Place attachment mediates links between pro-environmental attitudes and behaviors among visitors to Mt. Bukhan National Park, South Korea

Introduction

Efforts to understand visitors' participation in pro-environmental behaviors (PEB) are important for protected area management. Previous research in nature-based recreation settings suggests environmental attitudes may affect PEB, and that these relationships might be mediated by different dimensions of place attachment (place identity and place dependence).

Methods

We used structural equation modeling to test the mediating effect of hikers' place attachment in the relationship between environmental attitudes and PEBs that occur within (on-site) and outside a protected area (off-site): Mt. Bukhan National Park in South Korea.

Results

Results showed that cognitive (environmental knowledge) and affective (environmental sensitivity) components of environmental attitudes were significant predictors for place attachment. Place identity was linked to off-site PEB, while place dependence was a key antecedent for both off-site and on-site PEBs.

Discussion

Our findings could help researchers and practitioners better understand how place attachment forms and how it can impact outdoor recreationists' behavior, ultimately helping to promote PEBs and facilitate sustainable management goals.

Greenness and equity: Complex connections between intra-neighborhood contexts and residential tree planting implementation

Associations between neighborhood greenness and socioeconomic status (SES) are established, yet intra-neighborhood context and SES-related barriers to tree planting remain unclear. Large-scale tree planting implementation efforts are increasingly common and can improve human health, strengthen climate adaptation, and ameliorate environmental inequities. Yet, these efforts may be ineffective without in-depth understanding of local SES inequities and barriers to residential planting. We recruited 636 residents within and surrounding the Oakdale Neighborhood of Louisville, Kentucky, USA, and evaluated associations of individual and neighborhood-level sociodemographic indicators with greenness levels at multiple scales. We offered no-cost residential tree planting and maintenance to residents within a subsection of the neighborhood and examined associations of these sociodemographic indicators plus baseline greenness levels with tree planting adoption among 215 eligible participants. We observed positive associations of income with Normalized Difference Vegetation Index (NDVI) and leaf area index (LAI) within all radii around homes, and within yards of residents, that varied in strength. There were stronger associations of income with NDVI in front yards but LAI in back yards. Among Participants of Color, associations between income and NDVI were stronger than with Whites and exhibited no association with LAI. Tree planting uptake was not associated with income, education, race, nor employment status, but was positively associated with lot size, home value, lower population density, and area greenness. Our findings reveal significant complexity of intra-neighborhood associations between SES and greenness that could help shape future research and equitable greening implementation. Results show that previously documented links between SES and greenspace at large scales extend to residents' yards, highlighting opportunities to redress greenness inequities on private property. Our analysis found that uptake of no-cost residential planting and maintenance was nearly equal across SES groups but did not redress greenness inequity. To inform equitable greening, further research is needed to evaluate culture, norms, perceptions, and values affecting tree planting acceptance among low-SES residents.

Beyond "bluespace" and "greenspace": A narrative review of possible health benefits from exposure to other natural landscapes

Numerous studies have highlighted the physical and mental health benefits of contact with nature, typically in landscapes characterized by plants (i.e., "greenspace") and water (i.e., "bluespace"). However, natural landscapes are not always green or blue, and the effects of other landscapes are worth attention. This narrative review attempts to overcome this limitation of past research. Rather than focusing on colors, we propose that natural landscapes are composed of at least one of three components: (1) plants (e.g., trees, flowering plants, grasses, sedges, mosses, ferns, and algae), (2) water (e.g., rivers, canals, lakes, and oceans), and/or (3) rocks and minerals, including soil. Landscapes not dominated by plants or liquid-state water include those with abundant solid-state water (e.g., polar spaces) and rocks or minerals (e.g., deserts and caves). Possible health benefits of solid-state water or rock/mineral dominated landscapes include both shorter-term (e.g., viewing images) and longer-term (e.g., living in these landscapes) exposure durations. Reported benefits span improved emotional and mental states and medical treatment resources for respiratory conditions and allergies. Mechanisms underlying the health benefits of exposure consist of commonly discussed theories in the "greenspace" and "bluespace" literature (i.e., instoration and restoration) as well as less discussed pathways in that literature (i.e., post-traumatic growth, self-determination, supportive environment theory, and place attachment). This is the first review to draw attention to the potential salutogenic value of natural landscapes beyond "greenspace" and "bluespace." It is also among the first to highlight the limitations and confusion that result from classifying natural landscapes using color. Since the extant literature on natural landscapes - beyond those with abundant plants or liquid-state water - is limited in regard to quantity and quality, additional research is needed to understand their restorative potential and therapeutic possibilities.

Correlates of stress are interactive and not unidimensional: Evidence from U.S. college students early in the COVID-19 pandemic

Studies have investigated various aspects of how the COVID-19 pandemic has impacted college students' well-being. However, the complex relationships between stress and its correlates have received limited attention. Thus, the main objective of this study is to evaluate multiplicative associations between stress and demographic, lifestyle, and other negative emotion factors during the pandemic. We used data from a survey with 2,534 students enrolled in seven U.S. universities and analyzed such data with generalized additive Tobit models and pairwise interaction terms. The results highlighted associations and interactions between myriad factors such as students' social class, income, parental education, body mass index (BMI), amount of exercise, and knowing infected people in the student's communities. For instance, we found that the associations between feeling irritable and sad due to the pandemic were interactive, resulting in higher associated stress for students with higher levels of parents' education. Furthermore, associations between taking precautionary actions (i.e., avoiding travel and large gatherings) and stress varied with the intensity of negative feelings (i.e., sadness and irritability). Considering these interaction terms, the results highlighted a great inequality in pandemic-related stress within low income, lower social class, and higher BMI students. This study is among the earliest that employed a stratified approach with numerous interaction terms to better understand the multiplicative associations between different factors during the COVID-19 pandemic.

Factors associated with human tolerance of snakes in the southeastern United States

Conservation of snakes is influenced by humans’ beliefs, attitudes, and behaviors toward these often-maligned animals. We investigated public attitudes toward snakes through an online survey of undergraduate students (n = 743) at a large public university in a southeastern U.S. state. We used behavioral intent (i.e., how a person would react if they encountered a snake) to assess tolerance of different snake species. We also examined various predictors of tolerance including demographic attributes and a variety of cognitive (e.g., knowledge, value orientations) and affective (e.g., emotions) social-psychological variables. Tolerance of snakes varied based on whether the snake was venomous or non-venomous: about 36% of students said they were likely to kill venomous snakes they encountered, compared with 9% who said they would kill non-venomous snakes and 21% of students who said they would kill snakes whose identity was uncertain. However, most students (54%) could not distinguish between venomous and non-venomous species. Value orientations and emotions were strong predictors of tolerance for snakes, suggesting snake outreach and management strategies should account for both cognitive and affective antecedents of behavior.

The complex relationship between greenspace and well-being in children with and without autism

Greenspace (defined here as canopy coverage) positively correlates with improved well-being in typically developing individuals, but this relationship has not been established in children with autism spectrum disorder (ASD). To investigate this relationship, the current study merged data from the National Survey of Children's Health (2012) with the National Land Cover Database. Across typically developing children, children with ASD, and non-autistic children with special healthcare needs (CSHCN), greenspace unexpectedly negatively correlated with well-being. Further, compared with typically developing children, children with ASD or CSHCN status had lower well-being. Interestingly, typically developing children with conduct problems displayed an unexpected negative relationship (i.e. as greenspace increased whereas well-being decreased), though those without conduct problems showed no relationship. Children with ASD displayed no relationship between greenspace independent of conduct problems. CSHCN displayed non-significant trends suggesting mild positive relationships between greenspace and well-being. These data indicate the relationship between greenspace and well-being is more complex than expected and may depend on the diagnostic traits of the population studied.

Self-reported participation in outdoor and nature-based recreation before and during the COVID-19 pandemic supports psychological health and well-being

Restrictions associated with the COVID-19 pandemic significantly altered daily lives and affected human health and well-being. Outdoor and nature-based activities could potentially mitigate some of these negative impacts. To assess the impact of the COVID-19 pandemic on outdoor recreation and subjective well-being, we combined two samples of U.S. adults collected from April 30^th - June 15^th, 2020 and from August 7^th - August 26^th, 2020 (total n = 2178) using Qualtrics XM. During the pandemic, participation in outdoor activities declined by 35%, participation in nature-based activities declined by 33%, and subjective well-being declined by 24%. Participation in outdoor activities and nature activities prior to the pandemic and during the pandemic predicted smaller declines in subjective well-being. Results highlight the importance of outdoor recreation for building resilience to changes in subjective well-being before and during global crises like the COVID-19 pandemic.

Citizen Science as an Ecosystem of Engagement: Implications for Learning and Broadening Participation

The bulk of research on citizen science participants is project centric, based on an assumption that volunteers experience a single project. Contrary to this assumption, survey responses (n = 3894) and digital trace data (n = 3649) from volunteers, who collectively engaged in 1126 unique projects, revealed that multiproject participation was the norm. Only 23% of volunteers were singletons (who participated in only one project). The remaining multiproject participants were split evenly between discipline specialists (39%) and discipline spanners (38% joined projects with different disciplinary topics) and unevenly between mode specialists (52%) and mode spanners (25% participated in online and offline projects). Public engagement was narrow: The multiproject participants were eight times more likely to be White and five times more likely to hold advanced degrees than the general population. We propose a volunteer-centric framework that explores how the dynamic accumulation of experiences in a project ecosystem can support broad learning objectives and inclusive citizen science.

"Messy transitions": Students' perspectives on the impacts of the COVID-19 pandemic on higher education

The COVID-19 pandemic affected every area of students' lives, especially their education. Limited research has explored students' experiences during the pandemic. This study documents how students across seven United States universities viewed the impact of the COVID-19 pandemic on their educational experiences and how these students reacted to these impacts. We present qualitative data from an online survey conducted between March and May 2020 that resulted in 1267 respondents with relevant data. Conventional content analysis with an inductive approach was used to analyze open-ended responses to the question, "We are interested in the ways that the coronavirus (COVID-19) pandemic has changed how you feel and behave. What are the first three ways that come to mind?" Six categories emerged from the data: changes in instruction delivery mode, changes in schedule and everyday life, increased technology use, decreased academic opportunities and resources, negative reaction to the changes in higher education, and positive reactions to changes in higher education. Among our recommendations for practice are personalized approaches to material delivery and evaluation, synchronous classes and opportunities to connect with professors and students, and convenient support services.

Greenspace and park use associated with less emotional distress among college students in the United States during the COVID-19 pandemic

The COVID-19 pandemic has negatively affected many people's psychological health. Impacts may be particularly severe among socially vulnerable populations such as college students, a group predisposed to mental health problems. Outdoor recreation and visits to greenspaces such as parks offer promising pathways for addressing the mental health challenges associated with COVID-19. During the early stages of the pandemic (March-May 2020), we surveyed 1280 college students at four large public universities across the United States (U.S.) to assess how, and why, outdoor recreation and park use changed since the emergence of COVID-19. We also measured students' self-reported levels of emotional distress (a proxy for psychological health) and assessed potential demographic and contextual correlates of distress, including county-level per capita park area and greenness, using generalized linear models. We found that 67% of students reported limiting outdoor activities and 54% reported reducing park use during the pandemic. Students who reduced their use of outdoor spaces cited structural reasons (e.g., lockdowns), concerns about viral transmission, and negative emotions that obstructed active lifestyles. Students who maintained pre-pandemic park use levels expressed a desire to be outdoors in nature, often with the explicit goal of improving mental and physical health. Emotional distress among students was widespread. Models showed higher levels of emotional distress were associated with reducing park use during the pandemic and residing in counties with a smaller area of parks per capita. This study of U.S. college students supports the value of park-based recreation as a health promotion strategy for diverse populations of young adults during a time of crisis.

Political polarization of conservation issues in the era of COVID-19: An examination of partisan perspectives and priorities in the United States

As a zoonotic disease with unprecedented global impacts, COVID-19 may influence how people prioritize issues related to wildlife conservation. Using a nationally representative sample of US residents, we investigated: (1) how COVID-19 affected the relative importance of conservation issues among adults with different political ideologies, and (2) how the pandemic affected political polarization of conservation issues during the 2020 general election in the United States. Conservation issues such as endangered species and controlling zoonotic disease ranked low in importance among the 14 policy issues considered, even lower than environmental issues such as climate change and environmental protection; however, the importance of all conservation issues increased as a result of COVID-19. Political polarization surrounding the perceived importance of conservation issues also increased during the COVID-19 pandemic, with Democrats reporting larger increases in importance than Republicans. Polarization was driven by the most conservative Republicans and the most liberal Democrats. But this polarization was less extreme than it was for other issues such as climate change and healthcare. Findings highlight the need for communicating links between zoonotic disease and human interactions with wildlife and the environment. Acting quickly may be critical in areas where conservation issues are primed to succumb to political polarization.

Nature-based Pathways to Health Promotion: The Value of Parks and Greenspace

The built environment is a key social determinant of health. Exposure to parks and greenspace can improve physical and mental health and provide other benefits that enhance well-being. Programs and initiatives that capitalize on nature-based opportunities offer health care providers with a cost-effective alternative for upstream health promotion.

Citizen science as a tool for enhancing recreation research in protected areas: Applications and opportunities

As the popularity of nature-based recreation and tourism grows, protected area (PA) managers around the world are faced with escalating monitoring and management challenges across spatial and temporal scales. Citizen science, an emerging research approach which involves active public participation and collaboration with scientists in the scientific process, is an innovative tool that could help managers address these challenges. This study applied the Preferred Reporting Items for Systematic Review Recommendations (PRISMA) protocol to review published studies that utilized citizen science methods in recreation research, examining the extent and nature of such applications and identifying future opportunities. We identified 20 peer-reviewed journal articles from the Web of Science, most of which were published since 2015. These studies utilized different citizen science approaches to examine recreation patterns, behaviors, and impacts in terrestrial and marine PAs. We found that citizen science was used most often in marine PAs, with specialized recreationists (e.g., SCUBA divers) as the most frequent contributors. The types of volunteers recruited differed by their sources (i.e., general public, recreation specialists, and organizational affiliates) and roles (i.e., volunteers as agents of data collection and volunteers as research subjects), with innovative technology (e.g., participatory GIS) creating new engagement opportunities. Despite these benefits, the accuracy and reliability of citizen science data remain important considerations for managers. Our review demonstrates how citizen science can inform management and enhance public participation in PA stewardship activities, and it reveals the need for more research to explore applications of citizen science in different recreation contexts.

Using Participatory System Dynamics Modeling to Address Complex Conservation Problems: Tiger Farming as a Case Study

Conservation practitioners routinely work within complex social-ecological systems to address threats facing biodiversity and to promote positive human-wildlife interactions. Inadequate understanding of the direct and indirect, short- and long-term consequences of decision making within these dynamic systems can lead to misdiagnosed problems and interventions with perverse outcomes, exacerbating conflict. Participatory system dynamics (SD) modeling is a process that encourages stakeholder engagement, synthesizes research and knowledge, increases trust and consensus and improves transdisciplinary collaboration to solve these complex types of problems. Tiger conservation exemplifies a set of interventions in a complex social-ecological system. Wild tigers remain severely threatened by various factors, including habitat constraints, human-wildlife conflict, and persistent consumer demand for their body parts. Opinions differ on whether commercial captive tiger facilities reduce or increase the threat from poaching for trade, resulting in policy conflict among diverse stakeholder groups. This paper explains how we are working with international conservation partners in a virtual environment to utilize a participatory SD modeling approach with the goal of better understanding and promoting coexistence of humans and wild tigers. We highlight a step-by-step process that others might use to apply participatory SD modeling to address similar conservation challenges, building trust and consensus among diverse partners to reduce conflict and improve the efficacy of conservation interventions.

Neighborhood Built Environment Impacts Park Use of Diverse, Low-Income Mothers With Their Children

Built environment features, including parks, often exacerbate health disparities. We examined built environment perceptions and park use among a population at high risk for negative physical health outcomes: racially diverse, low-income mothers across the United States. Perceived safety from crime and living near a park were associated with more frequent park use for mothers with their children, and neighborhood walkability was linked to longer park visits. However, only 40% of mothers lived within a 10-minute walk of a park, and overall perceptions of walkability and safety from crime were low. To enhance physical activity and health of low-income mothers with their children, investments are needed to close disparities in park access and improve neighborhood safety.

Inclusion in citizen science: The conundrum of rebranding

Does replacing the term “citizen science” do more harm than good?

Nature as an Ecological Asset for Positive Youth Development: Empirical Evidence From Rural Communities

Despite increasing emphasis on youth contact with nature and associated benefits, research has not examined the direct relationship between adolescents' nature-based experiences and holistic measures of positive youth development (PYD). This gap may stem from the lack of interdisciplinary work on nature and PYD. Our study integrates multiple disciplinary perspectives to explore direct associations between time in nature, connection to nature, and the five Cs of PYD (competence, connection, confidence, character, and caring) as well as the "sixth" C of contribution. From 2015 to 2016, we collected data from 587 diverse South Carolina middle school students (57% female, 40% BIPOC) between the ages of 11 and 14 (M age = 12.9) and living in predominantly low-income communities. OLS regression analyses indicated that across all youth, self-reported connection to nature was a consistent positive correlate of overall PYD and each of the individual Cs. Time in nature was associated with overall PYD and competence. Findings demonstrate significant associations between nature-based experiences and PYD and underscore the importance of ensuring that diverse youth can access and enjoy the developmental benefits of nature and nature-based recreation opportunities.

Outdoor Activity Participation Improves Adolescents' Mental Health and Well-Being during the COVID-19 Pandemic

COVID-19 is reshaping human interactions with the natural environment, potentially generating profound consequences for health and well-being. To assess the effects of COVID-19 on the outdoor recreation participation and subjective well-being of adolescents, as well as how participation in outdoor activities may mitigate declines in subjective well-being, we used a Qualtrics XM panel to conduct a nationally representative survey of youth ages 10–18 across the United States (n = 624) between 30 April and 15 June 2020. Survey questions focused on frequency of participation in outdoor activities before and during the pandemic, as well as changes in subjective well-being. Paired t-tests revealed decreases in both outdoor recreation participation (64% reported declines) and subjective well-being (52% reported declines). A regression model examining correlates of changes in subjective well-being (R² = 0.42) revealed strong associations with changes in outdoor play (B = 0.44, p < 0.001) and nature-based (B = 0.21, p = 0.016) activities. Adolescents’ from all backgrounds who participated in these activities during the pandemic reported smaller declines in subjective well-being. Results highlight the critical role that time outdoors and time in nature play in bolstering adolescents’ resilience to stressors such as the COVID-19 pandemic and underscore the need to facilitate outdoor recreation opportunities for youth during times of crisis.

Psychological impacts from COVID-19 among university students: Risk factors across seven states in the United States

BACKGROUND

University students are increasingly recognized as a vulnerable population, suffering from higher levels of anxiety, depression, substance abuse, and disordered eating compared to the general population. Therefore, when the nature of their educational experience radically changes-such as sheltering in place during the COVID-19 pandemic-the burden on the mental health of this vulnerable population is amplified. The objectives of this study are to 1) identify the array of psychological impacts COVID-19 has on students, 2) develop profiles to characterize students' anticipated levels of psychological impact during the pandemic, and 3) evaluate potential sociodemographic, lifestyle-related, and awareness of people infected with COVID-19 risk factors that could make students more likely to experience these impacts.

METHODS

Cross-sectional data were collected through web-based questionnaires from seven U.S. universities. Representative and convenience sampling was used to invite students to complete the questionnaires in mid-March to early-May 2020, when most coronavirus-related sheltering in place orders were in effect. We received 2,534 completed responses, of which 61% were from women, 79% from non-Hispanic Whites, and 20% from graduate students.

RESULTS

Exploratory factor analysis on close-ended responses resulted in two latent constructs, which we used to identify profiles of students with latent profile analysis, including high (45% of sample), moderate (40%), and low (14%) levels of psychological impact. Bivariate associations showed students who were women, were non-Hispanic Asian, in fair/poor health, of below-average relative family income, or who knew someone infected with COVID-19 experienced higher levels of psychological impact. Students who were non-Hispanic White, above-average social class, spent at least two hours outside, or less than eight hours on electronic screens were likely to experience lower levels of psychological impact. Multivariate modeling (mixed-effects logistic regression) showed that being a woman, having fair/poor general health status, being 18 to 24 years old, spending 8 or more hours on screens daily, and knowing someone infected predicted higher levels of psychological impact when risk factors were considered simultaneously.

CONCLUSION

Inadequate efforts to recognize and address college students' mental health challenges, especially during a pandemic, could have long-term consequences on their health and education.

Urban Youth Perspectives on the Benefits and Challenges of Outdoor Adventure Camp

Consistent evidence indicates that urban youth, and particularly youth of color, report relatively low levels of participation in quality youth program experiences and spend less time outdoors as compared to non-urban and White youth. Outdoor adventure camps (OACs) provide an excellent opportunity for engaging these youth in experiences that can help promote positive youth development (PYD). In the present study, we examined the experiences and perceptions of 75 urban youth who participated in a 3-day high adventure camp experience. Through a mixed-method approach, results indicated that urban youth from all racial and ethnic backgrounds grew in several PYD outcomes including social competencies and self-improvement capacities. Many youth also reported growing in their connection to nature as a consequence of participating in the OAC. Youth thought camp was a positive and worthwhile experience, reflecting key attributes of a PYD setting. Overall, the OAC provided a challenging and engaging growth environment for youth. Findings highlight implications for socially just and culturally inclusive outdoor adventure programming aimed at diverse urban youth.

Characterizing conflict between humans and big cats Panthera spp: A systematic review of research trends and management opportunities

Conservation of big cats (Panthera spp.), a taxonomic group including tigers, lions, jaguars, leopards and snow leopards, is a daunting challenge. As expanding human populations across Panthera range countries exacerbate competition for land and prey, conflicts between humans and big cats are inevitable. Through a systematic review of the peer-reviewed literature published from 1991 to 2014 and indexed in Web of Science and Google Scholar (186 articles), our study explored the current state of knowledge regarding human-Panthera conflict and potential solutions, examining variables such as spatial and temporal distribution of research, methods used to study conflict, evaluation of interventions, and management recommendations. Our synthesis revealed several key data gaps and research needs. More studies could utilize diverse data collection approaches to focus on both the ecological and socio-cultural context for conflict. Additionally, only 21% of articles included in the review evaluated conflict mitigation interventions, and few of these yielded conclusive results. Success ratios suggest that compensation schemes and livestock management strategies were more effective tools for addressing conflict than either direct interventions (lethal removal or translocation of animals) or community interventions (e.g. education, ecotourism, local management). More studies should systematically evaluate the efficacy of conflict mitigation strategies, many of which are consistently recommended without empirical support. Results highlight trends and opportunities that can be used to inform future research and management efforts focused on human-Panthera conflict, ultimately enhancing the potential for coexistence between humans and carnivore species worldwide.

Local Government Capacity to Respond to Environmental Change: Insights from Towns in New York State

Local governments attempting to respond to environmental change face an array of challenges. To better understand policy responses and factors influencing local government capacity to respond to environmental change, we studied three environmental issues affecting rural or peri-urban towns in different regions of New York State: climate change in the Adirondacks (n = 63 towns), loss of open space due to residential/commercial development in the Hudson Valley (n = 50), and natural gas development in the Southern Tier (n = 62). Our analysis focused on towns' progression through three key stages of the environmental policy process (issue awareness and salience, common goals and agenda setting, policy development and implementation) and the factors that affect this progression and overall capacity for environmental governance. We found that-when compared to towns addressing open space development and natural gas development-towns confronted with climate change were at a much earlier stage in the policy process and were generally less likely to display the essential resources, social support, and political legitimacy needed for an effective policy response. Social capital cultivated through collaboration and networking was strongly associated with towns' policy response across all regions and could help municipalities overcome omnipresent resource constraints. By comparing and contrasting municipal responses to each issue, this study highlights the processes and factors influencing local government capacity to address a range of environmental changes across diverse management contexts.

Public Parks and Wellbeing in Urban Areas of the United States

Sustainable development efforts in urban areas often focus on understanding and managing factors that influence all aspects of health and wellbeing. Research has shown that public parks and green space provide a variety of physical, psychological, and social benefits to urban residents, but few studies have examined the influence of parks on comprehensive measures of subjective wellbeing at the city level. Using 2014 data from 44 U.S. cities, we evaluated the relationship between urban park quantity, quality, and accessibility and aggregate self-reported scores on the Gallup-Healthways Wellbeing Index (WBI), which considers five different domains of wellbeing (e.g., physical, community, social, financial, and purpose). In addition to park-related variables, our best-fitting OLS regression models selected using an information theory approach controlled for a variety of other typical geographic and socio-demographic correlates of wellbeing. Park quantity (measured as the percentage of city area covered by public parks) was among the strongest predictors of overall wellbeing, and the strength of this relationship appeared to be driven by parks’ contributions to physical and community wellbeing. Park quality (measured as per capita spending on parks) and accessibility (measured as the overall percentage of a city’s population within ½ mile of parks) were also positively associated with wellbeing, though these relationships were not significant. Results suggest that expansive park networks are linked to multiple aspects of health and wellbeing in cities and positively impact urban quality of life.

Low molecular weight heparin versus unfractionated heparin in the colonoscopy peri-procedure period: a cost modeling study

OBJECTIVE

The aim of this study was to compare the economic outcomes of peri-procedure anticoagulation approaches for elective colonoscopy.

METHODS

Decision analysis was used to model the economic outcomes of five peri-procedure anticoagulation options: outpatient low molecular weight heparin (LMWH), inpatient unfractionated heparin infusion (UFHi), continuous warfarin (with probability of a repeat procedure using LMWH or UFHi), and discontinuation of anticoagulation therapy. The model's base-case scenario assumed drug therapy options for high-risk patients were equally effective in preventing a thromboembolic event (0.1% risk), with a higher probability for the no anticoagulation strategy (0.4%); event costs were based on published data and adjusted to 1997 dollars. Drug costs reflected 1997 average wholesale price. Medical costs for other variables were estimated based on local hospital charges. Indirect costs were not considered. Risk probabilities and LMWH drug cost were tested in sensitivity analysis.

RESULTS

In the base-case scenario, costs for the options evaluated were $1436/patient, $1792/patient, $1848/patient, $2629/patient, and $5196/patient for no anticoagulation, continuous warfarin/repeat LMWH, LMWH as outpatient, continuous warfarin/repeat UFHi, and UFHi as inpatient respectively ($1997). Discontinuing anticoagulation was the least costly approach but involved the greatest thromboembolic risk. The cost of continued warfarin anticoagulation/repeat LMWH was minimally less than the LMWH option, but assumes 25% of patients would require a second procedure. The traditional approach (UFHi) requires an extended hospitalization and is the most costly option. Varying risk category or LMWH cost in sensitivity analysis had a negligible impact on overall costs.

CONCLUSION

Within the model's assumptions, LMWH offers a novel, convenient, and economical solution to the problem of peri-procedure anticoagulation for elective colonoscopy.

Cost effectiveness of rabeprazole versus generic ranitidine for symptom resolution in patients with erosive esophagitis

OBJECTIVE

To compare the cost effectiveness of rabeprazole (RAB) and ranitidine (RAN) in acute and maintenance therapy for erosive esophagitis using symptom response, rather than endoscopic healing, as the clinical outcome.

STUDY DESIGN

Decision analysis was used to model the cost effectiveness of competing therapies based on the results of clinical trials of RAB versus RAN and estimates from the medical literature.

METHODS

The model's base case scenario compared brand-name RAB (estimated average wholesale price) with generic RAN (25% of the average wholesale price of brand-name RAN). Medical costs for hospitalizations, procedures, and office visits reflected 1998 Medicare payments. The 1-year maintenance model accounted for drug-class switching and symptomatic, rather than endoscopic, recurrences. Effectiveness was reported as the percentage of patients in whom a symptomatic recurrence was prevented. The cost per symptomatic recurrence prevented was reported as an average and an incremental cost-effectiveness ratio.

RESULTS

The per-patient cost of RAB therapy was higher than that of RAN therapy ($2020 vs $1917); RAB therapy, however, was more effective than RAN therapy in preventing symptomatic recurrences (74% vs 41%). The average cost-effectiveness ratio was lower for RAB therapy than for RAN therapy ($2748 per symptomatic recurrence prevented vs $4719 per symptomatic recurrence prevented). The cost of preventing one additional symptomatic recurrence with RAB rather than RAN was $313 (incremental cost-effectiveness ratio). Sensitivity analysis conducted on key clinical and cost variables supported the robustness of the decision model.

CONCLUSION

This analysis demonstrates that management of esophagitis with RAB is more effective, and may be more cost effective, than management with generic RAN, despite RAB's higher per-unit cost.

Annual cost of care for Crohn's disease: a payor perspective

OBJECTIVE

The aim of this study was to estimate the annual cost of care of patients with Crohn's disease according to treatment setting.

METHODS

Using a 1994 integrated claims database, patients with a Crohn's-related medical claim (ICD-9 code 555) from 10/01/94 to 09/30/95 were included in this analysis. These patients were stratified into three mutually exclusive disease severity groups: group 1, required hospitalization for Crohn's; group 2, required chronic glucocorticoid or immunosuppressive drug therapy for >6 months; group 3, all remaining patients. Direct charges (based on reimbursement) and utilization of resources were reported for each group.

RESULTS

Six-hundred-seven patients were analyzed: 117(19%) in group 1, 31(5%) in group 2, and 459(76%) in group 3. Average age of all patients was 48 years and 43% of these patients were men. Average annual charges for all patients totaled $12,417. Group I patients experienced the highest mean charges ($37,135), whereas patients in groups 2 and 3 incurred $10,033 and $6,277. Approximately 25% of patients accounted for 80% of the total charges.

CONCLUSIONS

Crohn's disease is associated with high cost. Although a minority of Crohn's patients required hospitalization, they tended to have higher utilization and were responsible for a majority of total expenditures. New therapies have the potential to reduce overall cost of care, if they prevent Crohn's-related hospitalizations.

The cost of hospitalization in Crohn's disease

OBJECTIVE

The aim of this study was to evaluate the demographics, resource use, and costs associated with hospitalization of Crohn's disease patients.

METHODS

All patients hospitalized at our institution from 7/1/96 to 6/30/97 with a primary diagnosis of "Crohn's Disease" were analyzed using a computerized database. Data are presented "per hospitalization."

RESULTS

A total of 175 hospitalizations (147 patients) were identified. Mean patient age was 36.5 yr; 61% were female; 82% Caucasian. Payer mix was most commonly contracted (57%), commercial (21%), or Medicare (13%). 57% of hospitalizations had a primary surgical procedure; the remainder were medical. Average length of stay was 8.7 days (surgical, 9.6 days; medical, 7.5 days). The average cost of hospitalization, excluding physician fees, was $12,528 (surgical, $14,409; medical, $10,020), whereas average charges were $35,378 (surgical, $46,354; medical, $20,744), including physician fees, which averaged $7,249 (surgical, $11,217; medical, $1,959). Mean reimbursements were $21,968 (surgical, $28,946; medical, $12,666) with average weighted reimbursement rates of 60.17% of hospital charges, 69.57% of physician fees. The distribution of costs across subcategories was: Surgery (39.6%), Pharmacy (18.6%), Laboratory (3.8%), Radiology (2.1%), Pathology (0.8%), Endoscopy (0.3%), and Other Hospital Costs (34.9%). Of the hospitalizations, 87% included treatment with steroids, 23% with immunomodulators, and 14% with aminosalicylates; 27% included the administration of total parenteral nutrition, which accounted for 63% of the total pharmacy costs.

CONCLUSIONS

Surgery accounts for the majority of hospitalizations, nearly 40% of their total costs, and 75% of overall charges and reimbursements. Therapy that decreases the number of surgical hospitalizations should substantially reduce inpatient Crohn's disease costs, as well as overall costs.

Advances in the management of Crohn's disease: economic and clinical potential of infliximab

New therapies for Crohn's disease are being developed based on improvements in our understanding of the disease's immune and inflammatory properties. One of these new therapies is infliximab, a monoclonal antibody directed against the proinflammatory cytokine tumor necrosis factor-alpha. Recent studies indicate that treatment of moderately to severely ill Crohn's disease patients with infliximab produces a rapid and profound reduction in the signs, symptoms, and severity of this disease. Beyond its clinical impact, Crohn's disease also carries significant economic consequences. Earlier reports on the costs of managing this disease estimated the average annual medical costs per patient at $9197, with the total annual cost of illness estimated to exceed $1.7 billion. Hospitalizations and surgeries represented 80% of these costs. Additional analyses have been conducted for this review to reflect more current treatment patterns. Assuming that proven increases in response and remission rates lead to diminished disease severity, infliximab can be expected to reduce the number of hospitalizations and surgeries in moderately to severely ill patients, with substantial cost savings. Moreover, improvement in disease status and quality of life may allow Crohn's disease patients to lead more productive lives.

Prevention of nonsteroidal anti-inflammatory drug-induced gastropathy: clinical and economic implications of a single-tablet formulation of diclofenac/misoprostol

Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used to manage arthritis. While controlling symptoms and improving quality of life, NSAID use is associated with gastroduodenal injury and a 2%-4% annual risk for symptomatic gastroduodenal ulceration, hemorrhage, and perforation. This requires clinicians to balance the efficacy of NSAIDs against the potential risk of serious gastrointestinal events. Identification and stratification of risk can help guide the optimal approach for arthritis management of individual patients or large populations such as managed care organizations. NSAID-induced gastroenteropathy carries considerable economic consequences; 46% of arthritis costs are related to managing serious adverse events. It is reasonable to assume that these costs may not be incurred if high-risk patients are recognized and optimally managed. Newer therapies with proven safety margins present an attractive option, especially for patients at higher risk. The single-tablet formulations of diclofenac and misoprostol (Arthrotec) offer an alternative in managing NSAID patients because of their inherent safety profile. Studies with diclofenac/misoprostol indicate its effectiveness in treating signs and symptoms of arthritis and in reducing the incidence of NSAID-induced gastroenteropathy. As such, this agent may provide improved medical and economic outcomes. This review discusses the clinical aspects of NSAID-induced gastroenteropathy, including available preventive therapies. Approaches to assessing patients' risk for developing complications, and the relationship of medical risk and economic outcomes, are also examined. Although not all patients require preventive therapy, patients with heightened risk may benefit clinically and economically from gastroprotective NSAIDs. Additional research or modeling may provide further insight into the economic implications of managing and preventing NSAID-induced gastroenteropathy.

Management of NSAID-induced gastropathy: an economic decision analysis

The use of nonsteroidal anti-inflammatory drugs (NSAIDs) is associated with a 2% to 4% annual incidence of serious gastrointestinal complications. These adverse clinical outcomes, and the strategies used to prevent their occurrence, translate into a significant economic burden. A decision-analysis model was constructed to contrast the 6-month costs associated with various approaches to preventing and managing NSAID-induced gastropathy and to evaluate the economic impact of two treatment regimens using fixed-dose formulations of diclofenac/misoprostol. After incorporating expected medical out-comes and predicted practice patterns, 6-month per-patient costs were derived from the model for each of five treatment regimens: (1) NSAID alone; (2) NSAID with a histamine2-receptor antagonist; (3) NSAID with coprescribed misoprostol; (4) diclofenac/misoprostol 50 mg/200 micrograms TID/BID; and (5) diclofenac/misoprostol 75 mg/200 micrograms BID. The combined diclofenac/misoprostol regimens demonstrated an 18.6% per-patient cost advantage compared with the combined NSAID regimens. Based on a 6-month period, this cost savings translated into a $214.00 per-patient overall cost savings ($1153.00 per patient for NSAID regimens versus $939.00 for diclofenac/misoprostol regimens). The magnitude of this difference was verified by Monte Carlo simulation. Despite the considerable cost difference, sensitivity analyses revealed that our model was robust and that no single variation substantially influenced the results. Given the lack of long-term prospective, comparative clinical-outcomes studies in this area, this decision analysis provides guidance to clinicians in developing a rational and cost-effective approach to the treatment of patients requiring chronic NSAID therapy.

Identifying patient symptoms after radiotherapy using a nurse-managed telephone interview

PURPOSE/OBJECTIVES

To identify patients' symptoms following completion of radiotherapy for common cancers by a nurse-managed telephone interview.

DESIGN

Quality assurance project.

SETTING

Radiation therapy department in a community hospital in a large midwestern city.

SAMPLE

One hundred eleven patients treated by radiotherapy for primary cancer of the prostate, head/neck, lung, and breast.

METHODS

Two time points of data collection: nurses completed an end-of-treatment symptom evaluation within the last five days of treatment and conducted telephone interviews 14-21 days post-therapy. Interview questions were based on each individual's end-of-treatment symptoms and common site-specific side effects.

MAIN RESEARCH VARIABLES

Symptoms at end of treatment and 14-21 days after therapy completion, nursing assessments and interventions, and length of telephone interview.

FINDINGS

At the end of treatment, 104 (94%) patients were experiencing symptoms. Nurses contacted 106 (95%) patients by telephone 14-21 days after therapy completion and assessed symptoms in 84 (79%) patients. Nineteen (18%) patients reported the development of a new symptom. Nurses independently managed 95% of the calls.

CONCLUSIONS

The majority of patients experienced symptoms in the immediate post-therapy period. Telephone follow-up interviews served as a mechanism for evaluating short-term morbidity and provided the opportunity for nurses to intervene with many patients.

IMPLICATIONS FOR NURSING PRACTICE

A nurse-managed telephone follow-up program can be used as a component of a quality improvement process in radiation centers to assess patients' post-treatment symptoms and provide education and support.

Fatty acid profiles of phospholipids in rabbit and bovine dental pulp

The fatty acid profiles of purified phospholipids were similar in dental pulp from rabbit and bovine teeth. The characteristic fatty acid profile of each phospholipid was similar to that found in several other mammalian tissues. The ethanolamine phosphoglycerides had high levels of arachidonic acid and docosapolyenoic acids. Phosphatidylserine and phosphatidic acid contained high amounts of stearic acid and low levels of polyunsaturated fatty acids. Phosphatidylcholine and sphingomyelin contained high amounts of palmitic acid and low levels of C20 and C22 unsaturated fatty acids, and sphingomyelin contained C24 fatty acids. Phosphatidylinositol contained mainly stearic, oleic, and arachidonic acids. The fatty acid compositions of the purified pulp phospholipids are markedly different from those reported for dentin lipids which have been reported to contain little or no arachidonic acid and docosapolyenoic acids. The possible significance of the polyunsaturated fatty acids and phospholipids in tooth formation and maintenance is discussed.