Older adults with mild dementia are at an increased risk of falls. Preventing those at risk from falling requires complex interventions involving patient-tailored strength- and balance-challenging exercises, home hazard assessment, visual impairment correction, medical assessment and multifactorial combinations. Evidence for these interventions in older adults with mild cognitive problems is sparse and not as conclusive as the evidence for the general community-dwelling older population. The objectives of this realist review are (i) to identify the underlying programme theory of strength and balance exercise interventions targeted at those individuals that have been identified as falling and who have a mild dementia and (ii) to explore how and why that intervention reduces falls in that population, particularly in the context of a community setting. This protocol will explain the rationale for using a realist review approach and outline the method.A realist review is a methodology that extends the scope of a traditional narrative or systematic evidence review. Increasingly used in the evaluation of complex interventions, a realist enquiry can look at the wider context of the intervention, seeking more to explain than judge if the intervention is effective by investigating why, what the underlying mechanism is and the necessary conditions for success. In this review, key rough programme theories were articulated and defined through discussion with a stakeholder group. The six rough programme theories outlined within this protocol will be tested against the literature found using the described comprehensive search strategy. The process of data extraction, appraisal and synthesis is outlined and will lead to the production of an explanatory programme theory.As far as the authors are aware, this is the first realist literature review within fall prevention research and adds to the growing use of this methodology within healthcare. This synthesis of evidence will provide a valuable addition to the evidence base surrounding the exercise component of a fall intervention programme for older adults with mild dementia and will ultimately provide clinically relevant recommendations for improving the care of people with dementia.CRD42015030169PROSPERO The online version of this article (doi:10.1186/s13643-016-0212-x) contains supplementary material, which is available to authorized users. Cognitive impairment is a risk factor for falls . When anFall prevention is a complex intervention that is well evidenced in a healthy older adult population. Through meta-analysis, exercise has shown to have consistent effects at reducing falls when prescribed and completed at the correct progression and intensity . Many inA recent systematic review by Guo et al.  identifiThere is a strong rationale for early fall prevention in adults with mild cognitive problems as this population is at a higher risk of falling than people without impairment . This poBefore developing a suitable intervention, a review of the published literature was needed and a realist review methodology was chosen. The first stage of the review articulates the key theories and states how the review was conducted.Historically, older adults with cognitive impairment were excluded from fall prevention trials to preserve a homogenous population sample and for practical and pragmatic trial management reasons. Anecdotally, this population has been associated with increased attrition and poor adherence due to memory and executive problems and co-morbidity. In the attempt to produce valid results, older adults with cognitive impairment have been excluded, leading to a lack of quantity and quality of evidence on fall interventions for this population. Whilst it is reasonable to assume that some findings from research conducted in healthy older populations can be extrapolated to older adults with dementia, differences are likely and not all findings will be relevant. Older adults with mild dementia have specific impairments  that may influence the effectiveness of an intervention developed for a different patient population.A realist review is a methodology that extends the scope of a traditional narrative or systematic evidence review. There are several reasons for choosing this method for investigations in this field. Firstly, a traditional systematic review focuses on the effectiveness of a particular intervention, and whilst this is useful, there are currently not enough studies in this patient population to determine the effectiveness of strength and balance exercise programmes with any certainty. Secondly, at this early stage of intervention development and available evidence, the theoretical underpinning of an intervention should be considered . It is lresource) to feel safer (Mresponse) when walking outside (C). This configuration is only relevant in the context of the individual walking outside and having the response of feeling safer by holding a stick.A realist review explores how underlying mechanisms (M) might be “triggered” in the context (C) of different intervention strategies to produce a reduction in falls or other outcomes (O). Within a realist enquiry, CMO configurations are interlinked and dependent upon each other, creating chains of conceptual possibilities or realities. Mechanisms are further subdivided between resources and responses. For example, a fall (O) could be prevented if an individual uses a stick  to identify the underlying programme theory of strength and balance exercise interventions targeted at those individuals that have been identified as falling and who have a mild dementia and (ii) to explore how and why that intervention reduces falls in that population, particularly in the context of a community setting.What strength and balance exercises have been used in mild cognitive impairment populations to reduce falls?Why do those exercises reduce falls in that population?In what context do those exercises reduce falls in that population and to what extent?The aim of the current research is to understand how a strength and balance exercise programme might work with older adults with a cognitive impairment. In particular, what sorts of exercises reduce falls in older adults with cognitive impairment, under what circumstances, to what extent, and why? The research questions for the review are:The design utilises five practical stages of the review process identified by Pawson et al. . This isFall prevention is a complex intervention with many components that are introduced or employed according to individual patient characteristics. To clarify the scope of the review, the “patient journey” was identified, from case identification to discharge . The und(A)Physiological changesThe above process identified six rough programme theories to test against the literature. These were:resource) will experience a physiological response (Mresponse) which improves their physical ability (O1) and reduces their risk of falls (O2).An older adult with dementia (C) completing a strength and balance exercise programme  and response to perturbationCognition: increased capacity to divide and maintain attention, improved visuospatial awareness, neuroplastic adaptations and changes(B)EnjoymentThe hypothesised physiological responses are:response) from doing (O1) a strength and balance exercise programme (Mresource), and this will reduce their risk of falls (O2).(C)Encouraged (positive reinforcement)An older adult with dementia who has had a previously positive experience of falls or community services or exercise, who has a positive belief in exercise and who has the physical capability to do the exercises either independently or with support (C) will feel enjoyment (Mresource2) or network (Mresource3) and is well briefed or educated by that therapist or network (C) will feel encouraged (Mresponse1) to do (O1) the strength and balance exercise programme (Mresource1) and will recognise the positive benefits from participating in the programme (O2).An older adult with dementia who may not identify themselves as at risk of falling or remember any previous falls has poor or limited physical functioning, is not used to doing exercise but who is being appropriately supported  by a therapist (M2), they will feel motivated (Mresponse2) to continue with the programme (O3) and will reduce their risk of falls (O4).(D)Fearful of negative consequencesOnce an older adult with dementia recognises the positive benefits from participating in a strength and balance exercise programme (Cresource2) will feel fearful (Mresponse1) or concerned (Mresponse2) and will do (O) the strength and balance exercise programme (Mresource1).(E)Empowered to achieve goalAn older adult with dementia who identifies themselves as at risk of falls remembers that they have previously fallen or had a “near miss”, has limited physical activity or function or ability and believes that they may deteriorate either physically or cognitively (C) or who listens to the education or warnings of the therapist (Mresource2) and who believes that their goals can be achieved with the strength and balance exercise (Mresource1) programme (C) will feel empowered (Mresponse) to do (O1) the strength and balance exercise and achieve their goal (O2).(F)Influenced by social and cultural expectations or beliefsAn older adult who has something they want to achieve, whose goals align with that of the therapist (Mresource2) and has a network that reinforces or imposes these beliefs (C) will feel influenced (Mresponse) to do (O) the strength and balance exercise programme (Mresource1).An older adult with dementia who believes that exercise is good, associates exercise with youth or vigour or health and well-being, who believes that the therapists or doctors “know what is best for them” . Additional searching may be completed if more data are required to refine a particular aspect of the programme theory that could not be evidenced or tested from the literature found within the initial and second search phase.The searching will be both “iterative and interactive” , and it For screening article titles: Could this be about the strength and balance exercise component of fall rehabilitation in older adults with mild cognitive problems in the community?For screening article abstracts: Could this material provide useful information about completing the strength and balance exercise component of fall rehabilitation in older adults with mild cognitive problems in the community?Selection of material for inclusion in the review will be based on relevance to the research aims and will provide information to test or assist in programme theory development. The articles will be considered for relevance based on an assessment of the “fit” of the article to the research question. The titles and abstracts of retrieved studies will be screened against pre-determined questions to ascertain the relevance of the material to the synthesis aims . These wThe inclusion of material will not be limited by document, article or study type and could include the following: trials, editorials, experimental studies, qualitative research, treatment manuals or evaluations. Material will be excluded if it is not published in English, does not involve older adults and does not involve community-based participants or interventions . Reasons for exclusion will be documented. If the reviewer is unsure about a document’s inclusion, then the second reviewer (PL or RH) will be used to aid decision-making. Disagreements between inclusion and relevance of material will be discussed with the stakeholder group. Material that is considered irrelevant for full-text retrieval will be kept until the end of the review process as once the initial stage of the search has been completed there may be relevant material to inform programme theory development and testing from studies initially dismissed due to topic specificity. For example, material that does not involve older adults but those with traumatic brain injury or learning disabilities that relates to a specific area of programme theory development might be considered for inclusion during the second search phase if required.The full-text for eligible studies will be retrieved and assessed for quality and extraction of data by the main researcher (VB). Within realist synthesis and the quality standards developed for its reliability of reporting, there is no requirement for the screening, quality appraisal or data extraction to be completed independently by two researchers. Unlike a traditional systematic review, the realist process allows for theory development to be influenced from the material identified . HoweverQuality appraisal and data extraction will be conducted simultaneously within the review process but are distinct and separate processes. Relevance and rigour are the two key processes within a realist synthesis when considering the quality appraisal and extraction of data  and willIs the material cohesive? Does it tell a comprehensive story or is there a juxtaposition of ideas or isolated statements?What is the value of the evidence?What is the material’s position in relation to the programme theory and general topic area?“A series of judgements” (see p. 35 in ) will beAs within a traditional systematic review, the judgements about the rigour of methods used to generate data that is relevant to the review are assessed prior to inclusion.Data will be extracted from the included material based on its relevance to the aims of the synthesis and the rough programme theories. Data is sought that either refines, substantiates or refutes the theories. Relevant material within the documents will be highlighted, labelled and documented on the data extraction sheet  in collaboration with the stakeholder group will revisit and refine the search strategy, before conducting a purposive search with the revised focus.RelevanceInterpretation of meaningJudgements about CMO configurations (CMOcs)Judgements about programme theoryRigourPopulation contextual informationA series of questions will be asked of the extracted material to aid evidence synthesis. The data extraction sheet, adapted from previous realist reviews , outlineJuxtaposition of sources of evidence Reconciling of sources of evidence Adjudication of sources of evidence Consolidation of sources of evidence (when evidence about mechanisms and outcomes is complementary and enables a multifaceted explanation to be built)Situating sources of evidence The relevance of the text is questioned in relation to the rough programme theory. The content is then interpreted into context, mechanism or outcome relevancy. The CMOcs from the extracted material are written out, and judgements regarding their configurations are detailed. This will allow new CMOcs to be identified as well as compare the extracted material to the existing rough programme theories. Whether the material is trustworthy and rigorous enough to make changes to the rough programme theory or its CMOcs is then considered. Synthesis of the materials will occur in an iterative, complimentary process; as the researcher (VB) is engaging with and extracting data, there will be a simultaneous development of opinions and conclusions. A process of reasoning will occur whilst the questions from the data extraction sheet are being asked . This reExtracted, primary data will be compared to the relevant rough programme theory Fig.  to test The final programme theory will be narratively described, using text, tables and graphics as required. The review will be completed in accordance with guidance from the quality standards for a realist synthesis . The resOn completion, the review will be published in a leading journal within the field and the results presented at conference. The review will be reported according to the Realist and Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) publication standards  and the Ethical approval will not be required to conduct this review. Consent and agreement of discussion documentation was sought from the stakeholder group regarding the development of the rough programme theories. Prior to funding being issued, the project was reviewed by peer and lay members of the Alzheimer Society and is continued to be monitored by an expert lay member panel. The review has been registered with PROSPERO (CRD42015030169).This is the first realist literature review within fall prevention research, so it is important to highlight the limitations. Firstly, the methodology and theoretical assumptions behind realist enquiry encourages transparency about the influence of the researcher on certain aspects of the review, such as the initial rough programme theory development, and interpretation of material. Within this review, the researcher is clearly identified and the influences, whilst considered from a traditional systematic review method as producing potential for bias, assist the theory development in the review. As a clinician that has worked with this intervention in this patient population, there is potential for detailed recognition of the “hidden” mechanisms and understanding of the CMOcs. The stakeholder group and second reviewer are placed to ensure consistency and transparency of decision-making and to maintain the clinical and academic relevance of the review.Secondly, the focus and scope of the review is limited by time and resources. The review is one chapter of a PhD thesis and is therefore constrained to be focused and relevant to the direction and aims of the whole PhD research project. It could be construed that this may hamper the detail and depth that the review can achieve.Lastly, the published materials within this field may not include the detail of theoretical reasoning required to adequately test and define the programme theories. Research into falls is heavily weighted towards quantitative methods with publications following a rigid reporting structure. Calls for greater detail in publications regarding intervention reporting (such as the TiDieR guidelines ) may proFalls within older adults with mild cognitive problems are important to both the health and wealth of the nation. Traditional systematic reviews report a dearth of evidence for fall interventions for this population. However, there is potential to consider the evidence from a different methodological perspective, to gain a better contextual and detailed picture of how these interventions are implemented, who they are being effective with and why. This synthesis of evidence will provide a valuable addition to the evidence base surrounding the exercise component of a fall intervention programme for older adults with mild dementia and will ultimately provide clinically relevant recommendations for improving the care of people with dementia.Not applicable.


A major justification of environmental management research is that it helps practitioners, yet previous studies show it is rarely used to inform their decisions. We tested whether conservation practitioners focusing on bird management were willing to use a synopsis of relevant scientific literature to inform their management decisions. This allowed us to examine whether the limited use of scientific information in management is due to a lack of access to the scientific literature or whether it is because practitioners are either not interested or unable to incorporate the research into their decisions. In on-line surveys, we asked 92 conservation managers, predominantly from Australia, New Zealand, and the United Kingdom, to provide opinions on 28 management techniques that could be applied to reduce predation on birds. We asked their opinions before and after giving them a summary of the literature about the interventions’ effectiveness. We scored the overall effectiveness and certainty of evidence for each intervention through an expert elicitation process—the Delphi method. We used the effectiveness scores to assess the practitioners’ level of understanding and awareness of the literature. On average, each survey participant changed their likelihood of using 45.7% of the interventions after reading the synopsis of the evidence. They were more likely to implement effective interventions and avoid ineffective actions, suggesting that their intended future management strategies may be more successful than current practice. More experienced practitioners were less likely to change their management practices than those with less experience, even though they were not more aware of the existing scientific information than less experienced practitioners. The practitioners’ willingness to change their management choices when provided with summarized scientific evidence suggests that improved accessibility to scientific information would benefit conservation management outcomes.El Efecto de la Evidencia Científica sobre las Decisiones de Manejo de Quienes Practican la ConservaciónUna justificación mayor de la investigación en el manejo ambiental es que ayuda a quienes lo practican, aunque estudios previos muestran que rara vez se usa para informar sus decisiones. Probamos si quienes practican la conservación enfocada en el manejo de aves estaban dispuestos a usar una sinopsis de literatura científica relevante para informar sus decisiones de manejo. Esto permitió que examináramos si el uso limitado de información científica en el manejo se debe a una falta de acceso a la literatura científica o si se debe a que quienes practican la conservación no están interesados o no son capaces de incorporar la investigación a sus decisiones. En encuestas en línea les preguntamos a 92 practicantes de la conservación, la mayoría de Australia, Nueva Zelanda y el Reino Unido, que nos proporcionaran opiniones sobre 28 técnicas de manejo que podrían aplicarse para reducir la depredación de aves. Les pedimos sus opiniones antes y después de darles un resumen de la literatura sobre la efectividad de las intervenciones. Calificamos la efectividad general y la certidumbre de la evidencia para cada intervención por medio de un proceso de extracción por expertos – el método Delphi. Usamos las calificaciones de la efectividad para evaluar el nivel de entendimiento y de percatación de la literatura de quienes practican la conservación. En promedio, cada participante de la encuesta cambió su probabilidad de usar 45.7% de las intervenciones después de leer la sinopsis de la evidencia. Fue más probable que implementaran intervenciones efectivas y evitar acciones poco efectivas, lo que sugiere que sus estrategias de manejo futuras puedan ser más exitosas que las de práctica actual. Los practicantes con mayor experiencia tuvieron una menor probabilidad de cambiar sus prácticas de manejo que aquellos con menos experiencia, aunque no estuvieron más conscientes de la información científica existente que quienes tenían menos experiencia. La disponibilidad de los practicantes para cambiar sus opciones de manejo al proporcionárseles evidencia científica resumida sugiere que el acceso mejorado a la información científica podría beneficiar los resultados del manejo de la conservación. Potential application and benefit to society are core reasons for funding and conducting research. Environmental managers obtain their information from a wide range of sources . We aimIn experiments providing medical practitioners with easy access to summarized scientific information in different formats, clinical decisions improved, either through confirmation of prior knowledge or a change in practice. When evidence was easily accessible, junior general practitioners corrected 23% of their clinical decisions after conducting literature searches for patient cases and initiated new treatments or diagnostic tests for another 25% of their cases (Sackett & Straus http://www.conservationevidence.com), free electronic document, or printed book.To test this, we used the Bird Conservation Evidence Synopsis , we asked conservation practitioners if they had either heard of or used any of the 28 management interventions that address the threat of invasive or problematic species preying on birds of conservation concern Table. We alsodo not know and not relevant if the intervention was not relevant to their conservation problem ; these cases were excluded from the analysis. The question about the likelihood of changing their management examined whether practitioners found the information in the synopsis useful and whether the evidence provided would influence their future conservation management decisions.Once practitioners had completed the initial survey, we sent them a second on-line survey, which they were asked to complete while reading the section on bird predation in the unpublished Bird Conservation Synopsis , based on the evidence in the Bird Conservation Synopsis, and a score of the certainty of the evidence on its effectiveness (0 to +100), which was determined by the quantity and quality of the evidence in the synopsis. We also asked the experts to provide a justification for their scores. They were given instructions on how to score the interventions and an explanation of the Delphi process (Supporting Information).In both the second and third rounds of scoring, panel members were given the anonymous scores of effectiveness and certainty of evidence as well as comments of other experts from the previous round and were asked to reassess their own scores, once again providing a reason for changing or keeping their score. The median of the experts’ final scores from the third round formed each intervention's overall measure of effectiveness and certainty of evidence. These data were used as explanatory variables to test if practitioners interpreted the evidence correctly and whether providing the evidence improved management decisions.We followed recommendations from recent reviews and critiques of the Delphi method to ensure the process was rigorous and achieved the most accurate estimates for each variable (Supporting Information). We invited people to be on the expert panel who had extensive experience in either bird predation research or management, based on their publication record or personal contacts. Ten of the 12 invited experts participated in the Delphi process and completed all 3 rounds (except for one expert who missed the second round of scoring). Details about the reduction in variation of scores between rounds are provided in Supporting Information. The 5 interventions for which no evidence was available were automatically given a score of unknown effectiveness, a certainty of evidence score of 0, and were not included in the Delphi process.To determine if practitioners were interpreting the evidence correctly, we fitted 2 log-linear models between the direction of a practitioner's likelihood of using an intervention in the future  and the interventions’ effectiveness and certainty of evidence. For this analysis, we converted the effectiveness and certainty of evidence scores into categorical variables with the quartiles as cut-off points for each category.not relevant in the second survey, leaving 1050 data points from 92 practitioners and 23 interventions. Models with an Akaike information criterion (AIC) value within 2 from the model with the lowest AIC value were considered the best-fitting models  with a generalized linear mixed model with a binomial error distribution and logit link function. The full model included the practitioners’ past exposure to the interventions , their prior knowledge of the scientific literature for each intervention, the number of years experience they have in the conservation field, their role as an advisor or manager, the type of organization they work for , the region where they work , and the effectiveness and certainty of evidence of interventions. The full model also included 5 relevant 2-way interactions between 4 of the explanatory variables: practitioners’ prior knowledge of literature about an intervention, their past exposure to an intervention, their experience, and the effectiveness of interventions. Practitioner and intervention were included as random effects. We tested continuous variables for normality with diagnostic plots prior to modeling, though no transformations were required. We excluded interventions that had no evidence available or that participants had selected as We received 112 complete and 4 partial responses from eligible practitioners for the initial survey and 90 completed and 2 partial responses for the second survey (80.5% response rate for the second survey). We included data from partial responses in the analyses where possible. Conservation practitioners from 26 countries, mainly the United Kingdom, New Zealand, and Australia, and from a diverse range of organizations participated in the study . A similar relationship was found between the certainty of evidence for each intervention and the proportion of practitioners who had used it .On average, practitioners had heard of 57.1% of the possible 28 interventions used to reduce predation of birds by invasive or problematic species  and had previously implemented 18.5% of the listed interventions . There was a positive significant relationship between the effectiveness of an intervention and the proportion of practitioners who had used the intervention . The majority of the other practitioners who were not influenced by the evidence were already using, on average, 79% of the effective interventions  and had no reason to change their existing practices. Of the practitioners who were more likely or much more likely to use an intervention, over three-quarters on average had not previously used that intervention, indicating these were true changes of intent, rather than strengthening of support for their existing management practices.p < 0.001, df 12). There was a similar association between an intervention's certainty of evidence and the likelihood of a practitioner using it after reading the evidence . Effectiveness and certainty of evidence for interventions were significantly correlated . These results show that the practitioners were able to accurately interpret the content and quality of the evidence provided in the synopsis.After reading the evidence, respondents said they would be more likely to use those interventions that were effective at reducing bird predation and less likely to use interventions that were ineffective or for which there was no evidence of their effectiveness , 47% of all practitioners in this study said they would be more likely to use them in the future; 78% of these had not previously used them. With limited access to summarized scientific information, practitioners may remain unaware of the most suitable and effective management options and be limited in their capacity to make effective decisions.Despite practitioners expressing a desire to change on average 46% of their management actions when given the existing evidence in a useable format, in the majority of occasions the participants stayed with their current management. The most likely explanation for this is that their existing means of collating information and deciding upon effective solutions was sufficient. The major reason for survey participants not to change their management preferences was that they were already using the effective interventions. For example, 69% of the practitioners who did not change their likelihood of using the most effective management intervention  was unavoidable. Because of this, participants may have indicated a change in their likelihood of using interventions only to satisfy or impress the researchers.Our results suggest it is worthwhile to improve access to scientific information for conservation practitioners. This access could be improved through open access publication . These systematic methods of collating scientific evidence have successfully revolutionized clinical medical practice (Sackett et al. Summarizing and evaluating research findings in clear, concise, relevant, and freely accessible packages overcome the problems of physical availability of the literature and reduces the time and skills practitioners need to digest the information. Several initiatives exist for this purpose, including the Conservation Evidence Synopses and systematic reviews (Collaboration for Environmental Evidence,


Eye tracking is commonly used in marketing to understand complex responses to materials, but has not been used to understand how low-literacy adults access health information or its relationship to decision making.n = 21) or literacy-appropriate aid (n = 29) shown on a computer screen. Using 7 content similar slides, gaze patterns, mean pupil fixation time and mean overall time reading and looking at slides were compared. Groups were also compared by literacy level and effect on 'confidence of knowledge' and intended behavior.This study assessed how participants use a literacy appropriate “dirty bomb” decision aid. Participants were randomized to receive a CDC “factsheet”  contains supplementary material, which is available to authorized users. Eye tracking technology assesses how individuals view visual content by monitoring and recording eye movements as a subject processes the stimulus in real time. All systems use cameras, with some mounted to a flat stable surface and others embedded in a computer screen or mounted on lightweight glasses. Eye tracking is commonly used in marketing research , traininWhile eye tracking has been used in a number of health-related studies –19 few hth of 24 developed nations in literacy ability [National Center for Education Statistics (NCES) found that having only basic health literacy was greater in urban areas (16.3 %) compared to non-urban areas (13.1 %), with minorities and those over age 65 being most at risk of having literacy issues [The importance of examining low-literacy populations’ perceptions of and responses to Radiological Terror Events (RTEs) such as a “dirty bomb” is evident. The 2003 National Assessment of Adult Literacy, the most recent national-level assessment of literacy, revealed that 14 % of adults in the United States have below basic literacy, 22 % have basic literacy, 53 % have intermediate literacy, while only 12 % are proficient . Overally issues . This prThe needs of low-literacy populations in the event of a terror or bioterror event are not well understood. This is especially critical because as we move farther away from the September 11, 2001 attacks, a decrease in resources directed toward emergency preparedness has occurred. RTEs, such as the explosion of a “dirty bomb”, present a threat that requires national, state, and local preparedness , but litAn added area of concern is the public's trust of government authorities in times of crisis. While “sheltering in place” in an intact structure is the recommended way to stay safe in the event of a “dirty bomb” explosion, research shows that barriers to complying with government directives include distrust and lack of confidence in government or public health authorities, fear of subsequent attacks, and beliefs that needed supplies or help will not be made available –31. ThesThe present study sought to address this gap by using eye tracking to assess how a systematically-developed, literacy appropriate decision aid, designed to foster understanding about how to respond to a “dirty bomb” event, addressed the needs of adults with limited literacy compared to a higher-literacy sample. The content of the decision aid was based on “Frequently Asked Questions” information developed by the Centers for Disease Control and Prevention (CDC), one of the few materials on RTEs publically available. Results showed clear patterns of differential text use in a small randomized pilot and demonstrated that eye tracking is a viable and useful tool in the quest to design materials for low-literacy groups to enhance decision-making.This study included a multi-phase protocol. Phase I included qualitative focus groups and quantitative surveys. Results of this phase were used in Phase II to develop a low-literacy risk communication decision aid about “dirty bomb” RTEs. Phase III involved testing the developed decision aid in a pilot randomized controlled trial. This paper discusses the results of Phase III, and focuses on the eye-tracking results.Phase I included both qualitative and quantitative data collection. This involved three focus groups with thirty-seven urban 18 to 65-year-olds, representing both men and women recruited from areas with low income and education levels in Philadelphia, PA [phia, PA . From exphia, PA . These qphia, PA , 40.Focus group results were then used to develop a comprehensive survey administered to 50 low-literacy adults, which assessed perception and understanding of a “dirty bomb,” trust of information sources, and intention to comply with government directives about “sheltering in place.” Implemented as a cross-sectional intercept survey, recruitment of respondents occurred in a variety of community-based sites in North Philadelphia, including local hospitals, neighborhood youth and senior community centers, and supermarkets. Four groupings of conceptually-related statements were included in the survey, including: 1. Statements on knowledge of a dirty bomb, trust of information sources if a dirty bomb occurred, and need for information about who was responsible for the event; 2. Statements on action intentions , belief in general preparedness, and preparedness activities such as having an emergency plan, food, and water; 3. Statements on what respondents would be worried about in the event of a dirty bomb, such as safety of food and water, risk of illness, breathing radiation, and its effects and risks to children and pets; and, 4. Statements that assessed participants’ perspectives of how likely a dirty bomb is to occur; likelihood of this event occurring compared to other threats ; beliefs about the trustworthiness of local, state, and federal authorities; and, whether their neighborhood would be treated fairly in response/recovery efforts.Phase II consisted of analyzing survey results using a variety of methods, including perceptual mapping and message vector modeling, and a cluster analysis to identify potential differences within the sample group that might need to be addressed in the design of the resulting decision aid [http://sites.temple.edu/turiskcommlab/).sion aid . Perceptsion aid –45. MessBased on these results, we developed a literacy-appropriate decision aid, optimizing the fit between the subjects’ perceptual maps and the content and format of literacy-appropriate information about a “dirty bomb”. The resulting decision aid included overall information about what a “dirty bomb” is and how to respond should an explosion occur, as well as specific message concepts determined to be important through the perceptual mapping. These concepts included: (1) Emphasizing trust in the information and recommended responses of authorities/experts, (2) Complying with recommended actions, and (3) Getting prepared for an emergency before one occurs. We also emphasized that in such a crisis, it is less important to dwell on who was responsible for the attack (a common need felt by victims of attacks that can impede taking immediate action) than it is to determine how to immediately protect yourself and your family. As well, the decision aid presented straight-forward information about what a dirty bomb is and how to respond if one occurred.http://emergency.cdc.gov/radiation/dirtybombs.asp) and presented in a question/answer format. The reading level of this material, assessed using the Flesch-Kincaid test [th grade reading level and utilized graphics to represent words. The CDC FAQs decision aid was 19 slides, compared to the intervention (low-literacy) decision aid, which was 35 slides. Many slides were content similar, but the intervention decision aid was longer to account for special message content derived from the perceptual mapping but not addressed in the CDC's FAQs. Figure The control material was the CDC’s printed document, “Frequently Asked Questions” for a “dirty bomb”, which is available to the public on the CDC website  and the existing CDC “dirty bomb” FAQs (control) was conducted with a convenience sample of 50 adults  in the Risk Communication Laboratory at Temple University in Philadelphia. The testing occurred over six months, between January and June, 2012. We conducted this pilot study to assess the feasibility of conducting a fully powered randomized trial on whether a systematically developed, literacy appropriate decision aid would help urban residents understand the risks of a “dirty bomb” and how to respond if one occurred, as well as to determine if eye tracking was a useful and valid method of determining how those with low-literacy can or cannot access text.During Participants were recruited for the pilot through community-based methods, including placing flyers in the Temple University Hospital’s General Internal Medicine Clinic, community organizations surrounding Temple University, as well as local pharmacies and supermarkets. Flyers included a “tear tab” with a phone number so those interested could call about participating in the study. We also focused on users of a neighborhood food bank, a senior services organization, and a federal services office. In these cases, research assistants visited the sites, talked with people about the study and screened them for eligibility. The goal was to have participants who closely represented people who matched the socio-demographic groups represented in the focus group and survey analysis.Screening included demographic information  and health literacy level. In-person literacy screening utilized the Rapid Estimate of Adult Literacy in Medicine – Revised (REALM-R) test, which is a word recognition test in which participants are asked to pronounce eleven medical words of increasing difficulty . The firWhen participants arrived at the Risk Communication Laboratory a trained research assistant orally administered all consent forms and instruments, which were tailored for people with low literacy. The eye tracking data collection procedures were explained to participants using pictures of the equipment and samples. Participants were then escorted to the testing lab, which is a small private room, and they were connected to the eye tracking system in preparation for viewing their assigned decision aid. The input from the physiological monitors was fed directly into a computer database for storage and analysis. Eye tracking was performed using an Applied Science Laboratory stationary eye tracker (Eye Trac 6000). This equipment requires a participant to sit in front of a screen with a Velcro band around his/her head, which automatically corrects for any head movement during eye tracking data collection. The control and intervention messages were presented on a computer monitor for each participant to view. Once the system acquired a pupil lock and calibrated the subject’s eye tracking, he/she was told to look at the screen and read the slide presented, and then indicate to the technician when he/she was done. The technician then advanced the slide for the participant until he/she was done looking at all slides. Once the participant was finished, he/she was directed back to another room where the post-education survey protocol was conducted. The full study took approximately 45 min to administer. Results of eye tracking analyses are discussed here.The two groups (Intervention v. Control) are profiled in Table =“Very chaotic tracking with very limited ability to follow text”,= "Mostly chaotic tracking and quite limited ability to follow text,"= “Mixed tracking, where tracking of some areas of the text/slide were precise, and the rest chaotic and inconsistent,"= "Mostly precise tracking and relatively consistent following of text,"= "Very precise tracking and highly consistent following of text."To extract pupil fixation and average time to complete a slide, as well as extracting the gaze patterns, the Eyenal software program  was used (Applied Science Labs). In addition, a 5-point subjective rating scale was developed and tested by the authors to rate the consistency of a participant's gaze patterns, including the ease with which the participant appeared to follow the text. To establish inter-coder reliability in the use of this scale, three study coders first came to agreement about what each scale point meant. The five-point tracking consistency scale was defined as follows:Coder training involved practicing use of the scale to rate eye-tracking consistency until a high level of inter-coder reliability was achieved . After training, coders independently rated each participant's eye-tracking patterns on each slide. In the few cases where rater discrepancies occurred, the coders reviewed the gaze pattern in question together, and discussed their ratings to arrive at a consensus scale value.What is a dirty bomb?Dirty bomb is not the same as an atomic bomb.What to do if you are inside and close to the explosion?What to do if you are outside and close to the explosion?What should I do about my kids and family?Will my food and water be safe?How do I know if I’ve been exposed to radiation?Eye-tracking comparisons were only performed on seven content-similar slides to control for content. These seven slides included similar questions and responses and allowed us to compare eye tracking patterns across similar content. The slides included:As illustrated in Table p = .032), “what to do if you are outside and close to the explosion”  = 2.48, p = .02), “what to do if you are inside and close to the explosion”  = 3.61, p = .001), and “what should I do about my children and family”  = 2.70, p = .012) slides. Intervention participants had higher means on all but one of the slides (“What is a dirty bomb”), which in both groups was very simple and contained only one statement describing what a dirty bomb is.Table Figure p = .002), “What to do if you’re inside”  = 2.03, p = .048), “How do I know about radiation exposure”  = 2.46, p = .02). A fourth slide, “What should I do about my children and family” approaches significance, with the control group having more mean fixations  = 1.86, p = .069). This is indicative of the more densely worded material in the control slides and their low-literacy level. In some cases, control participants had twice the number of pupil fixations compared to the intervention participants, most likely because of the density of the text. This correlates with the observations of real time tracking, where control participants can be seen repeating lines of text or skipping back and forth on the slide.Mean number of pupil fixations on the seven selected slides indicated that the control group spent significantly longer looking at specific words or phrases on three of the slides Table . These ip = .015). Similar patterns are seen in the other slides: “An dirty bomb is not an atomic bomb”  = 5.79, p = .000), “What to do if you’re outside”  = 2.46, p = .018), “What to do if you’re inside”  = 2.91, p = .006), “What should I do about my children and family”  = 3.51, p = .001), “What to do about food and water”  = 5.02, p = .000), and “How do I know about radiation exposure”  = 2.84, p = .007). This correlates with both the eye tracking ratings and the pupil fixation analysis and strengthens the argument that the control participants had a difficult time reading and processing the text-heavy control slides.Table p = .024; What do with family, .409, p = .031; What to do about food/water, .473, p = .006; Radiation Exposure, .406, p = .024). In addition, comparing average time, fixation and tracking ratings by intervention group, the Intervention, Very Low Literacy group had lower time and fixation composite scores  and higher tracking scores (3.32 vs. 2.79). These differences, however, were not significant.In addition to looking at individual slides, composite scores for overall ability to track slides, fixations and time were calculated and then correlated to the dichotomized literacy variable. Pearson Correlations indicates that literacy level was associated with four of the 7 slides on the eye tracking rating ; Know what to do if a bomb blows up  = 2.49, p = .02); My ability to follow instructions if a “dirty bomb” happens  = 2.87, p = .008). These differences were not seen in the Low Literacy by intervention groups.Finally, Independent Samples T-Tests were run comparing effects of the intervention on those with the lowest literacy levels on outcome measures, specifically confidence in knowledge of what a “dirty bomb” is, and intended behavior (i.e. sheltering in place) if one occurred . Table Monitoring of eye tracking in real time and watching video of each participant’s session clearly revealed that in this pilot study the control group participants had a difficult time getting through the dense text. For many of the low-literacy participants, it was obvious that they either chose to randomly glance around the slide text and not systematically work through it, or they began to work through the text, often re-reading given lines several times before giving up and resorting to random looking patterns. In some instances, it seemed that control participants would look off the slide for a period of time before deciding enough time had passed to tell the technician to advance to the next slide. Observing these patterns could be difficult to watch, as the apparent frustration many participants had with the text was evident. These observations were supported by the data, which indicated significant differences in not only the gaze patterns tracked across time, but was also in the measures of time spent at each fixation point, and the total number of fixation points per slide. These differences also remained once tracking fixations and time were combined as a composite score and compared, and when the sample was compared by their literacy level and intervention group. It was clear that the dense text provided in the control condition caused participants to spend more time with trying to get through the text and attempting to read lines more than once. Despite the small sample size of this study, the differences we found in tracking and outcome measures (confidence in knowledge and ability to follow instructions) indicate a large effect size (cohen’s d = .94). However, future studies using eye tracking measures will have to take into account the intent of the trial (eye tracking as outcomes vs. changes in knowledge and behavior) and whether larger sample sizes are required to test the effect of these types of materials are larger audiences.th grade reading level or higher [Clearly, having access to literacy appropriate materials is important. In this study, significant effects on confidence in knowing what a dirty bomb was, how to respond if one occurred and ability to carry out instructions was seen in those with the very lowest literacy. This is a significant finding, indicating that even those with very low literacy can benefit from having information presented in a manner that addresses their needs. Because of the serious consequences of exposure to a “dirty bomb’, it is important that disaster planning and management teams address the accessibility of risk communication materials designed for limited-literacy groups, so that everyone can have equal access to potentially lifesaving information and make informed decisions for themselves and their families. Health literacy studies suggest that a third-to-a-half of the US population has some difficulty using written materials , such asr higher , 51. If Public trust and confidence can help mitigate and improve the ability to manage a terror threat , but thiOn a conceptual level, the goal of effectively communicating a health/risk message to a particular target audience must take into account not only their literacy skills, but also their level of education and experience with the topic being addressed. As such, the design of effective messages strategies requires attention to the task of informing and educating the receiver of the message, and the task of creating an information processing experience that effectively and efficiently optimizes the formatting, graphics, and visual/auditory aspects of message structure. These latter structural elements are critical to optimizing overall processing, learning, motivation, decision making, and behavior. Eye tracking analyses are particularly well suited to understand both the content/educational aspects of message design and the structural information processing aspects, and to understand how difficult it may be to access material that is not developed for those with low literacy. In this pilot study it was clear that low-literacy participants were more comfortable with the decision aid written at their literacy level and were more receptive to its messages; this is especially true in those with the lowest literacy. Eye tracking was thus a viable and useful method for understanding how low literacy adults may respond to and understand emergency communications, informing the development of better, more accessible materials.The limitations of this research include the fact that as a pilot study the sample size is, by design, small. Although this is the case, care was taken to accurately assess the participant's literacy level and to randomly assign participants to the control and intervention test-groups. Future studies should expand the sample size and also expand the geographic scope of the study to explore urban v. suburban differences as well as potential regional differences across the country.There are also other types of eye tracking data that could have been used in the analysis of this study, including saccades and smooth pursuits. These could be useful in larger studies to assess ease of tracking and reading material, especially when video or other interactive activities are incorporated into learning materials. These were not used here. In addition, the subjective eye tracking rating, despite rigorous training of raters and good reliability, is still a source of bias. Perhaps in a larger study this could be compared through a more objective mathematical evaluation of areas of interest and/or machine learning techniques. These measures were not available for this study. In addition, screening participants for visual acuity and vision quality would be advised.Another limitation involves the current focus on the topic of radiological terror events (Dirty Bomb). Individual responses, in terms of information processing, physiological reactions, and knowledge gain will likely vary with different types of content . Public Health officials will have to develop "preparedness" materials for these types of differences as the frequency of such events continues to increase. This may also affect eye tracking results, as information more familiar to an audience may hinder the ability to differentiate as easily between tested materials.A third important limitation of the present study is that it focuses on a particular aspect (literacy) of the audience's ability to access, interpret, and apply critical information about what to do in a particular emergency situation. The eye tracking and message design methodology used in this research can be directly applied to areas other than audience literacy levels. For example, it can be used to design more effective materials for individuals with learning disabilities, or those with limited media-literacy skills, or those needing to access the diverse array of assistive technologies now available.The use of eye tracking is an effective approach to understand how health communication materials are accessed and processed by individuals with limited-literacy skills. We believe that this pilot work clearly demonstrates the feasibility of using these methods on a wider scale to develop more effective health and risk communication messages designed to increase knowledge of and compliance with general health guidelines on the one hand and specific health-based emergency directives on the other. It is also clear that the message design and testing approach has application not only for those with low-literacy, but for those with learning disabilities, those with limited media-literacy skills, and those needing to access the diverse array of assistive technologies now available. The long-term goal is to evolve and refine powerful message design tools that will contribute to effective decision making and the elimination of health disparities evident in educational, social, and personal contexts.CDC, Centers for Disease Control and Prevention; REALM-R, Rapid Estimate of Adult Literacy in Medicine-Revised; RTE, Radiological Terror Event; SILS, Single Item Literacy Screener


Spencer Phillips Hey and Aaron Kesselheim propose that informativeness—asserting scientific facts—rather than truthfulness ought to be the standard for regulating commercial speech about pharmaceuticals. The United States Food and Drug Administration (FDA) generally does not permit pharmaceutical manufacturers to promote their products for non-FDA-approved (“off-label”) indications. A lawsuit filed by Amarin Pharmaceutical in May 2015 sought permission to distribute off-label statements relating to its product Vascepa, because it argued that those statements were “truthful and non-misleading” and that the First Amendment’s protection of commercial speech gave it the right to make those statements. In August 2015, a federal court agreed with Amarin.We argue that Amarin’s argument is faulty, because the so-called “truthful and non-misleading” statement is a tautology—that is, it is only truthful because of its logical construction—not because it is consistent with the state of scientific evidence. Since the off-label marketing statement is actually misleading when viewed from this perspective, the federal court’s conclusion was incorrect.We propose that informativeness in asserting scientific facts, rather than truthfulness, ought to be the gold standard for evaluating commercial speech about pharmaceuticals.In May of 2015, a small Irish pharmaceutical manufacturer, Amarin, caused a major stir when it preemptively filed suit against the United States Food and Drug Administration (FDA) to ensure that it could distribute certain statements about its prescription pill Vascepa, composed of an esterified form of the omega-3 fatty acid eicosapentaenoic acid (EPA), derived from fish oil  ability to engage in truthful and non-misleading speech free from the threat of a misbranding action” . At the C: Supportive but not conclusive research shows that consumption of EPA and docosahexaenoic acid (DHA) omega-3 fatty acids may reduce the risk of coronary heart disease.The FDA argued that although C would be acceptable for promoting a dietary supplement, the statutory standards relating to prescription drugs are higher. Since Vascepa is marketed as a prescription drug, this statement was deemed to be “potentially misleading” about the strength of the evidence ,10. NeveWe can agree with the court that C is in some sense truthful. However, it is not truthful because it is informative about the state of scientific evidence. Instead, it is truthful because it has almost no truth content—that is, the truth of C does not depend upon scientific facts. To illustrate, we can alter the language of C slightly:or may not reduce the risk of coronary heart disease.C*: Supportive but not conclusive research shows that consumption of EPA and DHA omega-3 fatty acids may This alteration makes explicit how the second clause is a tautology—it is trivially true because of its logical construction. A proposition of the form “P or not P” is always true, regardless of the state of scientific evidence. Logically speaking, C* asserts almost nothing about the state of scientific evidence. The “supportive but not conclusive” qualification is therefore a red herring vis-à-vis the truthfulness of C or C*. All this qualification really “says” is that non-conclusive research has been conducted, but then the second half of the claim expresses nothing at all about the clinical import of that research.But the more important point is that the truth content of C does not differ from C*. Yet, C* is almost certainly less likely to persuade physicians that Vascepa is a clinically useful product. This suggests that Amarin’s economic interest can only be furthered by C being misleading. That is, for C to convey the “information” that the company wants it to convey—i.e., that Vascepa is a viable treatment option for reducing the risk of CVD—it needs to be trading off on the ambiguity between two states of affairs: (1) a state of evidence that has confirmed a causal relationship, but for which uncertainty still remains about whether or not this relationship is clinically significant; and (2) a state of evidence that has neither confirmed nor disconfirmed a causal relationship. The current state of scientific evidence concerning EPA is decidedly the latter of these two choices, which is made clearer in C* but is ambiguous in C.Setting aside the specific promotional statements that Amarin wished to make, the case here ultimately boils down to a difference in how the parties interpret the state of scientific evidence and, in particular, how the parties understand the truthfulness of another scientific claim:X: Lowering moderate, persistent triglyceride levels reduces the incidence of CVD among patients already treated with a statin (and diet and exercise).Amarin and the FDA agree that X is not yet known to be either definitively true or false, although, as noted above, the FDA believes there is now good reason to doubt the truth of X. Nevertheless, Amarin is arguing that they should be allowed to market Vascepa as if X is true. In other words, because X is not yet known to be false, then this is sufficient to make Amarin’s statement C—which amounts to saying that “X is possibly true”—truthful and non-misleading.In justifying its position to the federal district court, Amarin also argued that physicians already use triglyceride-lowering drugs in combination with a statin for the off-label indication of interest ,2. That However, there is a problematic circularity of reasoning here. Physicians’ behavior concerning X is conditional on their belief in the truth of another, related claim:Y: Reducing low-density lipoprotein (LDL) cholesterol with a statin reduces the incidence of cardiovascular events.Y has been well confirmed by rigorous investigations, and there are now several statins on the market for which this relationship between the surrogate outcome (reducing LDL cholesterol) and the clinical outcome (incidence of cardiovascular events) holds . The preThis is a prima facie reasonable inference and was the basis for the original agreement between the FDA and Amarin. However, after the signing of that agreement, new evidence emerged casting doubt on the validity of this inference . The relIn its court filings, Amarin responded to this objection by arguing that its drug is different from fenofibrates and niacin, the other two drug classes that had recently failed to uphold the lipid–CVD relationship . Amarin This argument appears to have been decisive to the federal district court judge . HoweverThis analysis reveals a number of important considerations about promotional speech for off-label drug marketing. First, there is a need to distinguish between “truthful claims,” on the one hand, and “informative claims,” on the other. Amarin’s statement about what may or may not be the case as concerns their product is certainly a truthful claim. But it is only vacuously so. It is a tautology, not a statement of empirical fact. A tautology is not misleading in itself; however, disguising a tautology, even as a weak claim about evidence, is misleading. We thus believe that “truthfulness” is not a sufficiently restrictive criterion for regulating promotional speech as concerns off-label medications. A better and clearer standard would demand that promotional claims must be informative, in the sense that they actually have empirical truth content, which is the assurance that FDA review and validation provides.Second, even if Amarin’s claims cannot be considered fraudulent, we believe it would be unethical for a company to rely on misinterpretations of truth in marketing its products. Given how weak the evidence is for EPA having any cardiovascular benefits in the patient population sought by Amarin , it is aFinally, if the possible truth of a scientific claim is sufficient to market a pharmaceutical off-label, then this would seriously undermine the authority of the FDA and potentially erode public trust in the regulatory system . Trust iFor all of these reasons, Amarin’s successful lawsuit providing it the ability to make truthfully-ambiguous claims when marketing its prescription drug products is troubling. There can certainly be disagreement over the state of evidence and the warrant of inferences. But this does not mean that anything goes. The FDA rescinded its agreement with Amarin because of a qualitative shift in the accumulating state of scientific evidence, transforming what would have been a valid scientific claim into an invalid one. This is unfortunate for Amarin, but uncertainty about how evidence will evolve is an intrinsic feature of the scientific enterprise. The truth must evolve accordingly.


The particle sizes of the sediments in the storm-deposited layer became coarser, indicating that the fine-grade compositions spread over a wider range out of the coastal zone.Typhoons have a significant effect on the marine depositional environment and depositional process. In this paper, we used the high-resolution Chirp sonar sub-bottom profiler and radioisotope detection techniques to examine the storm-deposited layer formed in the seawater near the path of Typhoon Saola along the coast of Fujian, China. The thickness of the typhoon-deposited layer acquired using these two methods was 10–25 cm. The thickness, sediment grain size, and δ The source of sediments in the storm layer and the deposition process during the typhoon are discussed by analyzing the distributions of sedimentary thickness, sediment grain size and δ13C in the storm deposition layer. The results may contribute to a better understanding of the formation and identification of storm deposition layers in coastal areas.The present study comprehensively utilized a high-resolution Chirp Sonar Sub-bottom Profiler System and Typhoon Saola was first formed east of the Philippines on July 28, 2012 and moved northwest after its formation. It was strengthened to a typhoon on the afternoon of July 30 and intensified to a strong typhoon at 14:00 on August 1. Typhoon Saola landed on Hualien, Taiwan at 19:00 on August 1. The typhoon gradually weakened and landed second time on Fuding, Fujian at 22:00 on August 2. The maximum wind at the center of the typhoon at the second landing was 33 m/s. The typhoon continued to move into inland Fujian after landing and weakened into a tropical storm. The numbering stopped on the evening of August 3 1516. Typ15The study area was located in the mud depo-area off the Zhejiang-Fujian coast , where t17The characteristics of the shallow stratum profile on the 4 survey profilers are shown in Due to the uniform physical characteristics of seafloor sediments in the study area, the reflection of stratum should be uniform without any sub-reflections just as shown in the reference profiler SL60 ; d-2 and17210Pbex activity, particle size and δ13C in the 4 box-type samples collected in the study area, along with a reference core  are shown in 1713C is shown as a steady pattern with little fluctuations from the top to bottom of sediments with value generally ranging from −23 to −22.4‰ in the 4 cores (13C was decreased to around -26‰ with the increase of sand content in the 2–14 cm depth of sediments (210Pbex (less than 2 dpm/g) and average grain size (range from 7 to 7.4 Φ) in the core ND-1 were relatively uniform from the top to bottom  without significant vertical decay in the top sediments, while it was gradually reduced in the bottom layer. In the upper sediment layer, the grain size was significantly larger than that in the lower sediment layer in the 3 cores. The variations of the content of 210Pbex, average grain size and sand content in the sediments were similar in the 3 cores. The distribution of 210Pbex in the reference core MJK9 showed a different pattern, with high value and significant vertical decay (from 5 decreased to 2 dpm/g) in the top 28 cm, while it was low and stable (less than 2 dpm/g) in the bottom layer. The average grain size in the upper layer was slightly larger than that in the bottom layer  by Typhoon Saola was distinguished in the mud depo-area off the Zhejiang-Fujian coast. The distribution patterns of 210Pbex, showing that a gradually radioactive decaying sediment layer covered by a stable and high-content 210Pbex top sediments in the typhoon-affected area, were significantly different from that in a reference station (MJK9), in which the 210Pbex content gradually decayed from top to bottom sediments (210Pbex content in the whole core of ND-1 was very low (<2 dpm/g) compared with other cores (mainly higher than 4 dpm/g). This distribution pattern indicated that the sediment in the top of core ND-1 was mainly old deposit, and there was no sediment deposition during the typhoon processes. At the other stations, the variations in 210Pbex content indicated that the storm-deposited (disturbed) layer was relatively thick. The difference in the physical properties between the upper and bottom sediment layers was significant, and the storm-deposited (disturbance) layer was identified on the shallow stratum profile.The Chirp sonar sub-bottom profiler can distinguish and detect the reflections of shallow stratum due to the different physical properties of sediments. The ediments . It was ediments ; a-2. Th13C value of the sediments in the 4 cores sediment did not vary significantly  and the distributions of sediment grain size and the δ13C values, we preliminarily examined the material source and deposition process of the storm sediment layer. The results indicated that a 10–25 cm storm-deposited (disturbed) layer was formed near the path of Typhoon Saola in the Fujian coastal area, and the sediment mainly came from the re-suspension of seafloor materials. The grain size in the storm-deposited layer became coarser, which indicated that the fine-grained compositions spread across a wider range after the typhoon, thus increasing the material transport flux in the seawater. Typhoons play a significant role in the modern marine sedimentary process, and the combining use of the shallow stratum profile detection technique and radioactive geochemical method provides a new approach for estimating typhoon effects on modern sedimentary processes.In summary, this study used the Chirp sonar sub-bottom profiler and radioisotope method to determine the storm-deposited layer formed (disturbed) by Typhoon Saola in a mud depo-area off the Zhejiang-Fujian coast. By combining the thickness of the sediment layer , with a measuring error within 3%, and an elementary analysis-isotope ratio mass spectrometers (EA-IRMS) (Flash EA 1112 HT-Delta V Advantages), with a measuring error within ±0.2%. The 210Pb radioisotope activities of the sediment were analyzed in 3- to 4-cm intervals by gamma spectrometry.A high-resolution EdgeTech 0512i Chirp Sonar Sub-bottom Profiler (frequency range: 1–10 kHz/5 ms) was used to obtain 3 seismic lines (51.79 km) on August 14, 2012 around the path of Typhoon Saola in a mud depo-area off the Zhejiang-Fujian coast, and a reference seismic line SL60 (8.38 km) was obtained on August 19, 2012 in the inner-shelf off the Minjiang Estuary using the same profiler . An acouHow to cite this article: Li, Y. et al. Storm deposition layer on the Fujian coast generated by Typhoon Saola (2012). Sci. Rep.5, 14904; doi: 10.1038/srep14904 (2015).