systematic review research waste

A systematic review of the impacts of open burning and open dumping of waste in Ghana: A way forward for sustainable waste management

Anokye, Kwame
Mohammed, Asaah Sumaila
Agyemang, Portia
Agya, Bosompem Ahunoabobirim
Amuah, Ebenezer Ebo Yahans
Sodoke, Stephen

Waste management (WM) is a growing concern in Ghana, characterised by the widespread practice of open dumping and burning of waste. These unsustainable methods have raised significant environmental, health, and social concerns. This systematic review aims to comprehensively analyse the impacts of waste burning and open dumping in Ghana and propose a sustainable way forward for waste management. A systematic search of peer-reviewed articles, reports, and government documents was conducted using various academic databases and official websites. Studies published from 2000 to 2024 were included, focusing on the environmental, health, and socioeconomic impacts of waste burning and open dumping. Relevant sources were identified and critically assessed. The review revealed that open dumping and waste burning have substantial adverse impacts. The effects of waste burning and open dumping necessitate a holistic approach to address these challenges. This includes infrastructure development, implementation and enforcement of WM regulations, community engagement, technological solutions, promotion of recycling technologies, and public-private partnerships. By adopting these strategies, Ghana can mitigate the adverse effects of inappropriate waste disposal, protect public health, preserve the environment, and make significant progress toward a cleaner, healthier, and more sustainable future. This review contributes valuable insights for policymakers, researchers, and stakeholders committed to addressing the WM crisis in Ghana. It is a foundation for further research and action in this critical field.

Waste disposal;
Burning of waste;
Air pollution;
Land degradation;
Climate change;
Sustainable waste management

Here’s how you know

U.S. Department of Health and Human Services
National Institutes of Health

Meditation and Mindfulness: Effectiveness and Safety

.header_greentext{color:green!important;font-size:24px!important;font-weight:500!important;}.header_bluetext{color:blue!important;font-size:18px!important;font-weight:500!important;}.header_redtext{color:red!important;font-size:28px!important;font-weight:500!important;}.header_darkred{color:#803d2f!important;font-size:28px!important;font-weight:500!important;}.header_purpletext{color:purple!important;font-size:31px!important;font-weight:500!important;}.header_yellowtext{color:yellow!important;font-size:20px!important;font-weight:500!important;}.header_blacktext{color:black!important;font-size:22px!important;font-weight:500!important;}.header_whitetext{color:white!important;font-size:22px!important;font-weight:500!important;}.header_darkred{color:#803d2f!important;}.Green_Header{color:green!important;font-size:24px!important;font-weight:500!important;}.Blue_Header{color:blue!important;font-size:18px!important;font-weight:500!important;}.Red_Header{color:red!important;font-size:28px!important;font-weight:500!important;}.Purple_Header{color:purple!important;font-size:31px!important;font-weight:500!important;}.Yellow_Header{color:yellow!important;font-size:20px!important;font-weight:500!important;}.Black_Header{color:black!important;font-size:22px!important;font-weight:500!important;}.White_Header{color:white!important;font-size:22px!important;font-weight:500!important;} What are meditation and mindfulness?

Meditation has a history that goes back thousands of years, and many meditative techniques began in Eastern traditions. The term “meditation” refers to a variety of practices that focus on mind and body integration and are used to calm the mind and enhance overall well-being. Some types of meditation involve maintaining mental focus on a particular sensation, such as breathing, a sound, a visual image, or a mantra, which is a repeated word or phrase. Other forms of meditation include the practice of mindfulness, which involves maintaining attention or awareness on the present moment without making judgments.

Programs that teach meditation or mindfulness may combine the practices with other activities. For example, mindfulness-based stress reduction is a program that teaches mindful meditation, but it also includes discussion sessions and other strategies to help people apply what they have learned to stressful experiences. Mindfulness-based cognitive therapy integrates mindfulness practices with aspects of cognitive behavioral therapy.

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Meditation and mindfulness practices usually are considered to have few risks. However, few studies have examined these practices for potentially harmful effects, so it isn’t possible to make definite statements about safety.

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A 2020 review examined 83 studies (a total of 6,703 participants) and found that 55 of those studies reported negative experiences related to meditation practices. The researchers concluded that about 8 percent of participants had a negative effect from practicing meditation, which is similar to the percentage reported for psychological therapies. The most commonly reported negative effects were anxiety and depression. In an analysis limited to 3 studies (521 participants) of mindfulness-based stress reduction programs, investigators found that the mindfulness practices were not more harmful than receiving no treatment.

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According to the National Health Interview Survey, an annual nationally representative survey, the percentage of U.S. adults who practiced meditation more than doubled between 2002 and 2022, from 7.5 to 17.3 percent. Of seven complementary health approaches for which data were collected in the 2022 survey, meditation was the most popular, beating out yoga (used by 15.8 percent of adults), chiropractic care (11.0 percent), massage therapy (10.9 percent), guided imagery/progressive muscle relaxation (6.4 percent), acupuncture (2.2 percent), and naturopathy (1.3 percent).

For children aged 4 to 17 years, data are available for 2017; in that year, 5.4 percent of U.S. children used meditation.

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In a 2012 U.S. survey, 1.9 percent of 34,525 adults reported that they had practiced mindfulness meditation in the past 12 months. Among those responders who practiced mindfulness meditation exclusively, 73 percent reported that they meditated for their general wellness and to prevent diseases, and most of them (approximately 92 percent) reported that they meditated to relax or reduce stress. In more than half of the responses, a desire for better sleep was a reason for practicing mindfulness meditation.

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Meditation and mindfulness practices may have a variety of health benefits and may help people improve the quality of their lives. Recent studies have investigated if meditation or mindfulness helps people manage anxiety, stress, depression, pain, or symptoms related to withdrawal from nicotine, alcohol, or opioids.

Other studies have looked at the effects of meditation or mindfulness on weight control or sleep quality.

However, much of the research on these topics has been preliminary or not scientifically rigorous. Because the studies examined many different types of meditation and mindfulness practices, and the effects of those practices are hard to measure, results from the studies have been difficult to analyze and may have been interpreted too optimistically.

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A 2018 NCCIH-supported analysis of 142 groups of participants with diagnosed psychiatric disorders such as anxiety or depression examined mindfulness meditation approaches compared with no treatment and with established evidence-based treatments such as cognitive behavioral therapy and antidepressant medications. The analysis included more than 12,000 participants, and the researchers found that for treating anxiety and depression, mindfulness-based approaches were better than no treatment at all, and they worked as well as the evidence-based therapies.
A 2021 analysis of 23 studies (1,815 participants) examined mindfulness-based practices used as treatment for adults with diagnosed anxiety disorders. The studies included in the analysis compared the mindfulness-based interventions (alone or in combination with usual treatments) with other treatments such cognitive behavioral therapy, psychoeducation, and relaxation. The analysis showed mixed results for the short-term effectiveness of the different mindfulness-based approaches. Overall, they were more effective than the usual treatments at reducing the severity of anxiety and depression symptoms, but only some types of mindfulness approaches were as effective as cognitive behavioral therapy. However, these results should be interpreted with caution because the risk of bias for all of the studies was unclear. Also, the few studies that followed up with participants for periods longer than 2 months found no long-term effects of the mindfulness-based practices.
A 2019 analysis of 23 studies that included a total of 1,373 college and university students looked at the effects of yoga, mindfulness, and meditation practices on symptoms of stress, anxiety, and depression. Although the results showed that all the practices had some effect, most of the studies included in the review were of poor quality and had a high risk of bias.

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Few high-quality studies have examined the effects of meditation and mindfulness on blood pressure. According to a 2017 statement from the American Heart Association, the practice of meditation may have a possible benefit, but its specific effects on blood pressure have not been determined.

A 2020 review of 14 studies (including more than 1,100 participants) examined the effects of mindfulness practices on the blood pressure of people who had health conditions such as hypertension, diabetes, or cancer. The analysis showed that for people with these health conditions, practicing mindfulness-based stress reduction was associated with a significant reduction in blood pressure.

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Studies examining the effects of mindfulness or meditation on acute and chronic pain have produced mixed results.

A 2020 report by the Agency for Healthcare Research and Quality concluded that mindfulness-based stress reduction was associated with short-term (less than 6 months) improvement in low-back pain but not fibromyalgia pain.
A 2020 NCCIH-supported analysis of five studies of adults using opioids for acute or chronic pain (with a total of 514 participants) found that meditation practices were strongly associated with pain reduction.
Acute pain, such as pain from surgery, traumatic injuries, or childbirth, occurs suddenly and lasts only a short time. A 2020 analysis of 19 studies examined the effects of mindfulness-based therapies for acute pain and found no evidence of reduced pain severity. However, the same analysis found some evidence that the therapies could improve a person’s tolerance for pain.
A 2017 analysis of 30 studies (2,561 participants) found that mindfulness meditation was more effective at decreasing chronic pain than several other forms of treatment. However, the studies examined were of low quality.
A 2019 comparison of treatments for chronic pain did an overall analysis of 11 studies (697 participants) that evaluated cognitive behavioral therapy, which is the usual psychological intervention for chronic pain; 4 studies (280 participants) that evaluated mindfulness-based stress reduction; and 1 study (341 participants) of both therapies. The comparison found that both approaches were more effective at reducing pain intensity than no treatment, but there was no evidence of any important difference between the two approaches.
A 2019 review found that mindfulness-based approaches did not reduce the frequency, length, or pain intensity of headaches. However, the authors of this review noted that their results are likely imprecise because only five studies (a total of 185 participants) were included in the analysis, and any conclusions made from the analysis should be considered preliminary.

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Mindfulness meditation practices may help reduce insomnia and improve sleep quality.

A 2019 analysis of 18 studies (1,654 total participants) found that mindfulness meditation practices improved sleep quality more than education-based treatments. However, the effects of mindfulness meditation approaches on sleep quality were no different than those of evidence-based treatments such as cognitive behavioral therapy and exercise.

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Several clinical trials have investigated if mindfulness-based approaches such as mindfulness-based relapse prevention (MBRP) might help people recover from substance use disorders. These approaches have been used to help people increase their awareness of the thoughts and feelings that trigger cravings and learn ways to reduce their automatic reactions to those cravings.

A 2018 review of 37 studies (3,531 total participants) evaluated the effectiveness of several mindfulness-based approaches to substance use disorder treatment and found that they significantly decreased participants’ craving levels. The mindfulness-based practices were slightly better than other therapies at promoting abstinence from substance use.
A 2017 analysis specifically focused on MBRP examined 9 studies (901 total participants) of this approach. The analysis concluded that MBRP was not more effective at preventing substance use relapses than other treatments such as health education and cognitive behavioral therapy. However, MBRP did slightly reduce cravings and symptoms of withdrawal associated with alcohol use disorders.

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Studies have suggested that meditation and mindfulness may help reduce symptoms of post-traumatic stress disorder (PTSD).

A 2018 review supported by NCCIH examined the effects of meditation (in 2 studies, 179 total participants) and other mindfulness-based practices (in 6 studies, 332 total participants) on symptoms of PTSD. Study participants included veterans, nurses, and people who experienced interpersonal violence. Six of the eight studies reported that participants had a reduction of PTSD symptoms after receiving some form of mindfulness-based treatment.
A 2018 clinical trial funded by the U.S. Department of Defense compared the effectiveness of meditation, health education, and prolonged exposure therapy, a widely accepted treatment for PTSD recommended by the American Psychological Association. Prolonged exposure therapy helps people reduce their PTSD symptoms by teaching them to gradually remember traumatic memories, feelings, and situations. The study included 203 veterans with PTSD as a result of their active military service. The results of the study showed that meditation was as effective as prolonged exposure therapy at reducing PTSD symptoms and depression, and it was more effective than PTSD health education. The veterans who used meditation also showed improvement in mood and overall quality of life.

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Mindfulness-based approaches may improve the mental health of people with cancer.

A 2019 analysis of 29 studies (3,274 total participants) of mindfulness-based practices showed that use of mindfulness practices among people with cancer significantly reduced psychological distress, fatigue, sleep disturbance, pain, and symptoms of anxiety and depression. However, most of the participants were women with breast cancer, so the effects may not be similar for other populations or other types of cancer.

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Studies have suggested possible benefits of meditation and mindfulness programs for losing weight and managing eating behaviors.

A 2017 review of 15 studies (560 total participants) looked at the effects of mindfulness-based practices on the mental and physical health of adults with obesity or who were overweight. The review found that these practices were very effective methods for managing eating behaviors but less effective at helping people lose weight. Mindfulness-based approaches also helped participants manage symptoms of anxiety and depression.
A 2018 analysis of 19 studies (1,160 total participants) found that mindfulness programs helped people lose weight and manage eating-related behaviors such as binge, emotional, and restrained eating. The results of the analysis showed that treatment programs, such as mindfulness-based stress reduction and mindfulness-based cognitive therapy, that combine formal meditation and mindfulness practices with informal mindfulness exercises were especially effective methods for losing weight and managing eating.

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Several studies have been done on using meditation and mindfulness practices to improve symptoms of attention-deficit hyperactivity disorder (ADHD). However, the studies have not been of high quality and the results have been mixed, so evidence that meditation or mindfulness approaches will help people manage symptoms of ADHD is not conclusive.

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Some research suggests that meditation and mindfulness practices may affect the functioning or structure of the brain. Studies have used various methods of measuring brain activity to look for measurable differences in the brains of people engaged in mindfulness-based practices. Other studies have theorized that training in meditation and mindfulness practices can change brain activity. However, the results of these studies are difficult to interpret, and the practical implications are not clear.

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NCCIH supports a variety of meditation and mindfulness studies, including:

An evaluation of how the brain responds to the use of mindfulness meditation as part of a combined treatment for migraine pain.
A study of the effectiveness of mindfulness therapy and medication (buprenorphine) as a treatment for opioid use disorder.
A study of a mindfulness training program designed to help law enforcement officers improve their mental health by managing stress and increasing resilience.

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Don’t use meditation or mindfulness to replace conventional care or as a reason to postpone seeing a health care provider about a medical problem.
Ask about the training and experience of the instructor of the meditation or mindfulness practice you are considering.
Take charge of your health—talk with your health care providers about any complementary health approaches you use. Together, you can make shared, well-informed decisions

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Nccih clearinghouse.

The NCCIH Clearinghouse provides information on NCCIH and complementary and integrative health approaches, including publications and searches of Federal databases of scientific and medical literature. The Clearinghouse does not provide medical advice, treatment recommendations, or referrals to practitioners.

Toll-free in the U.S.: 1-888-644-6226

Telecommunications relay service (TRS): 7-1-1

Website: https://www.nccih.nih.gov

Email: [email protected] (link sends email)

Know the Science

NCCIH and the National Institutes of Health (NIH) provide tools to help you understand the basics and terminology of scientific research so you can make well-informed decisions about your health. Know the Science features a variety of materials, including interactive modules, quizzes, and videos, as well as links to informative content from Federal resources designed to help consumers make sense of health information.

Explaining How Research Works (NIH)

Know the Science: How To Make Sense of a Scientific Journal Article

Understanding Clinical Studies (NIH)

A service of the National Library of Medicine, PubMed® contains publication information and (in most cases) brief summaries of articles from scientific and medical journals. For guidance from NCCIH on using PubMed, see How To Find Information About Complementary Health Approaches on PubMed .

Website: https://pubmed.ncbi.nlm.nih.gov/

NIH Clinical Research Trials and You

The National Institutes of Health (NIH) has created a website, NIH Clinical Research Trials and You, to help people learn about clinical trials, why they matter, and how to participate. The site includes questions and answers about clinical trials, guidance on how to find clinical trials through ClinicalTrials.gov and other resources, and stories about the personal experiences of clinical trial participants. Clinical trials are necessary to find better ways to prevent, diagnose, and treat diseases.

Website: https://www.nih.gov/health-information/nih-clinical-research-trials-you

Research Portfolio Online Reporting Tools Expenditures & Results (RePORTER)

RePORTER is a database of information on federally funded scientific and medical research projects being conducted at research institutions.

Website: https://reporter.nih.gov

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Anheyer D, Leach MJ, Klose P, et al. Mindfulness-based stress reduction for treating chronic headache: a systematic review and meta-analysis . Cephalalgia . 2019;39(4):544-555.
Black LI, Barnes PM, Clarke TC, Stussman BA, Nahin RL. Use of yoga, meditation, and chiropractors among U.S. children aged 4–17 years . NCHS Data Brief, no 324. Hyattsville, MD: National Center for Health Statistics. 2018.
Breedvelt JJF, Amanvermez Y, Harrer M, et al. The effects of meditation, yoga, and mindfulness on depression, anxiety, and stress in tertiary education students: a meta-analysis . Frontiers in Psychiatry . 2019;10:193.
Burke A, Lam CN, Stussman B, et al. Prevalence and patterns of use of mantra, mindfulness and spiritual meditation among adults in the United States . BMC Complementary and Alternative Medicine. 2017;17(1):316.
Carrière K, Khoury B, Günak MM, et al. Mindfulness‐based interventions for weight loss: a systematic review and meta‐analysis . Obesity Reviews . 2018;19(2):164-177.
Cavicchioli M, Movalli M, Maffei C. The clinical efficacy of mindfulness-based treatments for alcohol and drugs use disorders: a meta-analytic review of randomized and nonrandomized controlled trials . European Addiction Research . 2018;24(3):137-162.
Cillessen L, Johannsen M, Speckens AEM, et al. Mindfulness‐based interventions for psychological and physical health outcomes in cancer patients and survivors: a systematic review and meta‐analysis of randomized controlled trials . Psychooncology . 2019;28(12):2257-2269.
Creswell JD. Mindfulness interventions . Annual Review of Psychology. 2017;68:491-516.
Davidson RJ, Kaszniak AW. Conceptual and methodological issues in research on mindfulness and meditation . American Psychologist. 2015;70(7):581-592.
Farias M, Maraldi E, Wallenkampf KC, et al. Adverse events in meditation practices and meditation-based therapies: a systematic review . Acta Psychiatrica Scandinavica. 2020;142(5):374-393.
Garland EL, Brintz CE, Hanley AW, et al. Mind-body therapies for opioid-treated pain: a systematic review and meta-analysis . JAMA Internal Medicine . 2020;180(1):91-105.
Goldberg SB, Tucker RP, Greene PA, et al. Mindfulness-based interventions for psychiatric disorders: a systematic review and meta-analysis . Clinical Psychology Review . 2018;59:52-60.
Grant S, Colaiaco B, Motala A, et al. Mindfulness-based relapse prevention for substance use disorders: a systematic review and meta-analysis . Journal of Addiction Medicine . 2017;11(5):386-396.
Haller H, Breilmann P, Schröter M et al. A systematic review and meta‑analysis of acceptance and mindfulness‑based interventions for DSM‑5 anxiety disorders . Scientific Reports . 2021;11(1):20385.
Hilton L, Hempel S, Ewing BA, et al. Mindfulness meditation for chronic pain: systematic review and meta-analysis . Annals of Behavioral Medicine. 2017;51(2):199-213.
Hirshberg MJ, Goldberg SB, Rosenkranz M, et al. Prevalence of harm in mindfulness-based stress reduction . Psychological Medicine. August 18, 2020. [Epub ahead of print].
Intarakamhang U, Macaskill A, Prasittichok P. Mindfulness interventions reduce blood pressure in patients with non-communicable diseases: a systematic review and meta-analysis . Heliyon. 2020;6(4):e03834.
Khoo E-L, Small R, Cheng W, et al. Comparative evaluation of group-based mindfulness-based stress reduction and cognitive behavioural therapy for the treatment and management of chronic pain: a systematic review and network meta-analysis . Evidence-Based Mental Health. 2019;22(1):26-35.
Levine GN, Lange RA, Bairey-Merz CN, et al. Meditation and cardiovascular risk reduction: a scientific statement from the American Heart Association . Journal of the American Heart Association. 2017;6(10):e002218.
Nidich S, Mills PJ, Rainforth M, et al. Non-trauma-focused meditation versus exposure therapy in veterans with post-traumatic stress disorder: a randomised controlled trial . Lancet Psychiatry . 2018;5(12):975-986.
Niles BL, Mori DL, Polizzi C, et al. A systematic review of randomized trials of mind-body interventions for PTSD . Journal of Clinical Psychology . 2018;74(9):1485-1508.
Rogers JM, Ferrari M, Mosely K, et al. Mindfulness-based interventions for adults who are overweight or obese: a meta-analysis of physical and psychological health outcomes . Obesity Reviews . 2017;18(1):51-67.
Rosenkranz MA, Dunne JD, Davidson RJ. The next generation of mindfulness-based intervention research: what have we learned and where are we headed? Current Opinion in Psychology. 2019;28:179-183.
Rusch HL, Rosario M, Levison LM, et al. The effect of mindfulness meditation on sleep quality: a systematic review and meta-analysis of randomized controlled trials . Annals of the New York Academy of Sciences . 2019;1445(1):5-16.
Schell LK, Monsef I, Wöckel A, et al. Mindfulness-based stress reduction for women diagnosed with breast cancer. Cochrane Database of Systematic Reviews. 2019;3(3):CD011518. Accessed at cochranelibrary.com on June 3, 2022.
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American Academy of Pediatrics Section on Integrative Medicine. Mind-body therapies in children and youth. Pediatrics . 2016;138(3):e20161896.
Coronado-Montoya S, Levis AW, Kwakkenbos L, et al. Reporting of positive results in randomized controlled trials of mindfulness-based mental health interventions. PLoS One . 2016;11(4):e0153220.
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Acknowledgments

Thanks to Elizabeth Ginexi, Ph.D., Erin Burke Quinlan, Ph.D., and David Shurtleff, Ph.D., NCCIH, for their review of this 2022 publication.

This publication is not copyrighted and is in the public domain. Duplication is encouraged.

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Anne-Farah Usman 3 , 4 ,
Ayumi Yonezawa 3 , 4 ,
Shane McCarthy 3 , 7 ,
Danielle Herrera 3 , 8 ,
Denise Vargas 3 , 4 ,
Emaad M Mir 3 , 4 ,
Talha Syed 3 , 9 ,
Sanam Desai 3 ,
Hector Shi 3 , 9 ,
William Kim 3 , 10 ,
Natalie Puhar 3 , 9 ,
Kushi Gowda 3 , 11 ,
Olivia Nowak 3 , 12 ,
Jin Kuang 3 , 13 ,
Flor Quiroz 3 , 9 ,
Eduardo L Caputo 14 ,
http://orcid.org/0000-0001-8882-1994 Qian Yu 13 ,
JJ Pionke 15 ,
http://orcid.org/0000-0001-6411-5710 Liye Zou 13 ,
http://orcid.org/0000-0002-6679-9551 Lauren B Raine 16 , 17 ,
http://orcid.org/0000-0003-3634-7463 Gabriele Gratton 9 , 18 ,
http://orcid.org/0000-0002-7579-2773 Monica Fabiani 9 , 18 ,
http://orcid.org/0000-0002-0204-8257 David R Lubans 19 , 20 , 21 ,
Pedro C Hallal 3 ,
http://orcid.org/0000-0001-7288-7921 Dominika M Pindus 3 , 18 , 22
1 Postgraduate Program in Epidemiology , Universidade Federal do Rio Grande do Sul , Porto Alegre , Brazil
2 Institute of Psychology , Jagiellonian University , Krakow , Poland
3 Department of Health and Kinesiology , University of Illinois Urbana-Champaign , Urbana , Illinois , USA
4 The School of Cellular and Molecular Biology , University of Illinois Urbana-Champaign , Urbana , Illinois , USA
5 Department of Kinesiology , University of North Carolina at Greensboro , Greensboro , North Carolina , USA
6 School of Integrative Biology , University of Illinois Urbana-Champaign , Urbana , Illinois , USA
7 Department of Physiology and Biophysics , University of Illinois College of Medicine , Chicago , Illinois , USA
8 Department of Surgery , Ann and Robert Lurie Children’s Hospital , Chicago , Illinois , USA
9 Department of Psychology , University of Illinois Urbana-Champaign , Urbana , Illinois , USA
10 Department of Economics , University of Illinois Urbana-Champaign , Urbana , Illinois , USA
11 College of Medicine Peoria , University of Illinois , Peoria , Illinois , USA
12 Research & Development Solutions , IQVIA , Overland Park , Kansas , USA
13 School of Psychology , Shenzhen University , Shenzhen , People's Republic of China
14 School of Public Health , Brown University , Providence , Rhode Island , USA
15 iSchool , Syracuse University , Syracuse , New York , USA
16 Department of Physical Therapy, Movement & Rehabilitation Sciences , Northeastern University , Boston , Massachusetts , USA
17 Department of Medical Sciences , Northeastern University , Boston , Massachusetts , USA
18 Beckman Institute for Advanced Science and Technology , University of Illinois Urbana-Champaign , Urbana , Illinois , USA
19 College of Human and Social Futures , University of Newcastle Australia , Callaghan , New South Wales , Australia
20 Hunter Medical Research Institute , New Lambton Heights , New South Wales , Australia
21 Faculty of Sport and Health Sciences , University of Jyväskylä , Jyväskylä , Finland
22 Neuroscience Program , University of Illinois Urbana-Champaign , Urbana , Illinois , USA
Correspondence to Dr Dominika M Pindus; pindus{at}illinois.edu

Objective To examine the acute and chronic effects of reducing prolonged sedentary time (ST) with physical activity (PA) on cognitive and brain health.

Design Systematic review and meta-analysis.

Data sources PubMed, Scopus, CINAHL, PsycINFO, SPORTDiscus, Web of Science, and ProQuest Dissertation and Theses.

Eligibility criteria Randomised controlled trials (RCTs) published from inception to 17 June 2024, with healthy participants without cognitive impairment or neurological conditions that affect cognitive functioning, aged ≥4 years, testing acute and chronic effects of reducing ST and/or prolonged ST by reallocating ST to PA on cognitive function, brain function, and structure.

Results We included 25 RCTs (n=1289) investigating acute (21 studies) and chronic (4 studies) effects on cognitive function (acute: n=20, chronic: n=4) and brain function (acute: n=7, chronic: n=1); there were no studies on brain structure. Acutely interrupting continuous ST with either multiple or a single PA bout improved cognitive function measured from 3 hours to three consecutive days based on 91 effect sizes ( g =0.17, 95% CI: 0.05 to 0.29, p=0.005, I 2 =45.5%). When comparing single versus multiple PA bouts, only multiple PA bouts yielded a positive effect on cognitive function based on 72 effect sizes ( g =0.20, 95% CI: 0.06 to 0.35, p=0.006; I 2 =48.8%). Chronic studies reported null findings on cognitive function (n=4), with some evidence of improved neural efficiency of the hippocampus (n=1).

Conclusion Interrupting ST with PA acutely improves cognitive function. The evidence from chronic studies remains inconclusive.

Systematic review registration PROSPERO CRD42020200998.

sedentary behavior
physical activity

Data availability statement

Data are available in a public, open access repository. All data used in this study are publicly available in the Open Science Framework: https://osf.io/wkyrb/?view_only=53fcae98b76b4f9e91f9208694512415 .

https://doi.org/10.1136/bjsports-2024-108444

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Correction notice This article has been corrected since it published Online First. The author ORCID details have been updated.

Contributors NF: drafted the manuscript and performed data analysis; TSL: acquired the data and performed qualitative data analysis; NB, RJS: screened and acquired the data; NP, TA, A-FU, AY, SM, DH, DV, EMM, TS, SD, HS, WK, KG, ON, FQ, ELC: screened the data; JJP: codesigned search strategies; TSL, LR, PCH: contributed to data interpretation; DMMP conceived of the work presented in the manuscript, designed search strategies, acquired the data, drafted the manuscript. All authors have critically reviewed the manuscript for important intellectual content. DP acts as a guarantor for the study.

Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. NF is funded by the CNPq (150161/2023-9). TSL is funded by the National Science Centre, Poland (2021/43/D/HS6/02959). LY was supported by Shenzhen Educational Research Funding [grant number zdzb2014], Shenzhen Science and Technology Innovation Commission [grant number 202307313000096], Social Science Foundation from the China’s Ministry of Education [grant number 23YJA880093], The Post-doctoral Fellowship [grant number 2022M711174], The National Center for Mental Health [grant number Z014], and Research Excellence Scholarships of Shenzhen University [grant number ZYZD2305] MF and GG are funded by the National Institute on Aging [grant numbers R01AG059878 and RF1AG062666]. DMP is funded by the National Institute on Aging [grant numbers R21AG080411-01A1 and R01AG059878].

Competing interests None declared.

Provenance and peer review Not commissioned; externally peer reviewed.

Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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The effects of the addition of strontium on the biological response to calcium phosphate biomaterials: a systematic review.

1. Introduction

2. material and methods, 2.1. database search strategy, 2.2. selection and eligibility criteria, 2.3. quality assessment of the selected studies and data extraction, 3.1. database search, 3.2. quality assessment, 4. discussion, 4.1. functionalization with strontium, 4.2. strontium release, 4.3. in vitro studies, 4.4. in vivo studies, 4.5. involvement of signaling pathways, 5. conclusions, author contributions, institutional review board statement, informed consent statement, data availability statement, acknowledgments, conflicts of interest.

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Click here to enlarge figure

Database	Search Key
PubMed	(“tissue engineering”[tiab] OR “Bone repair”[tiab] OR “Bone therapy”[tiab] OR “bone regeneration”[tiab] OR osteoblast[tiab] OR “Bone tissue” [tiab] OR “bone cell”[tiab] OR “mesenchymal stem cell”[tiab] OR “Mesenchymal Progenitor Cell”[tiab] OR “Bone Marrow Stromal Cells” [tiab] OR preosteoblast[tiab] OR osteocyte[tiab]) AND (“Strontium”[Mesh] OR SR [tiab] OR SR2+[tiab] OR strontium [tiab] OR “strontium-containing hydroxyapatite” [Supplementary Concept]) AND (“Hydroxyapatites”[Mesh] OR Hydroxyapatite[tiab] OR Ca10(PO4)6(OH)2 [tiab] OR “tricalcium phosphate”[tiab] OR “biphasic calcium phosphate”[tiab] OR BCP[tiab] OR beta-TCP[tiab] OR B-TCP[tiab] OR alpha-TCP[tiab] OR brushite[tiab] OR monetite[tiab] OR durapatite [tiab] OR HA[tiab] OR HAp[tiab] OR “amorphous calcium phosphate”[tiab]OR “calcium phosphate”[tiab]) AND (“Biocompatible Materials”[Mesh] OR biomaterial[tiab] OR “smart material”[tiab] OR “Biomimetic Material” OR “Biomimetic Materials”[mesh] OR “Biomimicry Material”[tiab]) AND (biocompatib[tiab] OR osteogen[tiab] OR cytocompatib[tiab] OR osteoind[tiab] OR osteoconduc[tiab] OR clinic[tiab] OR surg[tiab])
Scopus	TITLE-ABS-KEY (“tissue engineering” OR “Bone therapy” OR “bone regeneration” OR osteoblast* OR “Bone tissue” OR “bone cell” OR “mesenchymal stem cell” OR “Mesenchymal Progenitor Cell” OR “Bone Marrow Stromal Cells” OR preosteoblast OR osteocyte) AND TITLE-ABS-KEY (sr OR sr2* OR strontium OR “strontium-containing hydroxyapatite”) AND TITLE-ABS-KEY (“Biocompatible Materials” OR biomaterial* OR “smart material” OR “Biomimetic Material” OR “Biomimicry Material”) AND TITLE-ABS-KEY (biocompatib OR osteogen* OR cytocompatib* OR osteoind* OR osteoconduc* OR clinic* OR surg*) AND (LIMIT-TO (DOCTYPE, “ar”))
Web of Science	(tw:(“tissue engineering” OR “Bone repair” OR “Bone therapy” OR “bone regeneration” OR osteoblast* OR “Bone tissue” OR “bone cell” OR “mesenchymal stem cell” OR “Mesenchymal Progenitor Cell” OR “Bone Marrow Stromal Cells” OR preosteoblast* OR osteocyte)) AND (tw:(sr OR sr2+ OR strontium OR “strontium-containing hydroxyapatite”)) AND (tw:(“Biocompatible Materials” OR biomaterial OR “smart material” OR “Biomimetic Material” OR “Biomimicry Material”)) AND (tw:(biocompatib OR osteogen* OR cytocompatib* OR osteoind* OR osteoconduc* OR clinic* OR surg*)) AND (instance:”regional”) AND (type:(“article”))

Publication	Group I: Test Substance Identification	Group II: Test System Characterization	Group III: Study Design Description	Group IV: Study Results Documentation	Group V: Plausibility of Study Design and Data	Total

Aina et al. [ ]	4	2	5	3	2	16
Alkhraisat et al. [ ]	4	2	4	3	2	15
Alkhraisat et al. [ ]	4	4	6	3	2	19
Birgani et al. [ ]	4	3	5	3	2	17
Boanini et al. [ ]	4	2	5	3	2	16
Boanini et al. [ ]	4	2	6	3	2	17
Bracci et al. [ ]	4	2	5	3	2	17
Capuccini a et al. [ ]	4	2	5	3	2	16
Chen et al. [ ]	4	2	5	3	2	16
Chen et al. [ ]	4	2	4	3	2	15
Chen et al. [ ]	4	2	5	3	2	16
Chung et al. [ ]	4	1	5	3	2	15
De Lima et al. [ ]	4	3	6	3	2	18
Gu et al. [ ]	4	3	6	3	2	18
Gu et al. [ ]	4	2	6	3	2	17
Gu et al. [ ]	4	2	6	3	2	17
Harrison et al. [ ]	4	2	6	3	2	17
Hernández et al. [ ]	4	1	5	3	2	15
Huang et al. [ ]	4	3	6	3	2	18
Huang et al. [ ]	4	3	6	3	2	18
Jiang et al. [ ]	4	2	4	3	2	15
Jiang et al. [ ]	4	3	5	3	2	17
Kuang et al. [ ]	4	2	5	3	2	16
Li et al. [ ]	4	2	5	3	2	16
Liang et al. [ ]	4	1	3	2	2	12
Liu et al. [ ]	4	3	5	3	2	17
Lourenço et al. [ ]	4	2	6	3	2	17
Ma et al. [ ]	4	3	6	3	2	18
Mohan et al. [ ]	4	3	5	2	2	16
Nguyen et al. [ ]	4	2	5	3	2	16
Ni et al. [ ]	4	2	5	3	2	16
Olivier et al. [ ]	4	2	5	3	2	16
Pal et al. [ ]	4	2	6	3	2	17
Ramadas et al. [ ]	4	2	5	2	2	15
Sartoretto et al. [ ]	4	2	5	3	2	16
Stipniece et al. [ ]	4	2	6	3	2	17
Sun et al. [ ]	4	2	6	3	2	17
Tovani et al. [ ]	4	2	5	3	2	16
Xie et al. [ ]	4	2	5	3	2	16
Xie et al. [ ]	4	2	3	3	2	14
Xing et al. [ ]	4	2	3	3	2	14
Yang et al. [ ]	4	1	4	3	2	14
Yuan et al. [ ]	4	2	3	3	2	14
Zhang et al. [ ]	4	3	5	3	2	17
Zhao et al. [ ]	4	1	4	3	2	14
Zhao et al. [ ]	4	2	5	3	2	16
Zhou et al. [ ]	4	2	6	3	2	17

Ballo et al. [ ]	4	5	6	2	2	19
Chen et al. [ ]	4	5	7	3	2	21
Cheng et al. [ ]	4	5	7	3	2	21
Elgali et al. [ ]	4	5	7	3	2	21
Gu et al. [ ]	4	3	7	3	2	19
Gu et al. [ ]	4	4	7	3	2	20
Ni et al. [ ]	4	3	6	3	2	18
Hernández et al. [ ]	4	5	6	2	2	19
Jiang et al. [ ]	4	4	6	3	2	19
Li et al. [ ]	4	3	6	3	2	18
Lourenço et al. [ ]	4	4	7	3	2	20
Ma et al. [ ]	4	4	7	3	2	20
Machado et al. [ ]	4	4	7	2	2	19
Mohan et al. [ ]	4	5	7	3	2	21
Ni et al. [ ]	4	3	6	3	2	18
Ramadas et al. [ ]	3	3	7	3	2	18
Sartoretto et al. [ ]	4	5	7	3	2	21
Xie et al. [ ]	4	5	7	3	2	21
Xing et al. [ ]	4	5	7	3	2	21
Yan et al. [ ]	4	3	7	3	2	19
Yang et al. [ ]	4	3	4	3	2	16
Yuan et al. [ ]	4	2	5	3	2	16
Zarins et al. [ ]	4	5	7	3	2	21
Zhang et al. [ ]	4	3	6	2	2	17
Zhao et al. [ ]	4	3	6	2	2	17
Zhao et al. [ ]	4	5	7	3	2	21

Article	Type of the Biomaterial	Biomaterial’s Shape	Theoretical Amount of Sr in the Biomaterial (wt.%)	Amount of Sr Released from Biomaterial
Aina et al. [ ]	Sr-HA	Discs	20 and 40 (at.%)	0.5–3.2 ppm (MEM culture medium) after 14 days
Alkhraisat et al. [ ]	Sr Β-TCP	Cement	6.7–33 (at.%)	38–58 ppm (deionized water) after 3 days
Ballo et al. [ ]	Sr-HA	Rod (titanium coating)	10.6 ug (3.55 at.%)	Not specified
Birgani et al. [ ]	Sr-OCP	Scaffolds (titanium coating)	1 and 3 (at.%)	Not specified
Boanini et al. [ ]	Sr-OCP	Discs (titanium coating)	10 (0.6 experimental) (at.%)	Not specified
Boanini et al. [ ]	Sr-HA	Discs (titanium coating)	8.4 (experimental) (at.%)	Not specified
Bracci et al. [ ]	Sr-CaP	Powder/Discs (titanium coating)	5 and 10% (3.2/5.5 experimental) (at.%)	Not specified
Capuccini a et al. [ ]	Sr-HA	Discs (titanium coating)	1, 5 and 10 (0.5; 3.0 and 7.0 experimental) (at.%)	Not specified
Chen et al. [ ]	Sr-CPC	Discs	1 (at.%)	1.2–1.8 ppm
Chen et al. [ ]	Sr-HA	Coating on 3D printed scaffolds	Up to 8.2%	Gradually released, peaking at ~1.2 µg/mL on day 14
Chen et al. [ ]	Sr-BCP	Ceramic Porous scaffolds	6.75 wt%	1.84 ppm over 6 days in media without cells
Cheng et al. [ ]	Sr-CPC	Cement	0.7–2.2 (at.%)	Not specified
Chung et al. [ ]	Sr-HA	Discs (titanium coating)	0, 3, 7, 15, 25, 50, 75, and 100 (at.%)	Not specified
De Lima et al. [ ]	Sr-HA	Granules	1 (<0.5 experimental) (at.%)	Not detectable
Elgali et al. [ ]	Sr-HA	Granules	5, 25 and 50 (~24 experimental) (at.%)	26–139 ppm (Tris-HCL) after 7 days
Gu et al. [ ]	Sr-CPC	Discs	1 (at.%)	10 ppm in presence of cells/2 ppm in cell absence
Gu et al. [ ]	Sr-CPC	Scaffolds	8 (at.%)	Not specified
Gu et al. [ ]	Sr-HA	Coating on magnesium alloys	10%, 20%, 50%, 100%	Up to 20 µg/mL over 10 days
Harrison et al. [ ]	Sr-HA	Pastes and Gels	0, 2.5, 5, 10, 50, 100 at.% Sr	Not specified
Hernández et al. [ ]	Sr-HA	Cement	10 and 20% (Sr substitution)	Not specified
Huang et al. [ ]	Sr-CPP	Cylinders	8% (Sr substitution)	Not indicated
Huang et al. [ ]	Sr-TCP	Powder	1, 5, 10 and 15% (Sr substitution)	4.5% (PBS) after 30 days (cumulative release)
Jiang et al. [ ]	Sr-HA	Discs (titanium coating)	10%	~1.5 ppm (PBS) after 9 days
Jiang et al. [ ]	Sr-HA	Disc	2.5%, 5%, 10%, 20%	0.2–1.0 µg/mL over 4 days
Kuang et al. [ ]	Sr-CPC	Cement	5, 10 and 20 (at.%)	Not specified
Li et al. [ ]	Sr-HA	Scaffolds (titanium coating)	10, 40 and 100% (9.14, 37.80 and 100 experimental)	Not specified
Liang et al. [ ]	Sr-Brushite	Rod (titanium coating)	5, 10 and 20 (at.%)	Not indicated
Liu et al. [ ]	Sr-CPP	Cylinders	1, 2, 5, 8 and 10 (at.%)	Not indicated
Lourenço et al. [ ]	Sr-HA	Powders	5%, 10%, 15%, 20%	Not specified
Ma et al. [ ]	Sr-HA	Coating on PET artificial ligaments	2, 4, 6, 8, 10 mol%	6.33, 7.48, 11.23, 14.96, 20.26 mg/mL (PBS) after 30 days
Machado et al. [ ]	Sr-HA	Spheres	0.71 (at.%)	Not specified
Mohan et al. [ ]	Sr-HA	Discs	50 (at.%)	~8 ppm (SBF) and 20 ppm (PBS) after 28 days
Ni et al. [ ]	Sr-HA	Powder	1, 5 and 10% (Sr substitution)	5.05, 12.7 and 19.46 ppm in media after 24 h.
Olivier et al. [ ]	Sr-HA	Coatings on Activated Carbon Fiber Cloth	5% and 10%	Not specified
Pal et al. [ ]	Sr-HA	Powders and Pellets	10%, 30%, 50%, 70% of Ca replaced by Sr	Not specified
Ramadas et al. [ ]	Sr-HA	Porous Scaffold	2.8 wt%	Not specified
Sartoretto et al. [ ]	Sr-CHA	Microspheres	5 (at.%)	~4 ppm (culture medium) after 24 h
Stipniece et al. [ ]	Sr-nHAp	Powder	1, 3 and 10 wt%	up to 1 mg/mL
Sun et al. [ ]	Sr-α-TCP cement	Disc	8.3 and 16.7%	Not specified
Tovani et al. [ ]	Sr-CaP	Nanotubes	10% and 50 at.%	2–18 mg/L
Xie et al. [ ]	Sr-CPC	Scaffolds	8 (at.%)	~0.020 ppm (SBF) after 4 weeks
Xie et al. [ ]	Sr-CaP	Scaffold	4.2%	Not specified
Xing et al. [ ]	Sr-CaP	Coating on titanium alloy	2 wt%	Not specified
Yan et al. [ ]	Sr-HA	Rod (titanium coating)	5, 10 and 20 (7.6, 13 and 22.7 experimental)	Not specified
Yang et al. [ ]	Sr-HA	Disks	(9.1, 91 and 98.6 experimental) (at.%)	Not specified
Yuan et al. [ ]	Sr-HA	Injectable Gel	15 mol%	Not specified
Zarins et al. [ ]	Sr-HAP/TCP	Granules	5 wt%	Not specified
Zhang et al. [ ]	Sr-HA	Discs	10, 40 and 100 (8.73, 37.95 and 100 experimental) (at.%)	14, 35 and 50 ppm (DMEM) after 24 h.
Zhang et al. [ ]	Sr-HA	Cylinders (titanium coating)	2.5 (at.%)	~0.53 ppm (NaCl 0.9%) after 24 days
Zhao et al. [ ]	Sr-ABS	Scaffolds	~2–5 experimental (at.%)	~5 ppm (deionized water) after 5 days
Zhao et al. [ ]	Sr-HA	Whisker-like Scaffolds	10%	1.5–2.0 ppm (in vitro, over 7 days)
Zhou et al. [ ]	Sr-HA	Scaffolds (titanium coating)	16.5 (at.%)	Not specified

Article	Cell Type	Test Performed	Effects
Aina et al. [ ]	Human osteoblast	ALP, LDH and H3-thymidine incorporation	Increased osteoblast differentiation
Alkhraisat et al. [ ]	Human osteoblasts (hFOB1.19)	Electronic cell counting and WST1	Similar to the control
Birgani et al. [ ]	hMSCs	ALP, cell morphology	Increased ALP activity; smaller cell area
Boanini et al. [ ]	Osteoblast-like (MG-63)	WST1, ALP, Type 1 collagen, OSC and Cell morphology	Increased osteoblast differentiation
Boanini et al. [ ]	Osteoblast and osteoclast	WST1, ALP, Type 1 collagen, OPG, TRAP, RANKL and Cell morphology	Increased osteoblast differentiation
Bracci et al. [ ]	Osteoblast-like (MG-63)	WST1, LDH, ALP, Type 1 collagen, OSC and cell morphology	Increased osteoblast differentiation
Capuccini a et al. [ ]	Osteoblast-like (MG63)/Osteoclasts (human)	WST1, ALP, Type 1 collagen, OSC, OPG OSC, TRAP and cell morphology	Decreased formation of osteoclasts/increased osteoblast differentiation
Chen et al. [ ]	Human endothelial cells (ECV304)	SEM, MTT, migration activity	Increased migration and proliferation
Chen et al. [ ]	MC3T3-E1 osteoblasts	Cell attachment, proliferation (CCK-8 assay), differentiation (ALP activity, RT-PCR for Col I, Runx-2, OPN, and Osterix)	Enhanced cell attachment, proliferation, increased ALP activity, and upregulated expression of osteogenic markers (Col I, Runx-2, OPN, and Osterix)
Chen et al. [ ]	RAW 264.7 macrophages, mMSCs	Cell proliferation (AlamarBlue assay), cell morphology (CLSM, SEM), gene expression (RT-PCR), protein expression (ELISA, Western blot)	Enhanced osteogenic differentiation, inhibited osteoclastic differentiation, upregulated osteogenic gene expression, downregulated osteoclast-specific protein activity (TRAP, CAII)
Chung et al. [ ]	MC3T3-E1 osteoblast/RAW264.7 osteoclast	MTT and cell morphology.	Decreased formation of osteoclasts/increased osteoblast differentiation
De Lima et al. [ ]	Balb/c 3T3 fibroblasts/Primary human osteoblasts	XTT, NR, CVDE, apoptosis induction and cell morphology and adhesion.	Increased osteoblast differentiation
Gu et al. [ ]	Murine macrophage (RAW264.7)/rabbit osteoclasts	MTT, TRAP and SEM	Increased macrophage-mediated degradation/inhibited osteoclasts activity
Gu et al. [ ]	Endothelial cells/primary human osteoblasts	MTT, TLS	Increased proliferation and TLS formation
Gu et al. [ ]	MC3T3-E1 osteoblasts	Cell proliferation (CCK-8 assay), ALP activity, fluorescent staining	Enhanced proliferation, higher ALP activity, improved cell morphology with increasing Sr content
Harrison et al. [ ]	MG63 human osteoblast-like cells	Direct biocompatibility (PrestoBlue assay, Thermo Fisher Scientific, Waltham, MA, USA), indirect biocompatibility (PrestoBlue assay)	High viability for indirect biocompatibility; direct biocompatibility affected by paste/gel disaggregation, highest viability observed with 0 and 100 at.% SrHA
Hernández et al. [ ]	Human fibroblasts	MTT, Alamar blue, LDH, and SEM	Increased cytotoxicity
Huang et al. [ ]	hMSCs	Cell counting and WST8	Increased proliferation
Huang et al. [ ]	Osteoblasts (ROS17/2.8)/macrophages (RAW264.7)	OPG and RANKL	More secretion of OPG after 48 h and less secretion of RANKL after 24 h
Jiang et al. [ ]	MC3T3-E1 and rat’s BMSC	Flow cytometry, ALP, OCN, alizarin red	Increased differentiation and proliferation
Jiang et al. [ ]	Bone marrow stromal cells (BMSCs)	Cell adhesion, proliferation (MTT), ALP activity, gene expression (qRT-PCR), protein expression (Western blot)	Enhanced adhesion, proliferation, ALP activity; increased expression of COL1, BSP, BMP-2, OPN, VEGF, ANG-1
Kuang et al. [ ]	Osteoblast-like (MG63)	WST1, ALP, and SEM	Higher proliferation rate and ALP activity of MG-63
Li et al. [ ]	MC3T3-E1 osteoblasts	Cell adhesion, proliferation (MTT), ALP activity, gene expression (Runx2), protein expression (OPN, OCN)	Enhanced adhesion and proliferation, increased ALP activity, higher Runx2 gene expression, and elevated OPN and OCN protein levels
Liang et al. [ ]	Osteoblast (MC3T3-E1)	MTT	Increased proliferation in the 5 and 10% of Sr
Liu et al. [ ]	Osteoblast (ROS17/2.8)	ALP, MTT and SEM	Increased proliferation
Lourenço et al. [ ]	Human adipose-derived stem cells	Cell viability, differentiation (ALP activity, mineralization)	Sr-modified scaffolds promoted cell viability and differentiation, with increased mineral deposition compared to control
Ma et al. [ ]	Rat Bone Marrow Stem Cells (rBMSCs)	ALP activity, ARS staining, real-time PCR (RT-PCR)	Increased ALP activity and mineralization in 2SrHA-PET group.
Mohan et al. [ ]	Adipose-MSCs	Mineralization, ALP, SEM, CLS and Micro-CT	Increased differentiation and proliferation
Nguyen et al. (2018)	Mouse osteoblast-like cells (MC3T3-E1)	Cell attachment, cell proliferation (CCK-8), cell morphology (CLSM)	Enhanced cell attachment, better proliferation on ASH55 group with 20 cycles, improved cell morphology
Ni et al. [ ]	Fibroblasts (L-929)	Fluorescense microscopy	non-cytotoxic
Olivier et al. [ ]	Human primary osteoblasts	Cell viability and proliferation (calcein-AM and ethidium-homodimer-1 assay)	Sr-doped coatings (5% and 10%) showed significant improvement in cell proliferation compared to non-doped coatings
Pal et al. [ ]	Mouse osteoblast (MC3T3-E1)	MTT assay for cytotoxicity, cell proliferation	Non-cytotoxic, cell proliferation decreases with more than 50% Sr substitution
Ramadas et al. [ ]	MG-63 osteoblasts	Cytotoxicity (MTT assay), cell viability	Cell viability significantly reduced with increased concentration of scaffolds (93–45% for 10 and 1000 μg/mL, respectively)
Sartoretto et al. [ ]	Pre-osteoblastic MC3T3-E1 cells	MTS, Runx2, Osterix, ALP, Collagen 1a1	Higher than control (MTS assay); significant upregulation in osteogenic medium treated groups (qPCR analysis)
Stipniece et al. [ ]	MG-63 osteoblasts	ALP activity, gene expression (COL1, OCN, OPN)	Increased ALP activity, expression of collagen I and osteocalcin indicating boosted bone formation
Sun et al. [ ]	MC3T3-E1 pre-osteoblasts	Cell proliferation (MTT), cytotoxicity test	Enhanced proliferation, lower cytotoxicity at lower Sr concentrations
Tovani et al. [ ]	Pre-osteoblastic MC3T3-E1 cells; bone marrow macrophages (BMMs)	Cell viability (MTT assay), ALP activity (ELISA), Osteocalcin expression (PCR; Osteoclastic differentiation (TRAP activity))	Enhanced cell viability and differentiation, increased ALP activity and osteocalcin expression; dose dependent activation of osteoclasts
Xie et al. [ ]	Osteoblast-like (ROS17/2.8)	MTT	Similar to the control
Xie et al. [ ]	MC3T3-E1 osteoblasts	Cell proliferation assay, ALP activity assay, Alizarin red staining	Increased proliferation, higher ALP activity, and greater mineralization under high calcium conditions
Xing et al. [ ]	Rabbit bone marrow stromal cells (rBMSCs)	Cell adhesion assay, cell proliferation assay, ALP activity assay, Alizarin red staining	Enhanced cell adhesion, increased proliferation, higher ALP activity, and greater mineralization in Sr-CaP-p group
Yang et al. [ ]	Osteoblast (MC3T3-E1)/primary rabbit osteoclasts	Alamar Blue, ALP and resorption pits	Decreased resorption pits and ALP expression, similar to the control
Yuan et al. [ ]	Mouse Raw 264.7 macrophages, MC3T3-E1 osteoblasts	MTT assay, gene expression (IL-1β, IL-6, TNF-α), cytokine secretion (ELISA for IL-1β, IL-6, TNF-α, RANTES, MCP-1, MIP-1α), real-time PCR (OPG, ALP, OCN, COL-I, c-fos)	Decreased macrophage proliferation, down-regulated gene expression and cytokine secretion of IL-1β, IL-6, TNF-α, increased osteoblast viability, and osteogenic gene expression
Zhang et al. [ ]	Osteoblast-like (MG63)	MTT and ALP	The 10% Sr-HÁ promoted proliferation while higher concentrations decreased it
Zhao et al. [ ]	Fibroblasts (L929)	MTT	Similar to the control
Zhao et al. [ ]	Pre-osteoblastic MC3T3-E1 cells	ALP staining, real-time PCR	Increased osteoblast differentiation
Zhou et al. [ ]	Rat MSCs	CCK-8, ALP, OCN, OPN and Type 1 collagen	Interrod spacing larger than 137 nm inhibited in vitro mesenchymal stem cell functions

Article	Animal Type	Test Performed	Effects
Ballo et al. [ ]	Sprague-Dawley rats	Histology, histomorphometry, and SEM	Increased new bone formation
Chen et al. [ ]	Male Balb/c mice	Intramuscular implantation of Sr-BCP scaffolds; histological analysis, TRAP staining, IHC staining for CTSK	Enhanced ectopic osteogenesis and reduced osteoclastogenesis compared to BCP scaffolds
Chen et al. [ ]	Sprague-Dawley rats	3D fused PET-CT image	Similar to the control
Elgali et al. [ ]	Rats	Histology, histomorphometry, and immunohistochemistry	Increased bone area
Gu et al. [ ]	New Zealand white rabbits	VEGF histological marking	Increased angiogenesis
Gu et al. [ ]	New Zealand white rabbits	Histology, X-ray	Accelerated bone repair
Hernández et al. [ ]	Wistar rats	Histology	Similar to the control
Jiang et al. [ ]	Rat calvarial defect model	Micro-CT, histological analysis	Enhanced bone and blood vessel regeneration, highest in 10% Sr-doped mnHAp group
Li et al. [ ]	New Zealand rabbits	3D-CT analysis, histological evaluation	Significant bone formation and faster degradability in Sr10-TBC group, new bone area ratio higher in Sr10-TBC group compared to TBC
Liang et al. [ ]	Sprague-Dawley rats	X-ray, Micro-CT, removal torque	Accelerated bone repair in the 10% concentration and increased removal torque (5 and 10%).
Lourenço et al. [ ]	Rat Critical-Sized Defect Model	Bone regeneration	Promoted bone regeneration, modulated immune response towards M2 macrophage phenotype, induced collagen formation around implants
Machado et al. [ ]	Santa Ines sheep	X-ray microfluorescence, SEM histology and histomorphometry	Similar to the control
Mohan et al. [ ]	New Zealand rabbits	X-ray, Micro-CT, histology, and histomorphometry	Increased bone formation
Ramadas et al. [ ]	Rabbit tibia bone defect model	Histological analysis	Significant bone mineralization process, scaffold replaced with fibrous tissue, including trabecular and spongy bone tissues, vascular tissue
Sartoretto et al. [ ]	WT and ASC KO mice	Subcutaneous and tibia implantation; histomorphometry	Bone formation (% new bone) in Sr-containing groups higher in WT than ASC KO, CHA > HA for WT; degradation of biomaterial in vivo higher in CHA, similar between SrCHA and HÁ
Xie et al. [ ]	New Zealand rabbits	X-ray microradiography	Increased new bone formation after eight weeks
Xie et al. [ ]	Rabbits	Histological analysis, Micro-CT	Enhanced bone formation and osseointegration under high calcium conditions
Xing et al. [ ]	Rabbits	Histological analysis, Micro-CT	Improved bone formation and osseointegration in Sr-CaP-p group compared to control
Yan et al. [ ]	New Zealand white rabbits	Micro-CT, histology and pull-out test.	The 20% SrHA promoted better bone–implant integration and new bone formation.
Yuan et al. [ ]	Ovariectomized rat femoral defect model	Surgical procedure, micro-computed tomography (µ-CT), histological assessment, immunohistochemical staining for IL-6	Enhanced new bone formation with 15SrHA/G3-K PS group, lower gene expression of IL-1β, TNF-α, and IL-6, increased IL-6 expression in HA/G3-K PS group
Zarins et al. [ ]	Rabbits	Histological and immunohistochemical analysis	Enhanced bone regeneration, increased expression of OC, OPG, NFkB 105, BMP 2/4, and Col-1α in the peri-implant zone of Sr-enriched HAP/TCP group compared to non-operated leg and sham surgery groups
Zhang et al. [ ]	Sprague-Dawley rats	histomorphometry	Increased bone-to-implant contact and new bone apposition
Zhao et al. [ ]	New Zealand white rabbits	Compressive strength and confocal microscopy	Similar to the control
Zhao et al. [ ]	Osteoporotic rat model	Histological analysis, μCT analysis	Enhanced bone regeneration in osteoporotic defects, substantial vascular-like structures, increased new bone formation
Zhou et al. [ ]	New Zealand rabbits	Histology	Interrod spacing larger than 137 nm inhibited in vivo osseointegration

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Alves Côrtes J, Dornelas J, Duarte F, Messora MR, Mourão CF, Alves G. The Effects of the Addition of Strontium on the Biological Response to Calcium Phosphate Biomaterials: A Systematic Review. Applied Sciences . 2024; 14(17):7566. https://doi.org/10.3390/app14177566

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Published: 24 August 2024

Surgery versus intrapleural fibrinolysis for management of complicated pleural infections: a systematic review and meta-analysis

Jaewon Chang 1 ,
Ben Indja 1 ,
Jesse King 1 ,
Stephanie Chan 1 &
Campbell D. Flynn 1 , 2

Respiratory Research volume 25 , Article number: 323 ( 2024 ) Cite this article

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Complicated pleural infection comprises of complex effusions and empyema. When tube thoracostomy is ineffective, treatment options include surgical drainage, deloculation and decortication or intrapleural fibrinolysis. We performed a systematic review and meta-analysis to examine which technique is superior in treating complicated pleural infections.

PubMed, MEDLINE and EMBASE databases were searched for studies published between January 2000 to July 2023 comparing surgery and intrapleural fibrinolysis for treatment of complicated pleural infection. The primary outcome was treatment success. Secondary outcomes included hospital length of stay, chest drain duration and in-hospital mortality.

Surgical management of complicated pleural infections was more likely to be successful than intrapleural fibrinolysis (RR 1.18; 95% CI 1.02, 1.38). Surgical intervention group benefited from statistically significant shorter hospital length of stay (MD: 3.85; 95% CI 1.09, 6.62) and chest drain duration (MD: 3.42; 95% CI 1.36, 5.48). There was no observed difference between in-hospital mortality (RR: 1.00; 95% CI 0.99, 1.02).

Surgical management of complicated pleural infections results in increased likelihood of treatment success, shorter chest drain duration and hospital length of stay in the adult population compared with intrapleural fibrinolysis. In-hospital mortality did not differ. Large cohort and randomized research need to be conducted to confirm these findings.

Introduction

Complicated pleural infections, including complicated parapneumonic effusions and empyema, are characterised by the presence of purulent fluid within the pleural space [ 1 ]. They are associated with significant morbidity and mortality, with reported all-comer mortality rates exceeding 10% in the adult population [ 2 , 3 , 4 , 5 ]. Furthermore, the incidence of complicated pleural infections is increasing in all age groups, placing increasing burden on individuals and healthcare systems around the globe [ 6 ].

The American Thoracic Society describes empyema in three stages: stage I being the exudative stage; stage II being the fibropurulent stage; and stage III being the organized stage (Table 1 ). For stage I empyema, intravenous antibiotics and chest drain insertion is a common and often adequate initial management strategy, with success rate around 80% [ 7 ]. Several options exist to treat more advanced stages of empyema, varying from intra-pleural instillation of fibrinolytics, video-assisted thoracoscopic surgery and open decortication.

The rationale behind intrapleural fibrinolytic agent stems from observing decreased concentration tissue plasminogen activator and increased concentration of plasminogen activator inhibitor in the empyema fluid, resulting in overall decreased fibrinolytic activity [ 8 ]. By instilling intrapleural fibrinolytic agent, the aim of the treatment is to break down fibrin deposits, reduce fluid viscosity and facilitate drainage [ 9 ].

There is no consensus as to which treatment modality should be the next step in the management when antibiotic therapy and chest drain insertion fails, with proponents of early surgery suggesting that the surgical management leads to a better pleural space control, decreased risk of lung restriction and less requirement for an open decortication, while advocates of intrapleural fibrinolysis believe fibrinolysis can reduce the need for surgical intervention and is a reasonable initial management [ 10 , 11 , 12 ].

The aim of this systematic review and meta-analysis is to compare the outcomes between intrapleural fibrinolysis and the current gold standard surgical management in adult patients with complicated pleural infections.

Materials and methods

Literature search strategy.

Literature search was conducted on PubMed, Ovid MEDLINE and EMBASE databases from 1st January 2000 to 5th July 2023. The search terms used were (empyema OR effusion) AND (fibrinol* OR surg*). The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed.

Two authors (JC and BI) conducted independent literature search on selected databases to identify eligible studies. Screening of title, abstract and full manuscript were performed individually. Thirty-one full-text publications were independently reviewed for their eligibility. Discrepancies between authors’ decisions were resolved through consensus or referral to third author (JK). Details are outlined in Fig. 1 .

PRISMA flowchart

Eligibility criteria

The eligibility criteria for study inclusion were: (1) any retrospective or prospective investigative studies excluding case reports; (2) direct comparison between intrapleural fibrinolysis and thoracic surgery; (3) thoracic surgery defined video-assisted thoracoscopic surgery (VATS) or open decortication; (4) presentation of outcomes of stratified by intervention type; (5) publication date from January 2000 to search date; and (6) English language publication.

The primary surgical outcome of interest was treatment success. Secondary outcomes included hospital length of stay, post-operative chest drain duration and in-hospital mortality.

Risk of bias

Quality assessment for non-randomised studies was performed independently by two authors (JC and JK) using the Newcastle–Ottawa Scale [ 13 ] (Table 2 ). This scale assesses selection, comparability and outcome for quality and risk of bias.

Statistical analysis

Continuous variables were presented as either mean and standard deviation or median with interquartile range. Categorical variables were presented as numbers and/or percentages. Meta-analysis was performed using raw data presented in each study and summarised in the form of risk ratios (RR) for binary outcomes and mean difference (MD) for continuous outcomes. Outcomes of interest reported as median and interquartile range were converted to mean and standard deviation by the method outlined by Luo et al. [ 14 ], assuming a normal distribution for the cohort. The random effects model was used to assess effect estimates. Tau 2 (Τ 2 ) and I 2 values were used to assess heterogeneity. I 2 cut-off of 25%, 50% and 75% were used to indicate low, moderate, and high heterogeneity, respectively. Statistical significance was defined as p < 0.05. All statistical analysis was performed using Review Manager 5.4 (Cochrane Collaboration, Software Update, Oxford, UK).

Study characteristics

The literature search returned 4,332 records for screening. After duplicates were removed, 4,025 records were screened based on title and abstract. Thirty-one studies underwent full text review and application of inclusion criteria, following which ten studies were deemed eligible for inclusion in this review [ 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 ]. Five studies were prospective [ 15 , 18 , 21 , 23 , 24 ] and remaining five studies [ 13 , 14 , 16 , 17 , 19 ] were retrospective in nature. All ten studies were included in the meta-analysis.

The total study population was 757 and cohort sizes ranged from 20 to 159. All included studies directly compared intrapleural fibrinolysis with surgery (VATS and/or open decortication). 376 patients received intrapleural fibrinolysis and 381 patients underwent thoracic surgery. The baseline study characteristics are summarized in Tables 3 and 4 .

Intrapleural fibrinolysis

Fibrinolytic agents used included alteplase [ 16 ], streptokinase [ 12 , 14 , 17 , 18 , 19 ], urokinase [ 13 , 15 , 20 ], and a combination of tissue plasminogen activator (tPA) and dornase alfa (DNase) [ 15 , 21 ]. These agents were diluted in 30–250 ml of 0.9% NaCl and instilled via chest tube, where the tube was subsequently clamped for a period of between 1 to 6 h post instillation. The process was repeated up to twice per day, and the maximum duration of therapy was 14 days in one study [ 12 ]. Treatment duration was unspecified in two studies [ 16 , 20 ]. Some studies prescribed a fixed duration of therapy, while others were guided by drain output of < 100 ml/24 h [ 17 , 18 ].

Surgical technique

The most prevalent surgical technique was video-assisted thoracoscopic surgery (VATS) used in nine out of ten studies [ 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 ]. Only one study solely focused on thoracotomy and open decortication [ 12 ]. Three studies reported outcomes in both VATS and open approaches [ 13 , 18 , 20 ].

Cohort demographics

No statistically significant baseline patient demographic differences were demonstrated between the surgical and intrapleural fibrinolysis groups. Specifically, when comparing surgical group to the intrapleural fibrinolysis group, age (MD: − 1.54; 95% CI − 3.56, 0.47), female sex (RR: 0.86; 95% CI 0.39, 1.90), COPD (RR: 1.43; 95% CI 0.88, 2.34), smoking (RR: 1.10; 95% CI 0.59, 2.06), diabetes (RR: 1.25; 95% CI 0.80, 1.97) and detection of positive fluid culture (RR: 1.29; 95% CI 0.87, 1.92) did not differ significantly.

Clinical outcomes

Surgical management of complicated pleural infections was more likely to be successful than intrapleural fibrinolysis (RR 1.18; 95% CI 1.05, 1.32) (Fig. 2 ) . Patients who received surgical intervention benefited from statistically significant shorter hospital length of stay (MD: 3.85 days; 95% CI 1.09, 6.62 days) (Fig. 3 ) and chest drain duration (MD: 3.42 days; 95% CI 1.36, 5.48 days) (Fig. 4 ) . There was no observed difference between in-hospital mortality (RR: 1.00; 95% CI 0.99, 1.02).

Forest plot displaying relative risk (RR) of treatment success between surgical management and intrapleural fibrinolysis

Forest plot displaying mean difference (MD) of hospital length of stay between surgical management and intrapleural fibrinolysis, displayed in days

Forest plot displaying mean difference (MD) of chest drain duration between surgical management and intrapleural fibrinolysis, displayed in days

Sensitivity analysis was performed using the leave-one-out analysis method. Treatment success remained statistically significant. Treatment success remained statistically significant in favour of surgical approach (RR: 1.18; 95% CI 1.02, 1.38) when the largest study reporting treatment success was removed [ 18 ]. Similarly, hospital length of stay remained significantly shorter in the surgical group (MD: 4.33 days; 95% CI 1.28, 7.39 days). No statistically significant differences were observed in chest drain duration (MD: 3.75 days; 95% CI 0.76, 6.73) and in-hospital mortality (RR: 1.01; 95% CI 0.98, 1.04).

To the authors’ knowledge, this is the first systematic review and meta-analysis to directly compare outcomes of intrapleural fibrinolysis against the gold standard surgical management in the treatment of complicated pleural infections. Our meta-analysis demonstrated that surgery was more likely to be successful, lead to shorter chest drain duration and hospital length of stay in cohorts matched for potentially confounding factors including age, sex, smoking status, diabetes and positive pleural fluid culture.

Standard initial medical management, comprising of antibiotics and chest tube drainage, is reported to fail in approximately 30% of patients [ 25 ]. It should be noted that while intrapleural fibrinolysis may beneficially avoid surgery in a select group of patients, its failure means delayed surgical referral and treatment leading to further deterioration of patients. Further, it can increase the complexity of the operation by increasing the likelihood of conversion to open surgery and bleeding, given studies have reported approximately 4% clinically significant bleeding risk where majority of those affected required an active intervention such surgical exploration (25%), additional chest drain (6%) or administration of blood products (53%) [ 26 ]. Evidently, serious complications can arise within the intrapleural fibrinolysis group and in-hospital mortality did not differ between the two comparable cohorts. Thus, our analysis supports the notion that patients with complicated pleural infections should be promptly referred to thoracic surgeons for review and determination of surgical candidacy to avoid any delay in treatment with view to determining the best treatment strategy within the multidisciplinary setting involving surgeons and respiratory physicians.

This study has several limitations. The results of current meta-analysis are moderate- to highly heterogenous. The cause of the heterogeneity is likely multifactorial, reflecting the small pooled cohort size, inconsistencies in the treatment regimens particularly in the fibrinolysis arm and inherent ambiguity in defining what is “treatment success”. Sensitivity analysis performed to circumvent this issue showed that the primary outcome of treatment success as well as the important measure of hospital length of stay remained statistically significant in favour of surgical decortication. Difference in chest drain duration was no longer statistically significant and in-hospital mortality remained statistically indifferent. Selection bias is also particularly relevant in current meta-analysis as in many studies patient assignment to treatment were not randomized. This could mean that those who were referred and treated for surgery may have had a better physiological baseline to tolerate such invasive procedure. For example, the fibrinolysis cohort in the study by Federici et al. [ 18 ] were statistically significantly older, and almost significantly more likely to be diabetic whereas Dusemund et al. [ 16 ] observed that those in the surgical group were more frequent smokers and diabetic. These baseline differences may serve as a major confounder in the analysis.

Further, owing to the small number of studies that were eligible for this systematic review and meta-analysis, we were unable to examine several potentially insightful outcomes such as morbidity, time until return to work, opioid use and quality of life after discharge from the hospital. These deficiencies highlight the need for future high-powered trials which compare the two treatment strategies.

Our analysis demonstrates that surgical management of complicated pleural infections is more likely to be successful and result in shorter chest drain duration and hospital length of stay in the adult population. In-hospital mortality did not differ. Larger randomised controlled trials and research reporting on short and long-term outcomes, economic burden and other important measures of morbidity are required to confirm the current findings and to determine optimal treatment for complicated pleural infections.

Availability of data and materials

No datasets were generated or analysed during the current study.

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J.C. conducted the literature search, data analysis, Figs. 1 – 4 and wrote the manuscript. J.K. conducted the literature search and data analysis. B.I. conducted the literature search and prepared Table 1 . S.C. extracted data from research papers and prepared Tables 3 and 4 . C.F. provided expert opinion and guidance on the topic. All authors reviewed the manuscript.

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Chang, J., Indja, B., King, J. et al. Surgery versus intrapleural fibrinolysis for management of complicated pleural infections: a systematic review and meta-analysis. Respir Res 25 , 323 (2024). https://doi.org/10.1186/s12931-024-02949-1

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Introduction to the special section "Reducing research waste in (health-related) quality of life research"

Published: 30 July 2022
Volume 31 , pages 2881–2887, ( 2022 )

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Claudia Rutherford 1 , 2 , 3 &
Jan R. Boehnke 4

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In 2021, we issued a call for papers on reducing (health-related) quality of life ((HR)QL) research waste and optimizing patient-reported outcome (PRO)/(HR)QL data. As identified by Chalmers and Glasziou [ 1 ], research waste refers to avoidable inappropriate conduct and dissemination of research. It has multiple contributing factors and is likely a spectrum of impact rather than a dichotomous categorization (e.g., a question of how much of a given study could be considered research waste). In particular, Chalmers and Glasziou highlighted "the choice of research questions; the quality of research design and methods; the adequacy of publication practices; and the quality of reports of research" [ 2 ] as focal areas where decisions and actions of stakeholders in the research process could have negative impact.

The topic of research waste has received limited interest from our community. To date, publications have been largely focused on adherence to reporting guidelines and quality reviews [ 3 , 4 , 5 , 6 , 7 , 8 ]. We were therefore looking for current and innovative state-of-the-art thinking, evidence, and methodological and clinical approaches to reducing research waste in (HR)QL/PRO research. We considered research waste across five stages of research production: question selection; study design, conduct and analysis; ethics, regulation and delivery; publication and reporting; and bias and usability of results/reports [ 9 , 10 ]. We were looking for innovative theoretical approaches, applications, and research exploring this issue. We received 18 expressions of interest of which eight papers are now collected in this special section. The eight papers are presented under three headings that align with elements of the call and represent four of the five stages of research production.

The special section

The section opens with a focus on research design and conduct . Chalmers and Glasziou [ 2 ] identified four sources of research waste starting off with not asking the right research question. The first paper [ 11 ] in this special section explored the extent to which research questions in journals focused on PROs were clearly stated. The authors found that almost half of research questions were poorly framed or unframed. Even “adequately framed” questions rarely stated what researchers wanted to know a priori, increasing the risk of biased reporting. Despite standards for framing research questions being in use for over 30 years, researchers still often fail to include key elements when stating their research question. The first paper in the section summarizes existing frameworks available for formulating research questions and sets out two criteria for a good research question in the context of health outcomes research.

Further sources of research waste include poorly designed or conducted studies [ 12 ]. Systematic reviews have shown that trial protocols often lack important information regarding PROs [ 13 , 14 , 15 ]. To equip trialists with the motivation, knowledge and resources to write PRO content in trial protocols, the SPIRIT (Standard Protocol Items: Recommendations for Interventional Trials)-PRO guidance was developed [ 16 , 17 ]. The second paper [ 18 ] in this special section assessed whether a 2-day educational workshop intended to educate researchers on key considerations for designing a PRO study and how these aspects should be addressed in a clinical trial protocol improved the PRO completeness of protocols against consensus-based minimum standards provided in the SPIRIT-PRO Extension [ 17 ]. Although participants were highly satisfied with the workshops, completeness of PRO protocol content generally did not improve. Adverse consequences of not considering these minimum standards during study design and conduct may result in gathering inadequate or misleading information and lack of statistical precision or power. The authors highlighted the inadequacy of study protocols, failure to involve experienced PRO methodologists, and failure to train clinical researchers and statisticians in relevant PRO research methods and design, and provide suggestions for how future educational efforts may be more effective [ 18 ].

The third paper [ 19 ] addresses the importance of considering adequate sample size during study design to ensure research resources are utilized in an ethical manner and maximize impact and replicability. Common misconceptions related to sample size planning specific to (HR)QL/PRO studies and non-technical corrections to these misconceptions are discussed, including a sample size reporting checklist, to help researchers have a more nuanced understanding of sample size planning and items to consider during (HR)QL/PRO study design and reporting.

The second set of papers focuses on research waste related to reporting . Despite a number of guidelines developed to encourage better reporting across research designs [ 20 , 21 ], research waste continues to be a major problem for (HR)QL/PRO research. Systematic reviews consistently report poor PRO reporting according to CONSORT (CONsolidated Standards for Reporting)-PRO reporting standards [ 20 ]; studies either do not report PRO results or PRO results are inadequately reported [ 6 , 22 , 23 ], resulting in PRO results being unusable or not replicable, and calls into question the ethics of collecting PRO data that will not be used [ 2 ]. PRO ethics guidelines that provide recommendations on questions that should be asked of a study’s design to facilitate the evaluation of its ethical acceptability have been recently published [ 24 ].

Three papers address the issue of inadequate reporting. The first paper [ 25 ] reports a systematic review of papers reporting EQ-5D utility weights in patients with coronary artery disease and highlights the difficulties researchers face when trying to retrieve and reuse published (HR)QL/PRO data. A major contributor of research waste is the inability to reuse and/or include published studies in meta-analyses due to insufficient reporting, threatening the reliability of meta-analysis results, and wastes researcher time and cost reviewing poorly reported papers. As the authors found, missing about half of the data points that might otherwise have been included is problematic and potentially harmful through reliance on such meta-analyses [ 26 ]. Poor reporting is leading to similar problems in the context of cancer research [ 27 , 28 , 29 ]. To reduce waste, the authors recommend that studies using the EQ-5D (or any PRO measure (PROM) for that matter) should report appropriate summary statistics to enable reuse in meta-analyses and include the PROM in the title or abstract in line with current reporting guidelines (CONSORT-PRO and SPIRIT-PRO Extensions).

The second paper [ 30 ] appraises the use of the CONSORT-PRO Extension as an evaluation tool for assessing the reporting of PROs in publications and describes the reporting of PRO research across reviews. The authors found that many PRO studies published after the release of CONSORT-PRO in 2013 did not report recommended CONSORT-PRO items, and studies reviewing PRO publications omitted or largely modified recommended items from their evaluations. Such variation in evaluations impacts knowledge translation and may lead to potential misuse of the CONSORT-PRO Extension.

The third paper [ 31 ] describes a project undertaken to develop a clear, unified, universally applicable approach for the translation, dissemination, and impact of research undertaken by Health Service Evaluation staff and organizations. The authors provide a threefold approach of providing information, guidance, and training in the form of an explainer video, guidance, and learning modules to those who create and use research knowledge. However, the authors caution that a knowledge translation approach on its own does not guarantee research findings will be implemented. Patient and public involvement is necessary during research design to ensure that research conducted is relevant, reflects patient priorities, and that appropriate PROs are assessed and PROMs used. The results from the three papers reinforce the need for better reporting, implementation and translation of (HR)QL/PRO results to practice to maximize the value of research informing health service delivery and policy and reducing avoidable research waste.

The section closes with papers on usability of results . The first paper [ 32 ] discusses how validity theory provides a framework to evaluate whether re-purposing and adapting an existing PROM for a new use (e.g., new patient population, altered recall period), rather than creating a new one, is needed. Four examples of modifications including changing mode of administration, the recall period, extending from one clinical indication to another, and adapting a “general” PROM to encompass disease-specific aspects of the concept of interest are presented to demonstrate these ideas in practice. The authors propose that rather than assuming any change to an existing PROM requires the entire development process to be repeated, which consequently requires extensive resources, we can consider the nature of the proposed change and use validity theory to evaluate which inference/claim is impacted (and to what extent), limiting development of de novo PROMs to when such development is absolutely necessary [ 32 ].

The special section closes with a paper [ 33 ] focused on inefficient research regulation and management practices as sources of research waste, and discusses opportunities in (HR)QL/PRO research enabled by data linkage and data registries; barriers to data access and use and the implications for waste in (HR)QL/PRO research; and proposed legislative reforms. The authors argue that rather than investing in (HR)QL/PRO data infrastructure to support multiple studies, there is reliance on collecting data de novo for discrete studies, resulting in research waste that arises “from questions being overlooked or unnecessarily addressed, research being underpowered or done too slowly, and research being too costly” [ 34 ].

Editorial commentary

Research waste relating to the production and reporting of health and medical research is a major problem. It has been recognised that “[h]uge sums of money are spent annually on research that is seriously flawed through the use of inappropriate designs, unrepresentative samples, small samples, incorrect methods of analysis, and faulty interpretation" [ 35 ]. In 2014, the Lancet series about increasing value and reducing waste in medical research estimated that 85% of research is wasted because studies ask the wrong questions [ 36 ], are poorly designed or conducted [ 12 ], are inefficiently regulated and managed [ 34 ], produce inaccessible information [ 26 ], and are not appropriately reported, disseminated, or translated into decision making [ 10 ]. These issues are pertinent to (HR)QL/PRO research. In an attempt to reduce waste and maximise efficiency, the Lancet’s REWARD (REduce research Waste And Reward Diligence) Campaign invited everyone involved in research to critically examine how they work to reduce waste and maximize efficiency, and to strive to improve the value of the funds invested in the research we commission, deliver, publish, and implement [ 37 ]. However, despite nearly a decade since the Lancet series, research waste is still a major problem. We therefore felt that a call for papers reporting current and innovative thinking, evidence, and approaches to reducing research waste and maximizing (HR)QL/PRO data would continue the effort. Papers in this special section discuss the many contributors to research waste and we take the opportunity to highlight what we think are ongoing issues that as researchers we should all be mindful of, and potential ways in which we could all do our bit to reduce research waste in our field.

Poor (HR)QL/PRO study design, analysis, reporting, and application all contribute to research waste and reduce the benefit of (HR)QL/PRO data. As researchers and editors, we still see problems with study design across the (HR)QL/PRO literature. Firstly, better use of theoretical frameworks would allow researchers and practitioners to design better quality studies. For example, key terms in our field such as PRO(M)s and (HR)QL are often used interchangeably or without clear definitions [ 38 , 39 , 40 ] when actually frameworks for these terms exist that could be used [ 41 , 42 , 43 ]. Well-developed theoretical frameworks inform what needs to be assessed and when, and how constructs are operationalized in a specific setting. Use of theoretical frameworks could also help identify study design problems early on that arise from using PROMs for assessing the study’s independent and dependent variables, whose items are in their entirety or in parts assessing the same construct(s). Such overlap leads to spuriously inflated relationships which have wide-ranging impacts on the interpretation of results [ 44 ].

A second set of problems directly related to these first considerations concerns the PROs assessed within studies and how to increase their relevance and appropriateness:

Uninformative PROs assessed—for example, likely intervention effects might include pain, fatigue and sexual dysfunction but only global HRQL is assessed;

Inappropriate PROMs used—for example, study outcomes of interest are stated as pain, fatigue and sexual dysfunction but only a generic HRQL instrument is used, which does not assess fatigue or sexual function; or using a PROM not well-targeted at the intendend population(s) and therefore unable to detect an intervention effect due to floor or ceiling effects. Related is the problem of jingle-jangle fallacies when different constructs are incorrectly assumed to be the same because of a shared label ("jingle", most commonly in our field is probably not differentiating between HRQL and QOL [ 38 ]); or where different terms are used when in fact describing the same construct [ 45 , 46 ];

Uninformative time-points for PRO assessment—for example, likely intervention effects occur 1 month post-intervention but PROs are assessed at baseline before intervention and then 6 months after intervention when intervention effects are diluted or resolved.

Planning PRO assessments informed by theoretical frameworks, be it for research or practice, will not only reduce research waste as an academic exercise, but likely increase the relevance of the research findings for clinical practice and policy. And in particular for HRQL research, it is during these stages of study design where input from key stakeholders including co-creation and co-production is most beneficial for designing better quality studies and avoiding research waste [ 47 ].

A third problem area is study samples. While reporting guidelines [ 21 ] emphasise the importance of detailing how study participants were approached and any reductions in sample size from recruitment to the final analytic sample, this information is often not reported. Failure to report this limits transparency and the ability for readers to assess both quality and relevance of the sample for a particular research context and conceales the need for exploring the effects of such selection processes with appropriate additional details and/or sensitivity analyses. The problem with sampling is additionally conflated with exclusion of participants with missing PRO data, as it can cause loss of power and bias and seriously affect the external validity (generalizability) of the results. Strategies for reducing the instance and impact of missing PRO data have been summarised [ 48 , 49 ], and methods to explore the impact of missing data on study results have been developed [ 50 , 51 ]. Finally, small sample sizes may be underpowered for confirmatory PRO objectives and hypotheses. Especially in medical research where sample sizes are based on clinical endpoints such as survival or biomedical indicators, the resulting sample size may be insufficient for PROs as secondary outcomes. All relevant study outcomes should be considered during study design and planning a priori. In our continued effort to give PROs a prominent role in studies evaluating patient-facing health care interventions, we have previously argued [ 52 ] that short of achieving this goal, registered papers or Registered Reports in particular offer new ways of: (i) gathering early feedback on publication plans, (ii) using writing resources earlier in the study process, and (iii) ensuring timely dissemination.

Inadequate or inappropriate analysis of PRO data is another source of research waste. For example, not considering confounders or multicollinearity in the analysis increases the chance of false positive findings, resulting in potentially misleading findings [ 53 ]. From our experience, studies may also recruit patient samples with mixed disease type (e.g., breast, colon, and lung cancer patients), stage (e.g., early stage disease vs advanced stage disease) and treatment, and/or with a wide variation of time since end of treatment to data collection but pool their data for analysis rather than report their results separately [ 27 , 28 , 29 ]. These analyses are problematic as we cannot assume that their experiences and treatment impacts are equal and precludes observations due to specific treatment and disease type and stage. Pooling PRO data collected at widely variable times since diagnosis/end of treatment obscures patterns of adjustment over-time and rates of recovery, and tells us little about PRO trajectories but rather simply describes PROs in a sample of patients, which may have a purpose, but is not very useful for clinical decision making [ 27 , 28 , 29 , 53 , 54 ].

Many of these analysis problems could be mitigated with greater consideration of a study’s theoretical foundation and research question(s). Analyses are the operational reflection of these aspects of the research process. An area where this becomes especially apparent are non-randomised comparisons between participant groups. Such study designs are especially common in practice settings and can generate important insights with high relevance for implementation and application. But the descriptive report of observed differences between two groups (e.g., patients receiving two different treatments for the same condition) rarely results in actionable information. And it almost surely does not inform about any causal differences in effectiveness between the compared treatments. Existing frameworks for determining causal effects are available [ 55 , 56 , 57 , 58 ], and considering them when developing observational research is crucial. These ‘design’ issues can all lead to inaccurate conclusions about the benefits and harms of interventions and could be potentially harmful to future patients. We propose that all researchers consider ‘what is the purpose for collecting PROs’, ‘what information would be informative’, and ‘how will the PRO data be used’ when designing their studies. This will then in turn inform sample size and analytical considerations, and lead to better quality PRO data.

Another important source of research waste is poor reporting . Reporting issues pertinent to our field include lack of critical details, failure to publish PRO results, over-interpretation (e.g., overemphasis on positive results/benefits, gloss over harms/negative findings, causal interpretation of non-causal findings), selective reporting (e.g., unpublished hidden PRO data, not analysed or not reported), the spin, and manipulation of data [ 22 , 35 , 37 , 59 , 60 , 61 , 62 ]. Disappointingly, reporting guidelines exist but are not adhered to [ 30 ]. A noteworthy finding from one of the papers in this special section [ 30 ], of 13 journals that published reviews synthesizing PRO studies, none recommended use of the CONSORT-PRO reporting guidelines specifically; five recommended use of EQUATOR or CONSORT guidelines, and nine did not mention either in their instructions to authors. It seems journals publishing PRO studies have not endorsed use of the CONSORT-PRO. Author instructions and administrative checks by journals may be potential mechanisms/forcing functions to ensure better reporting. We would argue that a paper that adheres to reporting guidelines better places a reader to assess the quality of the study design and conduct and to interpret its findings accurately, improving the potential of the research to be impactful and meaningful to patients and clinical practice.

Not only does poor (HR)QL/PRO study design, conduct, analysis and reporting contribute to research waste, they limit the extent to which PRO data can benefit patients and inform clinical practice. Increasing the quality, availability and use of (HR)QL/PRO data may ultimately enable this data to inform public health, clinical practice and health policy. Assessment of PROs in a study should only be included if they will inform future decision making. Assessing outcomes such as HRQL requires time and effort. Researchers need to plan the HRQL data collection, and then enter the data, analyse it and report it. Patients spend their time completing the PROM(s) and staff at sites need to ensure that the PRO assessments are completed at scheduled time-points and record reasons for non-completion if they are not. And collecting PROs is expensive—there are costs associated with PROM licencing, staff time, and administration. All these factors need careful thought and planning so that PRO data are collected in a scientifically robust and meaningful way.

Resources exist to help researchers design (HR)QL/PRO studies, such as what to include in a PRO study protocol [ 16 ] and recommendations for selecting PROMs [ 63 , 64 ], analysizing PRO data [ 53 ], and reporting PRO studies [ 20 ]. A new initiative, PROTEUS (Patient-Reported Outcomes Tools: Engaging Users & Stakeholders), is promoting the systematic use of available tools to optimize the design, analysis, reporting, and interpretation of PROs in clinical trials [ 65 ]. The PROTEUS website includes checklists, web tutorials, and other resources to support the optimal use of PROs. And the individual papers in this special section provide additional resources for reducing research waste in our field. However, without education about robust PRO methodology, appreciation for the importance of high-quality research design, conduct and reporting, and dissemination and use of available resources, we will continue to contribute research waste and not realise the value of PRO data. Study design tools and reporting guidelines are just one part of the job. It is ultimately the responsibility of researchers to ensure appropriate methods and conduct are applied in any specific study, and it is ultimately the responsibilty of authors to ensure their study methods, conduct and results are adequately justified and reported.

We are grateful for the excellent range of submissions received and to all authors and reviewers involved in selecting the published papers. The issues raised in our commentary are only a small selection relevant to us as HRQL/PRO researchers, editors, and to the whole research and practice field. The papers in this special section further highlight sources of research waste and provide resources, recommendations and possible solutions for reducing research waste and maximizing PRO data. However, discussion of research waste since Chalmers and Glasziou [ 4 ] introduced the problem, highlights other areas that impact on the available resources we have to conduct research such as time needed for grant writing and peer-review in funding processes [ 66 , 67 ]; and not least at ourselves, with view to the peer-review of publications [ 68 , 69 ]. These issues become even more pertinent when we consider that "health" is a global priority needing a global agenda [ 70 , 71 , 72 ]. We expect therefore that the topic of research waste related to (HR)QL/PRO research and practice will remain an important issue on our community’s agenda.

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Rutherford, C., Boehnke, J.R. Introduction to the special section "Reducing research waste in (health-related) quality of life research". Qual Life Res 31 , 2881–2887 (2022). https://doi.org/10.1007/s11136-022-03194-z

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Int J Environ Res Public Health

A Systematic Review of E-Waste Generation and Environmental Management of Asia Pacific Countries

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Due to the rapid increase in the use of electrical and electronic equipment (EEE) worldwide, e-waste has become a critical environmental issue for many governments around the world. Several studies have pointed out that failure to adopt appropriate recycling practices for e-waste may cause environmental disasters and health concerns to humans due to the presence of hazardous materials. This warrants the need for a review of the existing processes of e-waste management. In view of the growing e-waste generation in the Asia Pacific region and the importance of e-waste management, this study critically reviews previous research on e-waste generation and management practices of major e-waste producing nations (Australia, China, India, Indonesia, and Malaysia) in the Asia Pacific region, provides an overview of progress made and identifies areas for improvement. To fulfil the aims of this research, previous studies from 2005 to 2020 are collected from various databases. Accordingly, this study focuses on e-waste generation and environmental management of these countries. This study found that e-waste management practices of the selected countries need to be enhanced and recommends several best practices for effectively managing e-waste.

1. Introduction

The Asia Pacific region is highly populated and is considered one of the fastest developing regions in the world. In addition, many countries in this region underwent rapid industrialisation, driven by foreign direct investments [ 1 ] due to a relatively cheap labour force. One of the industries that benefited from these factors is the electrical and electronics industry, which has experienced a major transformation due to increased technological and market developments [ 2 ]. Today, electrical and electronic equipment (EEE) has become indispensable and enhance living standards, but often contain toxic chemicals that negatively impact human health and the environment and fuel the climate crisis [ 2 , 3 ]. The growth in demand and increased sales of EEE have consequently led to the rise in the volume of e-waste [ 3 , 4 , 5 ].

E-waste is one of the most urgent and pressing challenges of our time; however, it is routinely ignored. Across the world, the growing amount of e-waste threatens the environment and local communities, as incorrectly disposed e-waste results in life-endangering toxic chemicals released into the environment and the loss of precious metals [ 2 , 4 , 5 , 6 , 7 ]. Perkins et al. [ 8 ] point out that the amount of e-waste generated each year is increasing at an alarming rate. In 2019 alone, more than 50 million tons (Mt) of e-waste was generated globally. Of this total e-waste, 24.9 million tons were generated in the Asia Pacific region alone. The amount of e-waste generated worldwide increased three times faster than the world’s population. Forti et al. [ 2 ] estimate that the volume of e-waste generated globally will exceed 74 million tons (Mt) by 2030. However, the level of recycling is not keeping up the pace. In fact, less than 13 per cent of e-waste was recycled in the same year. Moreover, the majority of e-waste generated is being diverted for landfilling, which is a common approach to disposing of e-waste worldwide [ 9 ]. The major issue with the current e-waste management practices is: (a) lack of efficient collection and recycling systems and (b) lack of mechanisms to hold producers of EEE accountable for the end-of-life disposal [ 2 ]. Hence, failure to adopt appropriate e-waste recycling processes may lead to enormous environmental and health issues [ 3 , 10 , 11 , 12 , 13 ].

This study identified three research gaps. Firstly, although, literature presents results of various studies on e-waste generation [ 3 , 4 , 5 , 8 , 14 , 15 , 16 , 17 ], recycling [ 14 , 15 , 16 , 17 ], treatment [ 4 , 18 , 19 , 20 ], and environmental management [ 8 , 21 , 22 , 23 , 24 ]; however, few studies have focused on the impact of e-waste generated in the Asia Pacific countries selected and its consequential effects on human health and the environment. Secondly, Forti et al. [ 2 ] suggest that many countries, including countries in the Asia Pacific region, are not sufficiently managing e-waste generated, and greater effort is needed to ensure smarter and more sustainable global production, consumption, management, and disposal of e-waste. The authors also indicated that more e-waste is generated than is being safely recycled in many countries of the world, and more corporative efforts are needed to tackle the escalating e-waste problem through appropriate research and training. Forti et al. [ 2 ] and Balde et al. [ 3 ] noted that the issues emanating from e-waste management in today’s digitally connected world are primarily due to the way we produce, use, and dispose of electronic devices, which are currently unsustainable. Bhaskar and Kumar [ 25 ] added that implementing appropriate e-waste management strategies will contribute to the achievement of sustainable development goals and reduce the global climate crisis through developing the necessary, needed, and required e-waste policies. Thirdly, while investigations and discussions on e-waste generation and management have been ongoing for several decades. However, the problems and challenges on e-waste generation and management remain unabated [ 2 , 26 , 27 ].

The purpose of this study is to critically review the existing strategies and practices adopted by the major e-waste producing countries in the Asia Pacific region in managing and regulating e-waste to minimise the environmental and health impacts created as a result of inappropriate recycling and disposal practices.

A key initiative and motivation of this study is to identify the problems/challenges in managing e-waste in the selected Asia Pacific countries and recommend appropriate management strategies and policy approaches to handle and regulate e-waste to significantly reduce environmental and health concerns. Accordingly, this study reviews previous research on e-waste generation and environmental management of Australia, China, India, Indonesia, and Malaysia, identifies problems and challenges that negatively impact e-waste management in these countries, provides an overview of progress made, and identifies areas for future research.

The selected countries (Australia, China, India, Indonesia, and Malaysia) are among the largest producers of e-waste in the Asia Pacific region [ 2 , 13 , 18 , 28 ]. To fulfil the aims of this study, a comprehensive review of previous research articles on e-waste published from 2005 to 2020 was conducted. This study focuses on aspects such as the amount of e-waste generated, current recycling and disposal methods, environmental management of e-waste, individual/collective attitudes towards e-waste, current e-waste problems/challenges of selected countries. In addition, prior studies of the selected countries are categorised based on the type and scope of research, location of study, and e-waste categories analysed. This study uses the outcomes of previous studies, considers country-specific issues, and identifies future research areas to present best practices for e-waste generation and environmental management.

This paper is organised into five sections. The first section presents current literature on e-waste, the research problem, research gaps and research aim, and justification for this study. The second section outlines the chosen methodology and the justification for considering a systematic literature review. The third section details the e-waste management practices in the selected countries. The fourth section provides the results of this study and analyzes the results. The final section presents the findings of this study, limitations associated with the current study, policy recommendations for effective e-waste management, and future research opportunities.

2. Research Methods

In recent years, researchers have increasingly used quantitative and qualitative research (mixed methods) techniques to expand the scope and improve the analytic power of their studies [ 29 , 30 ]. Quantitative research method is a statistical and interpretive technique used to describe or explain the meaning and relationships of a phenomenon under investigation. Quantitative research typically involves probability sampling to allow statistical inferences to be made [ 29 , 31 ]. In contrast, qualitative research method is a non-numerical, precise count of some behaviour, attitudes, knowledge, or opinion for ascertaining and understanding the meaning and relationships of certain phenomena for generalisation. It typically involves purposeful sampling to improve understanding of the issues being examined [ 29 , 30 , 31 ].

This study adopts a qualitative research method to explore the issues relating to e-waste in the selected countries from existing research over the past years to guide future research in this area. To achieve the aim of this study, the five-phase approach of Wolfswinkel et al. [ 32 ] for conducting a systematic review and analysis of the literature is adopted. Adopting this five-phase approach enables the researchers to conduct a thorough search process and critically review and analyse the articles retrieved from the databases. The five-phase approach includes: (a) defining the scope of the review, (b) searching the literature, (c) selecting the final samples, (d) analysing the samples using content analysis, and (e) presenting the findings.

The first phase is to define the scope of the review. This includes the definition of specific criteria for the inclusion and exclusion of relevant sources and the criteria for identifying and retrieving those sources in the literature. In this study, four prominent databases are used to source literature, including ProQuest, Emerald, ScienceDirect, and Web of Science. The selection of these databases is due to their representativeness and coverage in the publication of top academic papers on e-waste in the selected countries. To ensure broad coverage of the studies in these databases, several keywords have been used for the search, which includes “electronic waste”, “e-waste”, “waste electrical and electronic equipment”, “e-waste management”, “e-waste recycling,” “e-waste disposal methods”, “e-waste problems and challenges” and “environmental management of e-waste”. Several criteria are used to set the limitation, including restricting the document type to scholarly journals, peer-reviewed conference papers, book chapters, and other institutional reports from United Nations (UN) and World Health Organization (WHO); the language in English, and the publication date from 2005 to 2020. These document types have been selected as they represent state-of-the-art research outputs with high impact [ 32 ].

The second phase is to run the search query within the selected databases for retrieving the search results. A total of 688 articles are returned using the above pre-defined search strings. This initial search enables us to gain a general understanding of the coverage of e-waste topics.

The third phase involves selecting the final samples for detailed analysis. The search is limited to the title and the abstract to focus on the search results. Titles and abstracts of all initial articles are screened for checking the relevance to e-waste. This leads to the identification of 235 relevant articles. Duplicate articles are removed. A total of 210 articles is assessed for eligibility, and after excluding those articles that did not meet eligibility criteria, a total of 185 articles is identified for further review.

The 185 articles have been read in full for coding and analysis. NVivo 12.0 is used for providing an overview of the general topics from all the abstracts of the included papers. An overview of the dispersion of the selected papers in terms of year of publication shows there is increased interest in e-waste from 2005 to 2020. Figure 1 below illustrates the search process using the PRISMA flow diagram.

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PRISMA flow chart indicating the results of searches.

3. Overview of E-Waste

E-waste is defined as an electrical appliance that no longer satisfies the user for its intended purpose [ 33 ]. Meanwhile, StEP [ 34 ] defines e-waste as a term used to cover items of all types of EEE and its parts that have been discarded by the owner as waste without the intention of reuse.

Table 1 shows e-waste generated around the world and per continent in 2016. It is observed that the Asian continent generated the highest e-waste, followed by Europe and the Americas. Interestingly, the African continent produced one of the lowest e-waste even though it is the second most populated continent in the world [ 35 ]. Although the African continent produced the lowest amounts of e-waste due to slow technological growth and limited access to energy when compared to other continents, they suffer other kinds of pollution problems caused by traffic emissions, oil spills, heavy metals, refuse dumps, dust, and open burnings and incineration, which significantly contribute to environmental contamination in Africa [ 36 , 37 , 38 ]. Human exposure to toxic metals and environmental pollution has become a major health risk in Africa and is the subject of increasing attention to national and international researchers and environmentalists [ 37 , 38 ].

E-waste generated around the world and per continent in 2016 [ 4 ].

Indicator	Africa	Americas	Asia	Europe	Oceania	World
Number of countries with sufficient data availability	47	32	44	39	12	174
Population (millions)	1064	931.8	4295	737.9	39.29	7068
WEEE total (Mt)	2.23	11.08	18.23	12.26	0.68	44.49
WEEE per capita, average of continent (kg/inh)	2.09	11.89	4.24	16.61	17.36	6.29
GDP total	2,309,676	24,061,119	26,870,635	21,347,978	1,552,169	76,141,597
GDP per capita, average of continent (USD/inh)	2170.5	25,819.7	6256.2	28,929.1	39,496.4	10,772.4

A further study was conducted in 2019 whereby the Asia Pacific region also generated the highest amount of e-waste in comparison to America, Europe, Africa, and Oceania regions. The Asia Pacific region generated around 25 Mt, followed by America at 13.1 Mt and Europe at 12.1 Mt. The study also showed that Africa generated 2.9 Mt and Oceania generated 0.7 Mt of e-waste [ 2 , 39 ]. This warrants the need to conduct a study on e-waste generation and environmental management of countries in the Asia Pacific region [ 14 , 15 , 40 ].

3.1. Constituents of E-Waste

Over the years, the use of electronic devices for domestic and commercial purposes has grown rapidly [ 8 ]. E-waste generally consists of a range of hazardous materials ( Table 2 ), including metals, pollutants, printed circuit boards, computer monitors, cables, plastics, and metal-plastic mixtures [ 2 ]. The composition and quantities of these materials vary in each electronic device depending on the manufacturer, the equipment type, model, and the age it was discarded. In comparison to household e-waste, the e-waste from the IT and telecommunication sector generally contains metals that are of high economic value [ 41 , 42 ]. These metals are generally categorised into precious and toxic metals. Precious metals include gold, silver, aluminium, iron, copper, platinum, etc. The value of precious metals in e-waste is estimated to be worth USD 14 billion. However, more than 50 per cent of these metals are not recovered [ 2 ]. Meanwhile, toxic metals in e-waste include mercury, cadmium, lead, and chromium [ 2 , 43 ].

The distinctive contents of e-waste.

Contents	Percentage in E-Waste
Metal	60%
Plastics	15%
Screens	12%
Metal-plastic mix	5%
Pollutants	3%
Circuit boards	2%
Cables	2%
Other	1%

3.2. E-Waste Generation and Management Practices

This study has selected five countries, including Australia, China, India, Indonesia, and Malaysia, from the Asia Pacific region because they are the major e-waste producers in the region. In line with the aim of this study, this section presents an in-depth analysis of waste generation, policies and management practices adopted by the selected countries in the Asia Pacific region. In addition, this section presents literature on e-waste generation and the opinions of scholars in this field. The following sub-sections explain e-waste management practices for the selected countries in the Asia Pacific region. Table 3 below presents e-waste key statistics for the selected countries.

E-waste key statistics 2019.

Country	E-Waste Generated (kt)	E-Waste Generated (kg per Capita)	E-Waste Documented to Be Collected and Recycled (kt)	National Policy or Regulation in Place
Australia	554	21.7	58	Yes
China	10,129	7.2	1546	Yes
India	3230	2.4	30	Yes
Indonesia	1618	6.1	n/a	No
Malaysia	364	11.1	n/a	Yes

3.2.1. Australia

Australia is placed among the top 10 consumers of electronic products in the world. As a result, e-waste has become one of the fastest-growing waste streams in Australia [ 9 , 44 , 45 ]. The total and per capita e-waste generation in Australia has steadily increased in the last 10 years from 410 Kilotons (Kt) in 2010 to 554 Kt in 2019 as a result of an increase in sales of EEE [ 2 ]. Previously, due to the lack of an e-waste national regulatory framework, local government councils had difficulties in managing e-waste, and they had no strategies to address e-waste issues [ 46 , 47 ]. To resolve the nation’s escalating e-waste challenges, the Australian government established the National Waste Policy in 2019 to integrate existing policies and regulatory frameworks for e-waste management [ 9 , 45 , 48 ]. Thereafter, the Australian government introduced the National Product Stewardship Scheme in 2011 in collaboration with the State and Territory Governments and industries [ 9 , 26 , 45 ].

The introduction of the National Waste Policy in 2009 was designed to set the direction of Australia’s e-waste management and resource recovery for 10 years from 2010 to 2020. The policy was established to achieve several goals, including compliance to international obligations such as the Basel and Stockholm Conventions, reducing the generation of e-waste, and ensuring e-waste treatment, disposal, recovery, and reuse is safe and environmentally sound [ 44 , 47 ]. The Product Stewardship Act of 2011 was also designed to establish a framework by which the environmental, health, and safety impacts of electrical and electronic equipment and its recycling and disposal are adequately managed [ 44 , 45 ]. Currently, Australia’s e-waste system is in its evolving stages and while, progress has been made since the introduction of the National Waste Policy and the Product Stewardship Act, Australia’s e-waste is growing three times faster than other waste streams, and the capacity and sophistication of the nation’s systems need to grow and adapt [ 44 , 48 ].

3.2.2. China

China is one of the leading producers of EEE, and currently, the country is experiencing incredible growth in e-waste generation from both domestic and international sources [ 9 , 26 , 49 ]. Formal e-waste management in China is driven by government agencies designed to improve e-waste recycling and disposal and to encourage manufacturers to take back their products [ 21 , 49 ]. Thus, Chinese e-waste regulations are focused on extended producer responsibility (EPR), polluter pays, and 3Rs (reduce, reuse, recycle) principles [ 50 ].

Informal e-waste recycling in China is often carried out by individual recyclers and unauthorised dismantling companies. Informal recyclers purchase used items and often either dismantle or repair them for the second-hand market. This unregulated e-waste recycling method is currently flourishing in China. Informal recycling provides livelihoods for many Chinese citizens and is creating serious environmental and health concerns. Thus, e-waste generation and management in China has remained a major problem and are fuelled by China’s inexpensive labour and manufacturing abilities. Informal recyclers do the majority of e-waste collection and recycling in most cities throughout China [ 50 ].

3.2.3. India

The increasing average annual growth rate from 0.56% in 1991 to 1.62% in 2011 has contributed significantly to an alarming amount of e-waste generation in India. India is among the top 10 countries in the world in e-waste generation after the U.S. and China. It is estimated that three (3) million tons of e-waste were produced in 2018 and is expected to reach five (5) million tons by the end of 2020 [ 51 , 52 , 53 ]. According to the Confederation of Indian Industries, the Indian electronics industry has a market size of approximately USD 65 billion in 2013, and this is expected to reach USD 400 billion by the end of 2020 [ 52 , 54 ].

Today, e-waste in India is a significant waste stream both in terms of volume and toxicity [ 55 ]. Approximately 152 million units of computers will become obsolete in India by the end of 2021 [ 55 , 56 ], creating serious management challenges and environmental/health problems. Each year, India domestically produces approximately 400,000 tons of e-waste [ 24 ]. Thus, India’s e-waste recycling is a market-driven industry [ 55 ] and is dominated by a number of informal actors. About 90% of the e-waste in India is illegally recycled in the informal sector and involves different groups, including women and children [ 57 , 58 ].

The Ministry of Environment and Forests (MoEF) is the national regulator responsible for formulating legislation related to e-waste management and environmental protection. MoEF approves the guidelines for the identification of the various sources of e-waste in India and endorses the procedures for handling e-waste in an appropriate and environmentally friendly manner [ 59 ]. Those involving e-waste are the 2004 “Municipal Solid Waste Management Rules” and the 2008 “Hazardous and Waste Management Rules.” New regulations are classified as the 2010 “E-waste Management and Handling Rules”, which became effective in 2012 [ 60 ]. While there are regulations on e-waste management and disposal in India, no regulation has effectively addressed the e-waste problem in India [ 52 , 58 ]. Currently, the majority of the hazardous materials found in e-waste are covered under “The Hazardous and Waste Management Rules, 2011 and the 2016 E-waste Management and Handling Rules” [ 52 ].

Despite EPR being a major policy approach in both e-waste (Management and Handling) Rules 2011 and E-waste (Management and Handling) Rules 2016, they are not effectively implemented, and this can be attributed to certain peculiarities in India’s e-waste management system [ 51 , 61 ]. For example, due to some financial incentives involved, Indian consumers are willing to sell their obsolete e-waste to the “kawariwalas” (door-to-door scrap collectors). This behaviour is totally different from practices adopted by most developed countries whereby the producers and consumers have to pay “Recycling/Disposal Fee” [ 62 , 63 , 64 ].

3.2.4. Indonesia

Due to substantial growth in the economy coupled with rapid technological developments, e-waste generation in Indonesia has increased considerably [ 28 , 65 ]. In 2016, Indonesia generated 1274 kt of e-waste with a per capita generation of 4.9 kg [ 66 ]. Although e-waste appears as a global issue, it is not a common term for most people in Indonesia [ 67 , 68 ]. In Indonesia, e-waste management is dominated by the informal recycling sector, which is essentially made of unregulated and unregistered small businesses, groups, and individuals, while the formal sector consists of the country’s municipal agencies as the major actors [ 69 ].

Although the country has no presence of a specific regulation to manage its e-waste, the “Environmental Protection and Management Act No. 32/2009” and “Solid Waste Management Act No. 18/1999” are used in the regulation of e-waste produced in the country [ 70 , 71 ]. Since 2016, the Indonesian government has been in the process of formulating a unified e-waste regulation for the country, which would apply to all the 37 Indonesian provinces, but this is yet to be realised [ 28 , 72 ]. However, the absence of regulated licensed recycling companies in the country has encouraged inappropriate disposal of the majority of the EEE from households, businesses, and industries [ 71 ]. Currently, the informal sector illegally collects, treats, and disposes of discarded EEE triggering huge environmental and health concerns [ 65 , 72 ]. The difficulties/challenges in managing e-waste in Indonesia is primarily due to (a) the inability of the government to understand and deal with the interest of stakeholders involved, (b) the government regulations are beneficial to only a few parties, and (c) there is strong resistance between the government agencies [ 73 ].

3.2.5. Malaysia

In 2019, the International Monetary Fund (IMF), in its economic outlook, ranked Malaysia as the 3rd largest economy in Southeast Asia and the 37th largest economy in the world [ 74 ]. With a healthy economic indicator, e-waste generation in Malaysia is expected to increase in the coming years. The growth in e-waste generation is anticipated worldwide because there is a strong correlation between economic growth and e-waste generation [ 75 , 76 ].

Management of e-waste in Malaysia is still in its infancy and only began in 2005 [ 77 ]. In Malaysia, e-waste is classified as scheduled waste under the code SW 110, “Environmental Quality Regulations 2005” and managed by the Department of Environment (DOE) and the Ministry of Natural Resources and Environment (MNRE) [ 78 , 79 ]. The primary role of DOE and MNRE is pollution prevention and control through the enforcement of the “Environmental Quality Act 1974” (EQA 1974) [ 79 , 80 ]. Although there are strategies on e-waste management in place, they do not adequately guide the local consumers or the municipal authorities on how e-waste should be managed, reused, recycled, or disposed of [ 78 ]. Subsequent to the listing as e-waste under the “Environmental Quality Scheduled Waste Regulations (EQSWR) 2005”, e-waste in Malaysia was reported and managed as municipal solid waste through the Department of Solid Waste Management (DSWM) under the Ministry of Housing and Local Government [ 78 , 81 , 82 ].

3.3. A Review of Previous Studies

This study considered literature reviews to identify key issues associated with e-waste management and to conduct an extensive evaluation of e-waste management practices in the selected countries. We believe this knowledge will help the countries to overcome their challenges and develop appropriate strategies for recycling and disposing of e-waste. This section provides an overview of earlier studies in the selected countries. In particular, results from the literature review on e-waste generation and management practices adopted by the respective nations are presented. Furthermore, this section presents the scope and the context of earlier studies on e-waste management. Prior studies [ 83 , 84 , 85 , 86 ] offer valuable insights into e-waste management in the selected countries. They also highlight the challenges associated with e-waste management and the need for developing comprehensive e-waste management strategies. Table 4 presents previous research on e-waste conducted in the selected countries from 2005 to 2020.

Previous studies on e-waste conducted in the selected countries from 2005 to 2020.

Main Research Area	Countries
	Australia	India	China	Malaysia	Indonesia
Electrical and electronic equipment modelling and e-waste estimation	√		√
E-waste legislation and implementation practices	√	√	√
Material flow analysis of e-waste	√
E-waste generation estimation and recovery potential	√
E-waste management practices	√	√	√	√	√
Extended producer responsibility (EPR) legislation	√		√
E-waste recycling scheme	√	√	√		√
E-waste generation and mitigating measures		√	√	√	√
E-waste management systems			√
E-waste social related issues		√	√
E-waste environmental and health impacts	√	√	√		√

4. Results and Discussion

This study adopts a qualitative approach for studying e-waste management practices of the selected countries in the Asia Pacific region. As per Wolfswinkel et al. [ 32 ], this study adopted a five-phase approach. In the first phase, secondary data from 2005 to 2020 has been considered for reviewing existing literature on e-waste management in the selected countries. Then, a total of eight (8) keywords are used to identify and analyse the relevant articles. Finally, challenges and practices associated with e-waste management are discussed to present the proposed policy approaches and recommendations.

E-waste management has become a contentious issue due to the presence of hazardous materials and the health hazards it may cause if not managed properly. In fact, for more than a decade, scholars have conducted studies on informal e-waste collection and disposal methods [ 87 , 88 ]. However, these studies were limited to e-waste generation, prevention, quantification, recycling, treatment, reuse, pollution control, legislation, and life-cycle assessment, as noted in recent studies [ 83 , 85 , 87 , 89 , 90 , 91 ]. Undoubtedly, these studies presented opportunities to address some of the challenges associated with e-waste management. However, there is a limited study in addressing the environmental and health implications associated with e-waste for achieving sustainable e-waste management. Moreover, prior studies on e-waste are centred on a small number of developed countries, which represent a “standard” or “benchmark” for developing e-waste management policies for emerging countries. Therefore, this study aims to address these gaps.

4.1. E-Waste Studies in Selected Countries

After a critical review of the pertinent literature and a content analysis of the e-waste articles related to the selected countries, the dispersion of e-waste research in the selected countries according to the keywords/themes, e-waste categories examined, and the study location are illustrated in Table 5 . Based on the information presented in Table 5 , it is evident that most of the e-waste studies in the selected countries were focused on e-waste generation, management and recycling. A number of e-waste studies focused on problems and challenges, environmental management, and health impacts indicating that further research is required in these areas in the countries examined.

Distribution of e-waste research in selected countries.

Main Area	E-Waste Categories Analysed	Study Location	References
Environmental management	General	China	[ ]
Recycling	Computer, television, refrigerators, air conditioners, personal computers, mobile telephones, washing machines, home appliances and computers, printed circuit boards (PCBs), cathode ray tube, TVs and monitors, general	Australia, India, China, Indonesia	[ , , , , , , , , , , , , , , ]
E-waste disposal and behaviour	Mobile phones, general	India, China, Malaysia	[ , , , , , ]
E-waste problems and challenges	General	Malaysia	[ ]
Environmental and health impacts of e-waste	General	India, China	[ , , , , ]
E-waste legislation	Household hazardous waste, general, computers, printers, mobile phones, home appliances	Australia, India, China, Malaysia	[ , , , , , , , , , , , , , , , , , , , , , , ]
E-waste management	Printed circuit boards (PCBs), televisions, computers, printers, and IT peripherals, television and computer waste, photovoltaic panels and battery energy storage systems, mobile phones, home appliances	Australia, India, China, Malaysia, Indonesia	[ , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ]
E-waste generation	TV sets, refrigerators, washing machines, air conditioners, microwaves, vacuum cleaners, dryers, personal computers, heaters, mobile phones	Australia, India, China, Indonesia	[ , , , , , , , , , , , , , , ]

4.2. Analysis of Content Results

Given the background review and analysis in the previous sections, it is obvious that the problem and challenges of e-waste in the selected countries still persist. Our analysis shows that the e-waste management systems and infrastructure of the selected countries, particularly India, China, Malaysia, and Indonesia, are still in their infancy. Currently, e-waste scrap such as printed circuit boards, CRT monitors, and LCD screens have been, and are still being, recycled in China, India, Indonesia, and Malaysia, creating huge environmental and health issues. Informal e-waste collection, recycling, and its health implications on informal workers in these countries have become increasingly popular in the last 15 years [ 89 , 92 , 93 , 94 ]. Table 6 shows the findings from the analysis of the contents.

Findings from the analysis of the contents.

Country	Findings
Australia
China
India
Indonesia
Malaysia

In China, several towns have remained as a dumping ground for e-waste. For example, Guiyu town is often referred to as “the e-waste capital of the world” and employs more than 150,000 locals from four villages. These local informal workers dismantle and recapture valuable metals and parts that can be reused or sold from old computers. In Guiyu, it is not uncommon to see computer parts, cables, and huge tangles of wires scattered around the streets and riverbanks [ 88 , 95 , 96 , 97 ]. Findings/outcomes indicate that various issues geared towards developing a sustainable recycling system still need to be addressed.

In India, obsolete computers from households and businesses are sold by auction to door-to-door collectors who engage in informal methods of recycling. According to a report by the Confederation of Indian Industries (CII), approximately 146,000 tons of obsolete EEE are generated in India annually [ 86 , 109 ]. The results of the analysis show that the recycling of e-waste in India is heavily dominated by the informal sector, and only a few approved e-waste recycling facilities are available. In the majority of urban slums of India, more than 95% of e-waste is treated and processed by untrained workers who carry out illegal and risky procedures. These illegal procedures are not only injurious to the health of the locals who work without personal protective equipment but also to the environment [ 55 , 86 ]. It is found that the formal process of e-waste recycling and treatment is still rather slow as the collection and recycling of most e-waste remains in the hands of the informal sector [ 86 , 109 ].

In Indonesia, large amounts of e-waste are imported from developed countries. E-waste in the form of scrap materials or second-hand devices is sent to Indonesian islands from the adjacent ports in Singapore and Malaysia. Findings indicate that, in Indonesia, infrastructure and workable systems to quantify, recycle, monitor, and handle e-waste is lacking [ 65 , 127 ]. Currently, the informal sector illegally collects, treats, and disposes of discarded EEE, causing huge environmental and health issues [ 65 , 71 ].

The management of e-waste in Malaysia is still developing and only began in 2005 [ 77 ]. Results indicate that although there are strategies to manage e-waste in Malaysia, challenges persist and the pressure to manage e-waste is now even more crucial. Malaysia has become one of the popular destinations of e-waste imported from developed countries [ 139 , 140 , 141 ]. Results of the analysis also indicate the country still faces significant issues in managing the ever-increasing amount of e-waste generated even though several material recovery facilities (MFR) have been established.

In Australia, several government policies have been developed. The key issues are identified in the e-waste management including: (a) the narrow scope of e-waste categories for recycling, (b) the lack of clarity on the roles of key stakeholders involved, (c) the recycling and material recovery targets, and (d) the lack of auditing and compliance. The results of the analysis show [ 47 , 142 , 143 ] minimal research has been undertaken to assess the effectiveness of e-waste policy management strategies [ 47 , 144 , 145 , 146 , 147 ].

It can be seen that the majority of the selected countries in this present study are faced with an increasing amount of e-waste. Although the per capita e-waste generated in the emerging countries is much lesser than in the developing countries, the volume generated is greater due to the growing population and market size in emerging countries such as India, China, and Indonesia. These countries are ranked among the top e-waste generators in the world.

The importance of selecting these countries such as Australia, India, China, Indonesia, and Malaysia in the Asia Pacific region in terms of environmental and market perspectives cannot be overemphasised. These selected countries have significant population, natural resources, and financial potentials [ 67 , 148 , 149 , 150 , 151 ]. Moreover, these countries have contributed substantially to the world’s GDP, landmass, and market share. This calls for a responsible e-waste management effort by these countries to effectively manage the growing amounts of e-waste generated for reducing environmental and health concerns.

Clearly, e-waste management processes in the majority of these countries examined still need improvement. Most of these countries studied have no well-established e-waste infrastructure for efficient collection, storage, transportation, recycling, and disposal of e-waste. In addition, the enforcement of codes of practice and regulations relating to hazardous e-waste management in these countries is minimal or non-existent.

Exposure to e-waste is harmful to public health. E-waste has been found to negatively impact public health because communities are exposed to a complex mixture of chemicals from multiple sources and through multiple exposure routes [ 152 ]. The results of this study indicate that the impact of e-waste is linked to a variety of health problems in the countries examined, such as birth defects, premature births, respiratory diseases, and cancer. Furthermore, people living in e-waste recycling towns or working in e-waste recycling sites showed evidence of greater DNA damage. A review of the literature also revealed an association between e-waste exposure and thyroid dysfunction, adverse behavioural changes, and damage to the lungs, heart, and spleen due to prolonged exposure [ 152 , 153 ].

Hence, e-waste has become one of the major challenges in these countries, and it is, therefore, crucial for these countries to investigate the development of a well-organised and inexpensive recycling scheme to extract valuable resources with inconsequential environmental impacts.

5. Conclusions

This study has evaluated the e-waste generation and management practices of the selected countries in the Asia Pacific region. Based on the review of past studies and results of the analysis, it is obvious that the majority of the selected countries are yet to find a workable e-waste management strategy that will provide a sustainable solution to their e-waste concerns.

Results of the analysis show that the volumes of e-waste generated are fast exceeding the available infrastructure and recycling facilities in the countries examined, thereby driving e-waste streams to flow into illegal and informal recovery. On top of that, the absence of an integrated framework that could support the monitoring and management of toxic and hazardous wastes has also created additional problems in managing e-waste in the selected countries and calls for a generic e-waste policy approach.

In addition, the increasing demand for second-hand EEE, particularly in developing countries (China, Indonesia, India, and Malaysia) due to poverty and the continuing technological modernisation, has made these countries dumping grounds for e-waste from developed countries. For example, China’s Guiyu town is well-known for the informal recycling of printed circuit boards. Specifically, “metal-contaminated sediments and elevated levels of dissolved metals have been reported in rivers around the town of Guiyu” [ 85 ].

Furthermore, sophisticated facilities and infrastructure required for formal recycling of e-waste using efficient technologies are minimal or non-existent in the selected countries. Formal recycling is widely accepted as the best way to manage e-waste, which reduces greenhouse gas emissions and helps lessen the climate crisis. Thus, recycling e-waste will reduce air and water pollution associated with the illegal dumping of e-waste. By recycling discarded, unwanted, or obsolete EEE for new products, nations can further reduce the enormous health risks and environmental pollution associated with improper disposal of e-waste.

Therefore, to effectively manage e-waste in the selected countries, there is a need to develop generic structured policy approaches to tackle the e-waste problem in the selected countries and indeed across the world is required. These structured policies are projected to put in place formal systems and infrastructure for the recycling, management, and disposal of e-waste, taking into account country-specific issues.

One of the shortcomings of this study is that the information and analysis of previous studies are seen to be reality. This study is also limited to countries in the Asia Pacific region and considers the time limitation by the year of the articles found. Although the accuracy of some of the analyses in the present study is inescapably subjective, this study is a starting point for further research into various aspects of e-waste generation and management practices of the selected countries.

6. Recommendations

This study has exposed the current situation of e-waste generation and management practices of the selected countries. The following recommendations are suggested based on the findings of this study:

E-waste regulations tailored to each country’s current situations should be enacted, recognising the lessons learned from more developed and experienced nations such as Japan, Switzerland, and South Korea;
Extended producer responsibility (EPR) and 3Rs strategy should be implemented in EEE manufacturing regulations in all countries to support the production of simple, lightweight products, planned for reuse rather than obsolescence so that recycled materials can become resources for new products, thereby reducing the request for raw materials;
Local government councils are key stakeholders in the management and recycling process and therefore incur major expenditures while handling e-waste. This, therefore, necessitates policymakers understanding of the determinants, drivers, and costs associated with e-waste collection and disposal;
International integrated organisations should be established for checking specific e-waste material generation across the globe. This initiative will restrain the transboundary movement of e-waste across international borders.

Policy Approaches

Although different countries have endorsed and passed their respective e-waste regulations in other to manage e-waste, implementing appropriate and structured policy approaches will support all efforts directed towards effectively managing e-waste across the globe. Firstly, it is critical to have stepwise, and well-thought-out policy approaches for effectively formulating and implementing e-waste regulations and guidelines. Such approaches have been found to be effective in more advanced countries such as Switzerland, South Korea, and Japan, as noted above. In view of the multidimensional socio-economic nature of emerging economies, it is vital to consistently assess and evaluate existing policies to identify gaps and areas for improvement. This technique has also been found to be effective in Australia. Secondly, when implementing e-waste policies, interdisciplinary research approaches need to be considered. This will allow policymakers to better understand and address the various health and environmental problems associated with e-waste management. Finally, we believe that the policy approaches of respective countries geared towards dealing with the persistent and challenging e-waste issues require a local and specific approach where inherent socio-cultural, economic, political, and environmental concerns of that country are taken into consideration.

7. Future Research

Future research should use a quantitative approach or other research methods and expand the number of selected countries to understand e-waste generation and management practices of countries in the Asia Pacific region. This will provide additional viewpoints in the management, recycling, and environmental management of e-waste in the regions.

Author Contributions

L.A.: Conceptualisation, Methodology, Formal analysis, Investigation, Resources, Writing—Original Draft; S.W.: Visualisation, Validation, Writing—Review and Editing, Supervision; S.G.: Visualisation, Validation, Writing—Review and Editing, Supervision. All authors have read and agreed to the published version of the manuscript.

This research received no external funding.

Institutional Review Board Statement

Informed consent statement, data availability statement, conflicts of interest.

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

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Systematic reviews and research waste

Affiliation.

1 School of Public Health, University of Illinois at Chicago, Chicago, IL 60612, USA. Electronic address: [email protected].
PMID: 26841994
DOI: 10.1016/S0140-6736(15)01355-0

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How systematic reviews cause research waste. Roberts I, Ker K. Roberts I, et al. Lancet. 2015 Oct 17;386(10003):1536. doi: 10.1016/S0140-6736(15)00489-4. Lancet. 2015. PMID: 26530621 No abstract available.

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A Systematic Review of E-Waste Generation and Environmental Management of Asia Pacific Countries

1. Introduction

2. Research Methods

3. Overview of E-Waste

3.1. Constituents of E-Waste

3.2. E-Waste Generation and Management Practices

3.2.1. Australia

3.2.2. China

3.2.3. India

3.2.4. Indonesia

3.2.5. Malaysia