the issues reflected in debates about the appropriateness and meaning of White Coat Ceremonies. Challenges to the autonomy of the medical profession are not only of a financial or administrative nature, but also reflect challenges to the humanistic expectations of patient centeredness and empathy. For that reason, it has been suggested that the term “burnout” should be replaced by the term “moral injury” [10].

When I discuss these issues with students, either individually or in small group learning settings, I emphasize that medicine is one of the professions as traditionally defined. More specifically, it is one of the three characterized as “learned professions”. Medicine is also a vocation, or if one prefers, a “calling”. The word “vocation” derives from the same Latin root as “vocal”. It refers to something to which one is called or summoned, and accepting the call implies a commitment with attendant obligations. For medicine, the commitment is to the service of the patient. For each of us, the obligation is for that service always to reflect our best, with a further obligation that through lifelong learning we will strive to ensure that the gap between our best and the ever-shifting target of “THE best” is always small as circumstances permit. The White Coat Ceremony and the acceptance by a student of her or his first white coat symbolize recognition that they are beginning the path to that commitment and to the obligations that follow from it.

In thinking about these issues, I am reminded of things other than Monty Python. When I was in college, the US Navy ran a series of recruiting commercials with the tagline “It’s not a job, it’s an adventure”. Medicine is not just a job: it is a profession, a calling, a commitment. However, a lot of us believe it is also an adventure [11].

Adapted from remarks made at the James H. Quillen College of Medicine Class of 2022 White Coat Ceremony – July 20, 2018.  Dr. Means is a former dean of the College

The White Coat Ceremony was supported in part by the Arnold P. Gold Foundation.

References

  1. Gold A, Gold S (2006) Humanism in medicine from the perspective of the Arnold Gold Foundation: challenges to maintaining the care in health care. Journal of child neurology 21: 546–549.
  2. Tamai R, Koyawala N, Dietrick B, Pain D, Shochet R (2019) Cloaking as a community: re-imagining the White Coat Ceremony with a medical school learning community. J Med Educ Curric Dev 6: 2382120519830375.
  3. Kavan MG (2009) The White Coat Ceremony: a tribute to the humanism of Arnold P. Gold. Journal of child neurology 24: 1051–1052.
  4. Lepore MJ (1982) Death of the Clinician: Requiem Or Reveille? Springfield, IL USA: Charles C. Thomas; 1982.
  5. Swick HM, Szenas P, Danoff D, Whitcomb ME (1999) Teaching professionalism in undergraduate medical education. Jama 282: 830–832.
  6. Goldberg JL (2008) Humanism or professionalism? The White Coat Ceremony and medical education. Academic Medicine: Journal of the Association of American Medical Colleges 83: 715–722.
  7. Russell PC (2002) The White Coat Ceremony: turning trust into entitlement. Teaching and learning in medicine 14: 56–59.
  8. Huber SJ (2003) The White Coat Ceremony: a contemporary medical ritual. Journal of medical ethics. 29: 364–366.
  9. Veatch RM (2002) White coat ceremonies: a second opinion. Journal of medical ethics. 28: 5–9.
  10. Heston TF (2019) Pahang JA. Moral Injury or Burnout? South Med J 112: 483.
  11. Robinson GC (1957) Adventures in Medical Education. A Personal Narrative of the Great Advance of American Medicine. Cambridge: Commonwealth Fund 1957.

Blood Transfusion Guided by Physiological Markers

Abstract

Introduction: For decades, intraoperative anemia has been treated with red blood cell transfusions since it was believed that oxygen supply would increase by increasing hemoglobin levels. There is evidence that blood transfusion is associated with adverse events and should be avoid as much as possible. For this purpose, it is essential to know the compensatory physiological mechanisms during anemia. Venous oxygen saturation is a clinical tool that integrates the relationship between oxygen intake and consumption, which is easy to obtain once a central venous catheter, is available.

Material and methods: A longitudinal, prospective, observational study was conducted which included patients schedule for elective or emergency procedures that, due to their clinical conditions, had a central venous catheter. A sample of venous blood was taken from the central venous catheter and sent to the laboratory for gasometry. The results were correlated with the clinical status and vital signs of the patient. The following variables were evaluated: vital signs, hemoglobin, and hematocrit and oxygen saturation before and after transfusion.

Results: 34 patients were evaluated with an average age of 52 years. 58.8% was transfused. Despite the transfusion and variations of hemoglobin, the SaO2 in the pulse oximeter remained without changes pre and post transfusion. In gasometry, a difference between hemoglobin and initial hematocrit and pre-transfusion was observed, this due to bleeding that occurred. No differences in SaO2 values were observed for pre-transfusion vs post-transfusion pulse oximetry.

Conclusions: We found no evidence to support the linear correlation of ScvO2 with the hemoglobin levels, there is great variability of ScvO2 at different hemoglobin level, we suggest the use of venous central saturation as a physiological marker for transfusions, avoiding with this practice making decisions only with the hemoglobin levels.

Keywords

Transfusion, Oxygenation, Saturation, Blood, Hemoglobin, Catheter

Introduction

For decades, intraoperative anemia has been treated with red blood cell transfusions based on the concept that the oxygen supply to the tissues is increased by increasing hemoglobin levels. Likewise, arbitrary transfusion rules such as the “10/30 rule” have been used indicating that the transfusion of erythrocyte concentrates is required when the hemoglobin concentration is less than 10g / dl or the hematocrit decreases by 30% [1]. There is evidence that blood transfusion is associated with adverse events, so it should be avoided as much as possible [1–3]. For this purpose, it is essential to know the compensatory physiological mechanisms during anemia. The main function of red blood cells is the transport of oxygen from the pulmonary capillaries to the peripherals. The oxygen delivery (DO2) is defined as the product of cardiac output (CO) and arterial oxygen concentration (CaO2). DO2 = CO × CaO2 where DO2 is expressed in mL/min, CO in dL/min, and CaO2 in mL/dL.

The arterial oxygen concentration can be defined with the following formula: CaO2 = (SaO2 × 1.34 × Hb) + (0.0031 × PaO2)

Where SaO2 is the arterial saturation (in %), 1.34 is the amount of oxygen carried on the hemoglobin (in mL/g), Hb represents the hemoglobin level (in g/dL), 0.0031 is the solubility coefficient of oxygen in human plasma at 37°C (in mL/dL*mmHg) and PaO2 the arterial tension measure in mmHg. From this equation, we can infer that to maintain the tissue oxygen supply the organism must adjust some variables such as: Hb, CO, oxygen consumption (VO2) and SaO2. The ratio of oxygen consumption (VO2) to oxygen delivery (DO2) is defined as “Oxygen extraction ratio” (O2ER) in normal circumstances the normal range is from 20–30% because the DO2 (800- 1200 mL/min) exceeds VO2 (200–300 mL/min) three to five times. In this way the hemoglobin concentration and the oxygen delivery (DO2) can decrease significantly without affecting the oxygen consumption, which makes it independent of DO2 [4,5].

However, below a critical threshold of hemoglobin concentration (HbCRIT) and critical oxygen delivery (DO2 CRIT), a level of VO2 / DO2 dependence is reached. This means that below this threshold any decrease in DO2 or Hb also results in a decrease in VO2 and therefore in tissue hypoxia. Venous oxygen saturation is a clinical tool that integrates the relationship between the intake and oxygen consumption in the body, in absence of a mixed venous saturation sample (SvO2) obtained through a pulmonary arterial catheter, central venous oxygen saturation (SvcO2) is being used as an accurate substitute. Central venous catheters are simpler to insert, safer and cheaper than pulmonary artery catheters [6].

By means of a central venous catheter, it is possible to take blood samples for the measurement of ScvO2, whose value ranges around 73% – 82% [6, 7]. Since, as stated, the Hb level does not guarantee an adequate tissue perfusion. Accordingly, the physiological transfusion markers should replace the arbitrary markers currently used based only on hemoglobin levels [8, 9]. In this way, we could avoid the unnecessary use of transfusions with the consequent savings in blood banks, reserving it only to those patients who really require it, avoid adverse transfusion reactions such as acute lung injury, infection transmission, among others. Transfusion guidelines should consider the individual ability of each patient to tolerate and compensate the acute decrement of hemoglobin concentration in the account that there is not a universal threshold to indicate a transfusion [10]. The markers should instead consider signs of tissue dysoxia, which may occur at different hemoglobin concentrations depending on the comorbidities of each patient. These signs may be based on signs and symptoms of inadequate oxygenation, however, before a decision is made regarding transfusion, it must be ensured that there is an adequate supply of volume with crystalloids and / or colloids and that the anesthetic management at the time is optimal. The objective of the present study was to demonstrate that physiological markers, specifically central venous saturation, are parameters that are useful to determine the use of blood transfusion

Materials and Methods

Study design and ethical aspects

A longitudinal, prospective, observational study was conducted which included patients from 18 to 60 years, of indistinct gender, who entered the operating room for any surgical procedure of any specialty in in a third level hospital. The procedures included needed to carry a risk of bleeding greater than 15–20% of the circulating blood volume and the patients that, due to its clinical conditions, required a central venous catheter. Exclusion criteria included patients who refuse to participate in the study, with active bleeding from the gastrointestinal tract, with anemia or blood dysrcrasias and hemodynamically unstable. The elimination criteria included patients in whom the history of blood dyscrasias is unknown or confirmed, patients who have some other pathological condition that alters the results and interpretation of the study, patients with active bleeding and who require an urgent blood transfusion. This protocol was submitted for evaluation to the ethics committee. Because the study was carried out only in patients who already have a central venous catheter in place, patient authorization was not required by informed consent. In the same way the patient was not intervened, since this is an observational study, only the data was collected and analyzed.

Study variables

For each patient who met the criteria a sample of venous blood was taken from the central venous catheter. The sample was then taken to the hospital’s gasometry laboratory where the study was conducted. Once the result of the sample was obtained, it was captured in a database including as variables the results of arterial gasometries, vital signs and laboratory tests that the patient will have, such as blood count and blood chemistry.

Statistical analysis

Epidemiological data such as age and sex will be obtained. The data will be analyzed with measures of central tendency such as mean, median and dispersion measures such as the standard deviation. In the bivariate analysis, it is planned to use the Shapiro-Wilk test to observe the dispersion of the data and classify it as parametric or non-parametric. Based on the results obtained, non-parametric statistical tests such as square chi for two groups and Wilcoxon were performed, given that related groups are compared. If the results obtained are parametric, tests such as Student’s T will be performed for related groups. The SPSS version 24 program was used to perform the statistical tests described above.

Results

34 patients were evaluated with an age average of 76 years (± 16 years). The average weight of the patients was 80 kg and the average size was 164 cm. 64.7% of the patients were male and 35.3% female (Table 1). 58.8% of the patients evaluated had the need to be transfused. An average of 777 cm3 of blood was transfused; the most common amount of transfused packets was two globular packages. Vital signs were evaluated with a range of 83–84 beats per minute, respiratory frequency varied from 21 breaths per minute prior the surgical procedure and an average pulse oximeter saturation of 98%. Systolic blood pressure fluctuated from 127–109 mmHg at the end of the procedure and the initial diastolic pressure was 74-mmHg compare to the 66 mmHg at the end of the procedure. (Figure 1–4). An initial mean Hb was obtained in venous gases of 8.9, pre-transfusion of 7.8 and post transfusion of 10. A statistically significant difference was observed in pre and post transfusion hemoglobin, as well as in pre and post transfusion hematocrit unlike SaO2, where there was no difference between pre-transfusion and post transfusion. In arterial gases, a statistically significant difference was found in the initial hematocrit levels and the hemoglobin levels pre transfusion, no differences were observed in SaO2 values or in any of the pre-transfusion vs. post-transfusion data (Table 2). Finally, a comparative analysis between the markets as cut- off points in the literature reviewed was made. A chi-square cross-tabulation table analysis was performed for qualitative variables, where no statistically significant differences were found in patients with indication of transfusion at the beginning of the procedure; pre-intervention and post-intervention (Table 3).

Table 1. Demographic characteristics of the patients.

Demographic data

Patients

34

Age (years)

52

Size (cm)

164 ± 11

Weight (kg)

80 ±20

Gender

Female 11 (%)

22 (64.7)

Male 11 (%)

12(35.3)

Table 2. Venous and arterial gases, pre transfusion and post transfusion.

Initial

Pre­ transfusion

P

Pre­ transfusion

Post transfusion

P

Venous Gases

Hb

8.980

7.800

0.074

7.800

10.028

0.008

Hcto

29.500

24.631

0.031

24.631

32.011

0.008

SaO2

118.35

72.94

0.198

72.94

114.50

0.683

Arterial Gases

Hb

9.970

8.893

0.035

8.93

9.817

0.239

Hcto

31.65

28.53

0.035

28.53

31.67

0.195

SaO2

99.00

98.73

0.627

98.73

98.83

0.219

Table 3. Patients with indication of transfusion at the beginning of the procedure, pre intervention and post intervention.

Venous Hb

Venous
SaO2

P

Arterial Hb

Arterial
SaO2

P

Initials

Requires transfusion

17

6

0.05

19

0

*

No transfusion required

15

32

14

32

*

Pre intervention

Requires transfusion

17

6

0.554

15

19

*

No transfusion required

2

13

4

15

Post intervention

Requires transfusion

12

9

0.056

13

21

0.05

No transfusion required

10

12

8

13

* The variables evaluated are constant, so there is no statistically significant difference.

IMROJ 19 - 141_Rodriguez Dominguez_f1

Figure 1. Average Hear Rate.

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Figure 2. Average Breathing Rate.

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Figure 3. Average Systolic Pressure.

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Figure 4. Average Diastolic Pressure.

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Figure 5. Average Arterial Oxygen Saturation.

Discussion

Based on the considerations above, the present investigation was carried out, with the aim of demonstrating, within our institution and in the operating room environment, the need to take other considerations in addition to a laboratory value when indicating a transfusion. The transfusion of erythrocyte concentrates is a very common practice within the operating room, it is very important for those who are responsible for carrying out this work to have deep knowledge about the physiology and biochemistry involved in the oxygenation process. This in order to achieve the main objective of hemotransfusion, without neglecting the other two variables that the blood influences, which are the rheological and volume effect [11, 12].

Unfortunately, routinely monitored variables such as blood pressure, heart rate, urine output, arterial gases and filling pressures do not necessarily reflect tissue perfusion. The mixed venous saturation (SvO2) and central venous oxygen saturation (SvcO2) are better indicators of oxygen delivery (DO2) and perfusion [13, 14]. The hemoglobin value has been considered as the determinant to indicate blood transfusion for many years. Although there are guides from different associations and different countries that provide us with great support when deciding if it is necessary to administer blood components to our patients, we propose that we also seek the support of physiological variables and markers when making this important decision. Taking into consideration that nowadays, at an international level, the transfusion of blood components cannot yet be performed without a residual risk [15,16].

The appropriate use of blood components should be promoted, avoiding abuse, by developing medical guidelines for therapeutic use by specialties based on scientific evidence. Awareness should be made of the high cost of production, the permanent existence of residual risks of infectious diseases and the possibility of causing immediate or late post-transfusion reactions in the patient [17]. Understanding the costs associated with blood products requires extensive knowledge about transfusion medicine and this is attracting not only clinicians but also administrative personnel from the health care sector worldwide. To improve both the clinical and the economic situation, the use of blood bank resources should be optimized [17–19]. Estimate the costs of storage, procurement, transfer among others is complex, however they should be minimized and used only when strictly necessary based on clinical judgment and on the use of technology and tools that allow estimating the state of patient oxygenation. With a rapid and accessible examination in many of the hospitals where surgical procedures are performed, we can obtain data about tissue oxygenation and thus be able to decide more effectively the use of blood bank resources.

Conclusion

This study does not find enough evidence to support the correlation of ScVO2 with hemoglobin, that is, there is great variability in venous saturation at different hemoglobin levels, and however, there is a tendency to increase ScvO2 after transfusion of globular packages. In the absent of a mixed venous saturation sample (SvO2) which is obtain via a Swan Ganz catheter, the central venous oxygen saturation (SvcO2) is a precise substitute and a reliable tool that integrates the relationship between the supply and consumption of oxygen in the body. By means of a central venous catheter, it is possible to take blood samples for the measurement of ScvO. We recommend that in patients who have this catheter use it to obtain a sample for gasometry and guide better decision-making regarding blood administration. There is an increase in interest in the use of mixed venous saturation and central venous saturation to guide therapeutic interventions during the intraoperative period. However, an understanding of the physiological principles and venous oximetry are essential for safe use in clinical practice. The venous oxygen saturation reflects the balance between the overall oxygen supply and its consumption, which can be affected by a large number of factors during the intraoperative period.

References

  1. Madjdpour C, Spahn DR, Weiskopf RB (2006) Anemia and perioperative red blood cell transfusion: a matter of tolerance. Crit Care Med 34: S102–108. [crossref]
  2. Vazquez Flores JA (2006) La seguridad de las reservas sanguíneas en la república mexicana. Revista de Investigación Clínica 58: 101–108.
  3. Añón JM, García de Lorenzo A, Quintana M, González E, Bruscas MJ (2010) [Transfusion-related acute lung injury]. Med Intensiva 34: 139–149. [crossref]
  4. Walley KR (2011) Use of central venous oxygen saturation to guide therapy. Am J Resp Crit Care 184(5): 514–520.
  5. Cain SM (1965) Appearance of excess lactate in anesthetized dogs during anemic and hypoxic hypoxia. Am J Physiol 209: 604–610. [crossref]
  6. Vallet B, Emmanuel Robin, Lebuffe G (2010) Venous oxygen saturation as a physiologic transfusion trigger. Critical Care 14: 213.
  7. Reinhart K, Kuhn HJ, Hartog C, Bredle DL (2004) Continuous central venous and pulmonary artery oxygen saturation monitoring in the critically ill. Intens Care Med 30: 1572–1578.
  8. Adamczyk S, Robin E, Barreau O, Fleyfel M, Tavernier B, et al. (2009) Contribution of central venous oxygen saturation in postoperative blood transfusion decision. Ann Fr Anesth 28: 522–530.
  9. Vincent JL (2012) Transfusion triggers: getting it right! Crit Care Med 40: 3308–3309. [crossref]
  10. Vallet B, Adamczyk S, Lebuffe G (2007) Physiologic transfusion triggers. Best Pract Res Clin Anaesthesiol. 21: 173–181.
  11. Colomina M, Guilabert P (2016) Transfusion according to haemoglobin levels or therapeutic objectives. Rev Esp Anestesiol Reanim 63: 65–68.
  12. Shander A, Gross I, Hill S, Javidroozi M, Sledge S (2013) A new perspective on best transfusion practices. Blood Transfus 11: 193–202.
  13. Carrillo R, Núñez J (2007) Saturación venosa central. Conceptos actuales. Rev Mex Anestesiol 30: 165–171.
  14. Cabrales P, Intaglietta M, Tsai AG (2007) Transfusion restores blood viscosity and reinstates microvascular conditions from hemorrhagic shock independent of oxygen carrying capacity. Resuscitation 75: 124–134. [crossref]
  15. Shander A, Hofmann A, Gombotz H, Theusinger OM, Spahn DR (2007) Estimating the cost of blood: past, present, and future directions. Best Pract Res Clin Anaesthesiol 21: 271–289. [crossref]
  16. Rojo J (2014) Enfermedades infecciosas transmitidas por transfusión. Panorama internacional y en México. Gac Med Mex 150: 78–83
  17. Goodnough LT (2005) Risks of blood transfusion. Anesthesiol Clin North Am 23: 241–252, [crossref].
  18. Shepherd SJ1, Pearse RM (2009) Role of central and mixed venous oxygen saturation measurement in perioperative care. Anesthesiology 111: 649–656. [crossref]
  19. Park D, Chun B, Kwon S (2012) Red blood cell transfusions are associated with lower mortality in patients with severe sepsis and septic shock: A propensity-matched analysis. Crit Care Med 40: 3140–3145.