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Volunteering is a way for people to develop meaningful relationships within a social group and can lead to the building of social capital, from which both individuals and the wider group can benefit in the form of enhanced well-being. This study aimed to explore and describe the impact of volunteering on the volunteer coordinators and volunteers themselves in the eastern suburbs of Christchurch, New Zealand, an area particularly impacted by the devastating earthquakes in the period 2010/2011. Data were collected via semi-structured interviews with volunteer coordinators and volunteers (n = 35; 16 men, 19 women) from November 2018 to mid-January 2019. Thematic analysis of data highlighted a key theme of Creating and strengthening valued community connections, with subthemes of Personal growth, Community connections and Role of coordination. The key theme illustrated how formal volunteering created effort and opportunities towards the strengthening of personal and community connectedness. Our study demonstrates the importance of social connection for both individual and community well-being, emphasises the important role of "champions" in facilitating the building of bridging and bonding relationships between individuals and communities, and suggests a role for healthcare professionals to prescribe volunteering as a way to improve individual health and well-being outcomes.

Background: This study investigates the association between television (TV) viewing and child adiposity and if parental education and child ethnicity moderate this association.Method: Cross-sectional, pooled (2013/2014–2016/2017) adult and child New Zealand Health Survey were matched resulting in 13,039 children (2–14 y) and parent dyads. Child TV viewing was estimated using self-reported time for each weekday and weekend. The height (in centimeters), weight (in kilograms), and waist circumference of parents and children were measured. Childhood body mass index and obesity were defined using the International Obesity Task Force cutoff values. Effect modification was assessed by interaction and then by stratifying regression analyses by parent education (low, moderate, and high) and child ethnicity (Asian, European/other, Māori, and Pacific).Results: Overall, watching ≥2 hours TV on average per day in the past week, relative to zscore (b = 0.123 [0.061–0.187]), and higher waist circumference (b = 0.546 [0.001–1.092]). Interactions considering this association by child ethnicity and parent education revealed little evidence of effect modification.Conclusion: While TV viewing was associated with child adiposity, the authors found little support for a moderating role of parental education and child ethnicity.

Globally, geospatial concepts are becoming increasingly important in epidemiological and public health research. Individual level linked population-based data afford researchers with opportunities to undertake complex analyses unrivalled by other sources. However, there are significant challenges associated with using such data for impactful geohealth research. Issues range from extracting, linking and anonymising data, to the translation of findings into policy whilst working to often conflicting agendas of government and academia. Innovative organisational partnerships are therefore central to effective data use. To extend and develop existing collaborations between the institutions, in June 2019, authors from the Leeds Institute for Data Analytics and the Alan Turing Institute, London, visited the Geohealth Laboratory based at the University of Canterbury, New Zealand. This paper provides an overview of insight shared during a two-day workshop considering aspects of linked population-based data for impactful geohealth research. Specifically, we discuss both the collaborative partnership between New Zealand’s Ministry of Health (MoH) and the University of Canterbury’s GeoHealth Lab and novel infrastructure, and commercial partnerships enabled through the Leeds Institute for Data Analytics and the Alan Turing Institute in the UK. We consider the New Zealand Integrated Data Infrastructure as a case study approach to population-based linked health data and compare similar approaches taken by the UK towards integrated data infrastructures, including the ESRC Big Data Network centres, the UK Biobank, and longitudinal cohorts. We reflect on and compare the geohealth landscapes in New Zealand and the UK to set out recommendations and considerations for this rapidly evolving discipline.

Background The availability of a skilled health professional (nurse, midwife or doctor) who has been trained and is fit for practice to provide maternity care is fundamental in scaling down and ending preventable maternal and child deaths. Knowing the determinants of the development of ideal skills for effective practice ensures that women and their babies receive quality maternity care services from skilled birth attendants who are fit for practice. This study aimed to find and build on the existing evidence addressing aspects linked to competence and confidence development during training among students, newly qualified nurses, doctors and midwives from a global perspective. Methods A literature review was undertaken, using the ‘SPIDER’ search strategy to identify relevant papers from multiple databases. Studies were included if they were written in English and related to midwives, nurses and medical doctors when they were students, newly qualified professionals or after they had been working for 3-4 months. Opinion or non-empirical papers, editorials, conference papers and empirical articles with abstracts were excluded. Search words were used to identify papers that examined competence and confidence development while training these health professionals. A total of 2281 papers were identified, from countries in Europe, Australia, Asia, America and Africa. Overall, 62 papers were analysed. Results One core category, ‘learning environment’, emerged, with two overarching subcategories, ‘internal environment’ and ‘external environment’ when examining facilitators and barriers to competence and confidence development. Conclusions Facilitators and barriers to competence and confidence development are centred on the learning and practice environment. These are difficult to separate, as they are driven by either the student's or the newly qualified professional's experience with the learning and practice environment. This highlights the need for diversity and open mindedness among mentors and administrators in manipulating the environment to the benefit of either the student or the newly qualified professional so that mothers and their babies receive quality care.

COVID-19 can affect the entire population, but it poses an increased risk for particular population groups. Socioeconomic and demographic factors, as well as long-term health conditions, can make p...

Many molecular biology and biochemistry instructors have altered their classroom behavior in favor of evidence‐based, active learning instructional strategies. Overwhelming evidence confirms that lecture‐only classrooms are detrimental to student learning outcomes, but we know less about the impact textbooks have on students outside the classroom. Two influential projects, the AP Biology redesign and Vision and Change, called for extensive restructuring of course content and hoped that textbooks would be restructured accordingly. This study evaluated all figures and tables from two introductory biology textbooks to quantify how well they implement recommendations from Vision and Change and AP Biology redesign. We documented significant differences among figures and tables when looking for experimental data, questions for students to answer, and quantitative interpretation. Using think‐aloud interviews, we interrogated whether students engage differently with figures from the two textbooks. When figures provided take‐home messages, students relied on written text rather than analyzing the graphical information for their understanding. Students frequently employed words from summaries within the figures to construct “inflated explanations” that mimicked comprehension.

Background The prevalence of children with elevated weight or obesity is concerning for public health due to associated comorbidities. This study investigates associations between parental adiposity, physical activity (PA), fruit and vegetable consumption, and child adiposity and moderation by both child and parent gender. Methods Cross-sectional nationally representative data from the New Zealand Health Survey were pooled for the years 2013/14-2016/17. Parent and child surveys were matched resulting in 13,039 child (2-14 years) and parent (15-70 years) dyads. Parent and child, height (cm), weight (kg) and waist circumference (WC) were measured objectively. Height and weight were used to calculate BMI. Linear regression, accounting for clustered samples (b [95% CI]) investigated associations between parental characteristics and child BMI z-score and WC. Interactions and stratification were used to investigate effect moderation by parent gender, child gender, and parent adiposity. Results Parental PA and fruit and vegetable consumption were unrelated to child adiposity. Overall, higher parent BMI was related to a higher child BMI z-score (b = 0.047 [0.042, 0.052]) and higher parental WC was related to a higher child WC (0.15 [0.12, 0.17]). A three-way interaction revealed no moderation by parent gender, child gender, and parent BMI for child BMI z-score ((b = 0.005 [-0.017, 0.027], p = 0.318). However, a three-way interaction revealed moderation by parent gender, child gender, and parent WC for child WC (b = 0.13 [0.05, 0.22]). The slightly stronger associations were seen between father-son WC (b = 0.20 [0.15, 0.24]) and mother-daughter WC (b = 0.19 [0.15, 0.22]). Conclusions The findings are highly relevant for those wishing to understand the complex relationships between child-parent obesity factors. Findings suggest that family environments should be a key target for obesity intervention efforts and show how future public health interventions should be differentiated to account for both maternal and paternal influences on child adiposity.

Background We examined the association between area-level deprivation and dental ambulatory sensitive hospitalizations (ASH) and considered the moderating effect of community water fluoridation (CWF). The hypothesis was that higher levels of deprivation are associated with higher dental ASH rates and that CWF will moderate this association such that children living in the most deprived areas have greater health gain from CWF. Methods Dental ASH conditions (dental caries and diseases of pulp/periapical tissues), age, gender and home address identifier (meshblock) were extracted from pooled cross-sectional data (Q3, 2011 to Q2, 2017) on children aged 0–4 and 5–12 years from the National Minimum Dataset, New Zealand (NZ) Ministry of Health. CWF was obtained for 2011 and 2016 from the NZ Institute of Environmental Science and Research. Dental ASH rates for children aged 0–4 and 5–12 years (/1000) were calculated for census area units (CAUs). Multilevel negative binomial models investigated associations between area-level deprivation, dental ASH rate and moderation by CWF status. Results Relative to CWF (2011 and 2016), no CWF (2011 and 2016) was associated with increased dental ASH rates in children aged 0–4 [incidence rate ratio (IRR) = 1.171 (95% confidence interval 1.064, 1.288)] and aged 5–12 years [IRR = 1.181 (1.084, 1.286)]. An interaction between area-level deprivation and CWF showed that the association between CWF and dental ASH rates was greatest within the most deprived quintile of children aged 0–4 years [IRR = 1.316 (1.052, 1.645)]. Conclusions CWF was associated with a reduced dental ASH rate for children aged 0–4 and 5–12 years. Children living in the most deprived areas showed the greatest effect of CWF on dental ASH rates, indicating that the greater health gain from CWF occurred for those with the highest socio-economic disadvantage. Variation in CWF contributes to structural inequities in oral-health outcomes for children.

To explore how childbirth-related blood loss is evaluated and excessive bleeding recognised; and to develop and test a theory of postpartum haemorrhage (PPH) diagnosis.Two-phase, exploratory, sequential mixed methods design using focus groups, interviews and a pilot, randomised crossover study.Two hospitals in North West England.Women (following vaginal birth with and without PPH), birth partners, midwives and obstetricians.Phase 1 (qualitative): 8 focus groups and 20 one-to-one, semi-structured interviews were conducted with 15 women, 5 birth partners, 11 obstetricians, 1 obstetric anaesthetist and 19 midwives (n = 51). Phase 2 (quantitative): 11 obstetricians and ten midwives (n = 21) completed two simulations of fast and slow blood loss using a high-fidelity childbirth simulator.Responses to blood loss were described as automatic, intuitive reactions to the speed, nature and visibility of blood flow. Health professionals reported that quantifying volume was most useful after a PPH diagnosis, to validate intuitive decisions and guide ongoing management. During simulations, PPH treatment was initiated at volumes at or below 200 ml (fast mean blood loss 79.6 ml, SD 41.1; slow mean blood loss 62.6 ml, SD 27.7). All participants treated fast, visible blood loss, but only half treated slow blood loss, despite there being no difference in volumes (difference 18.2 ml, 95% CI -5.6 to 42.2 ml, P = 0.124).Experience and intuition, rather than blood loss volume, inform recognition of excessive blood loss after birth. Women and birth partners want more information and open communication about blood loss. Further research exploring clinical decision-making and how to support it is required.During a PPH, clinical decision-making is intuitive with clinicians treating as soon as excessive loss is recognised.

BackgroundThe COVID-19 pandemic has asked unprecedented questions of governments around the world. Policy responses have disrupted usual patterns of movement in society, locally and globally, with resultant impacts on national economies and human well-being. These interventions have primarily centred on enforcing lockdowns and introducing social distancing recommendations, leading to questions of trust and competency around the role of institutions and the administrative apparatus of state. This study demonstrates the unequal societal impacts in population movement during a national ‘lockdown’.MethodsWe use nationwide mobile phone movement data to quantify the effect of an enforced lockdown on population mobility by neighbourhood deprivation using an ecological study design. We then derive a mobility index using anonymised aggregated population counts for each neighbourhood (2253 Census Statistical Areas; mean population n=2086) of national hourly mobile phone location data (7.45 million records, 1 March 2020–20 July 2020) for New Zealand (NZ).ResultsCurtailing movement has highlighted and exacerbated underlying social and spatial inequalities. Our analysis reveals the unequal movements during ‘lockdown’ by neighbourhood socioeconomic status in NZ.ConclusionIn understanding inequalities in neighbourhood movements, we are contributing critical new evidence to the policy debate about the impact(s) and efficacy of national, regional or local lockdowns which have sparked such controversy.

To investigate risk factors for women with obesity of childbearing age. A cross-sectional survey of New Zealand women (15–49 years) with measured height and weight was used [unweighted (n = 3625) and weighted analytical sample (n = 1,098,372)] alongside sociodemographic-, behavioural- and environmental-level predictors. Multilevel logistic regression weighted for non-response of height and weight data was used. Meeting physical activity guidelines (AOR (adjusted odds ratio) 0.66, 95% CI 0.54–0.80), Asian (AOR 0.15, 95% CI 0.10–0.23) and European/other ethnicity (AOR 0.46, 95% CI 0.36–0.58) and an increased availability of public greenspace (Q4 AOR 0.55, 95% CI 0.41–0.75) were related to decreased obesity risk. Older age (45–49 years AOR 3.01, 95% CI 2.17–4.16), Pacific ethnicity (AOR 2.81, 95% CI 1.87–4.22), residing in deprived areas (AOR 1.65, 95% CI 1.16–2.35) or secondary urban areas (AOR 1.49, 95% CI 1.03–2.18) were related to increased obesity risk. When examined by rural/urban classification, private greenspace was only related to increased obesity risk in main urban areas. This study highlights factors including but not limited to public greenspace, which inform obesity interventions for women of childbearing age in New Zealand.

Calculating an appropriate sample size for a study can be crucial to how valid the conclusions are deemed to be by readers. Malcolm Campbell details how to calculate a sample size, while factoring in attrition and incomplete data

How can you avoid type I and type II errors when representing your data? Malcolm Campbell explains the tests on offer to compare variables and correctly identify relationships of significance

Background Accounting for the co-occurrence of multiple environmental influences is a more accurate reflection of population exposure than considering isolated influences, aiding in understanding the complex interactions between environments, behaviour and health. This study examines how environmental ‘goods’ such as green spaces and environmental ‘bads’ such as alcohol outlets co-occur to develop a nationwide area-level healthy location index (HLI) for New Zealand. Methods Nationwide data were collected, processed, and geocoded on a comprehensive range of environmental exposures. Health-constraining ‘bads’ were represented by: (i) fast-food outlets, (ii) takeaway outlets, (iii) dairy outlets and convenience stores, (iv) alcohol outlets, (v) and gaming venues. Health-promoting ‘goods’ were represented by: (i) green spaces, (ii) blue spaces, (iii) physical activity facilities, (iv) fruit and vegetable outlets, and (v) supermarkets. The HLI was developed based on ranked access to environmental domains. The HLI was then used to investigate socio-spatial patterning by area-level deprivation and rural/urban classification. Results Results showed environmental ‘goods’ and ‘bads’ co-occurred together and were patterned by area-level deprivation. The novel HLI shows that the most deprived areas of New Zealand often have the most environmental ‘bads’ and less access to environmental ‘goods’. Conclusions The index, that is now publicly available, is able to capture both inter-regional and local variations in accessibility to health-promoting and health-constraining environments and their combination. Results in this study further reinforce the need to embrace the multidimensional nature of neighbourhood and place not only when designing health-promoting places, but also when studying the effect of existing built environments on population health.

Background Declining childhood immunization represents a serious public health problem globally and in New Zealand. To guide efforts to increase immunization coverage, this study monitors nationwide change in immunization coverage since the introduction of the National Immunisation Register (NIR) in 2005 and spatiotemporal patterns of immunization coverage from 2006 to 2017. Methods The study population consisted of 4 482 499 individual immunization records that were obtained from the NIR (2005–2017). Data on yearly and average immunization coverage in census area units (CAUs) in New Zealand were calculated by milestone age (6/8/12/18/24/60/144 months). Data for 2005 were excluded due to missing records in the introductory period of the NIR. We analyzed spatial and spatiotemporal patterns using Gi* and SaTScan methods. Results Immunization coverage improved since the introduction of the NIR in 2005, reaching a peak in 2014 and 2015 with a slight decrease in 2016 and 2017. Well and insufficiently immunized areas were identified with spatial autocorrelation analyses highlighting several hot- and cold-spots. Comparison of CAUs with neighbouring CAUs allowed for the identification of places where immunization coverage was significantly higher or lower than expected, over both time and space. Conclusion We provide the first spatiotemporal analysis of childhood immunization in New Zealand that utilizes a large sample of over 4.4 million individual immunization records. Our spatial analyses enable policymakers to understand the development of childhood immunization coverage and make more effective prevention strategies in New Zealand.

This study combines data on the location of health-constraining 'bads' (i: fast-food outlets, ii: takeaway outlets, iii: dairy outlets and convenience stores, iv: alcohol outlets, and v: gaming venues) and health-promoting 'goods' (i: green spaces, ii: blue spaces, iii: physical activity facilities, and iv: fruit and vegetable outlets) into a nationwide Healthy Living Index. This was applied to pooled (2015/16-2017/18) nationally representative New Zealand Health Survey data, with mental health conditions (depression, bipolar, and anxiety) and psychological distress as population-level outcomes. Mental health was associated with proximity to environmental 'goods' and 'bads'. Compared to those individuals who reside within the unhealthiest environments, there was a steady reduction in the odds of adverse mental health outcomes and psychological distress as the environment became more health-promoting.

Background Immunisation is a safe and effective way of protecting children and adults against harmful diseases. However, immunisation coverage of children is declining in some parts of New Zealand. Aim Use a nationwide sample to first, examine the socioeconomic and demographic determinants of immunisation coverage and spatial variation in these determinants. Second, it investigates change in immunisation coverage in New Zealand over time. Methods Individual immunisation records were obtained from the National Immunisation Register (NIR) (2005–2017; 4,482,499 events). We calculated the average immunisation coverage by year and milestone age for census area units (CAU) and then examined the immunisation coverage by selected socioeconomic and demographic determinants. Finally, local variations in the association between immunisation coverage and selected determinants were investigated using geographically weighted regression. Results Findings showed a decrease of immunisation rates in recent years in CAUs with high immunisation coverage in the least deprived areas and increasing immunisation rates in more deprived areas. Nearly all explanatory variables exhibited a spatial variation in their association with immunisation coverage. For instance, the strongest negative effect of area-level deprivation is observed in the northern part of the South Island, the central-southern part of the North Island, around Auckland, and in Northland. Conclusion Our findings show that childhood immunisation coverage varies by socioeconomic and demographic factors across CAUs. We also identify important spatial variation and changes over time in recent years. This evidence can be used to improve immunisation related policy in New Zealand.

Social and natural capital are fundamental to people’s wellbeing, often within the context of local community. Developing communities and linking people together provide benefits in terms of mental well-being, physical activity and other associated health outcomes. The research presented here was carried out in Christchurch - Ōtautahi, New Zealand, a city currently re-building, after a series of devastating earthquakes in 2010 and 2011. Poor mental health has been shown to be a significant post-earthquake problem, and social connection has been postulated as part of a solution. By curating a disparate set of community services, activities and facilities, organised into a Geographic Information Systems (GIS) database, we created i) an accessibility analysis of 11 health and well-being services, ii) a mobility scenario analysis focusing on 4 general well-being services and iii) a location-allocation model focusing on 3 primary health care and welfare location optimisation. Our results demonstrate that overall, the majority of neighbourhoods in Christchurch benefit from a high level of accessibility to almost all the services; but with an urban-rural gradient (the further away from the centre, the less services are available, as is expected). The noticeable exception to this trend, is that the more deprived eastern suburbs have poorer accessibility, suggesting social inequity in accessibility. The findings presented here show the potential of optimisation modelling and database curation for urban and community facility planning purposes.

Introduction Despite improvements in oral health outcomes in New Zealand over the last number of decades, there are still high levels of preventable tooth decay in adults and children. We investigate the prevalence and spatial variation of non-fluoride toothpaste use in a nationally representative sample of adults and children in New Zealand.Method Individual-level self-reported data were sourced from the New Zealand Health Survey (2017/18). Both child (n = 4,723) and adult (n = 13,869) data were used. Data included sociodemographic (for example, age), socioeconomic (for example, area-level deprivation) and dental-related (for example, type of toothpaste used) variables.Results Overall, 6.8% of adults and 6.4% of children use non-fluoride toothpaste. When split by deprivation, the highest prevalence of non-fluoride toothpaste use for children and adults was in the moderate to least deprived areas, while the lowest prevalence was in the most deprived areas. When disaggregated by ethnicity, the Asian population had the highest prevalence of non-fluoride toothpaste use for both adults and children compared to Māori, Pacific and European/Other. There was little difference in prevalence by rural/urban classification; however, prevalence varied geographically across the study area.Conclusion This is the first study that uses a nationally representative sample of adults and children to show variation in the use of non-fluoride toothpaste in New Zealand.

A previous article in this series explained why effect sizes are important and described effect sizes for differences between groups. This article will now cover commonly used effect sizes for relationships between variables

In this article, we will explain why effect sizes are important and we will look at effect sizes measuring differences between groups

In this article, we will introduce the idea of parametric and non-parametric methods, which can be used to compare statistical hypotheses about population parameters

In this article, we will look at the impact of sample size on methods for assessing whether a variable has a Normal distribution, which will be accompanied by practical recommendations

The aim of this research is to analyse the spatial epidemiology of Type 2 Diabetes Mellitus (T2DM) and investigate associations with the built environment in urban New Zealand. Data on T2DM was sourced from the New Zealand Virtual Diabetes Register (2016), and data on environmental variables sourced from the Ministry for Primary Industries and Territorial Authorities (2013–2016). Novel measures of the built environment using an enhanced two-step floating catchment area model were established using data on fast food outlets, takeaways, dairy/convenience stores, supermarkets and fruit/vegetable stores. Rates of T2DM per 1,000 population and standardised morbidity ratios were computed and visualised for all urban areas. Getis Ord was used to assess spatial clustering, and Bayesian modelling was used to understand associations between T2DM and environmental variables. Results indicate that T2DM is influenced by demographic factors, spatially clustered and associated with accessibility to environmental exposures. Health-promoting resources, such as fruit/vegetable stores, were shown to have a consistently protective effect on T2DM while those considered detrimental to health showed varying, and largely insignificant, associations. This is the first study in New Zealand to spatially quantify the effects of multiple environmental exposures on population level T2DM for all urban areas using a geospatial approach. It has implications for both policy and future research efforts as a deeper knowledge of local environments forms a basis on which to better understand spatial associations between the built environment and health, as well as formulate policy directed toward environmental influences on chronic health conditions.

In the first in a series on Normal distribution, we will consider the importance of assessing whether data have a Normal distribution, and describe the numerical and graphical methods available

Background Falls and fall-related injuries are important indicators for quality of nursing care in institutions. Few studies have been conducted specifically on this topic for hospitalized patients with cancer in Taiwan. Purpose The aims of this study were to understand falls and levels of injury; to identify associations among fall-related injuries, demographics, and causes of falling; and to predict fall-related injuries in hospitalized patients with cancer. Methods A retrospective survey design was used. Data were retrieved from the Taiwan Patient-Safety Reporting system query fall incidences for persons hospitalized with cancer at a medical center in northern Taiwan from 2010 to 2012. Data were encoded and analyzed with descriptive statistics, the chi-square test, and multiple stepwise logistic regression analysis using IBM SPSS Statistics version 18.0. Results One hundred fifty-six (85%) of the 184 hospitalized patients with cancer had fall-related injuries. Falling tended to be more frequent in men without a history of falls and more prevalentat night. The results of regression analysis showed that the variables being with companions at the time of a fall (OR = 5.411, 95% CI [1.619, 18.081]), lower limb weakness (OR = 0.284, 95% CI [0.097, 0.832]), postural hypotension (OR = 0.101, 95% CI [0.014, 0.733]), total score of fall risk factors (OR = 1.688, 95% CI [1.071, 2.660]), and a fall occurring at the bedside (OR = 3.493, 95% CI [1.119, 10.903]) were all positively associated with fall-related injuries, with a Nagelkerke R of 42.8%. Conclusions/implications for practice The risk factors for falls that affect hospitalized patients with cancer are complex. Nursing staff must evaluate the risk factors and treatment methods for each patient and facilitate fall prevention measures to achieve safety-centered quality of care. This study provides an example for nursing staff when assessing factors associated with falls and working to reduce fall-related injuries among patients with cancer.

In this article, we will look more generally at statistical methods for measuring and testing relationships between two or more variables

In a previous article, we looked at tests used to compare independent groups. In this article, we will explain what comparing dependent or related groups involves and look at commonly used tests.

In the previous article in this series ( Campbell, 2016b ), we discussed the use of hypothesis tests as a way of generalising findings from a sample to a population. In practice, the approach can follow a routine, but as we saw, there was one tricky step: there are so many statistical tests available, so how do we choose an appropriate one for our analysis? In this article, we will look at the most common situation, the comparison of different kinds of variables between independent groups of individuals.

This brief communication responds to the paper by Jeong and Cho (Qual Life Res 26(4):903–911, 2017) that has described activity pacing in limited terms of adjusting activities through going at a slower rate and taking breaks. Activity pacing was reported as not involving goal setting, in comparison to other strategies for long-term conditions such as Acceptance and Commitment Therapy. This brief communication aims to challenge this limited perception of activity pacing in light of numerous studies that recognise pacing to be a more complex strategy. Pacing is considered to be a multifaceted coping strategy, including broad themes of not only adjusting activities, but also planning activities, having consistent activity levels, acceptance of current abilities and gradually increasing activities, and one that includes goal setting as a key facet. It is essential that pacing is both defined and measured as a multifaceted strategy in order to assess the outcomes of pacing, and for meaningful comparisons with other strategies regarding efficacy for the management of long-term conditions.

Proliferation of pulmonary fibroblasts (PF) and distal migration of smooth muscle cells (PSM) are hallmarks of pulmonary arterial hypertension (PAH). Intermedin/adrenomedullin-2 (IMD/AM2) belongs to the Calcitonin Gene-Related Peptide (CGRP)/Adrenomedullin (AM) superfamily. These peptides act via Calcitonin-Like Receptors (CLR) combined with one of three Receptor activity-modifying proteins (RAMPs). IMD/AM2 is a potent pulmonary vasodilator in animal studies. The aim was to describe expression of IMD/AM2, AM and receptor components in human pulmonary vascular cells and to elucidate effects of IMD/AM2 on human PSM migration and PF proliferation. Gene expression was detected by immunofluorescence, immunoblotting and qRT-PCR. Normotension and hypertension were simulated by applying pulsatile mechanical stretch (Flexcell® apparatus). Viable cell numbers were determined by dye exclusion. PSM chemotaxis was measured via Dunn chamber. IMD/AM2 protein was co-expressed with AM and their receptor components in pulmonary artery and microvascular endothelial (PAEC, PMVEC) and non-endothelial cells (PF, PSM), and localised to vesicles. IMD/AM2 was secreted under basal conditions, most abundantly from PF and PMVEC. Secretion from PF and PSM was enhanced by stretch. IMD/AM2 mRNA expression increased in response to hypertensive stretch of PSM. IMD/AM2 inhibited PDGF (10−7 M)-mediated PSM migration maximally at 3 × 10-10 M and PF proliferation maximally at 3 × 10-9 M. Angiotensin II (5 × 10-8 M), normotensive and hypertensive stretch augmented PF proliferation. IMD/AM2 (10-9 M) abolished the proliferative effects of Angiotensin II and normotensive stretch and attenuated the proliferative effect of hypertensive stretch alone and combined with angiotensin II. These findings indicate an important counter-regulatory role for IMD/AM2 in PAH.

There is still much to learn about the predictors of therapeutic response in psychiatry, but progress is gradually being made and precision psychiatry is an exciting and emerging subspeciality in this field. This is critically important in the treatment of refractory psychotic disorders, where clozapine is the only evidence-based treatment but only about half the patients experience an adequate response. In this case report, we explore the possible biological mechanisms underlying treatment failure and discuss possible ways of improving clinical outcomes. Further work is required to fully understand why some patients fail to respond to the most effective treatment in refractory schizophrenia. Therapeutic drug monitoring together with early pharmacogenetic testing may offer a path for some patients with refractory psychotic symptoms unresponsive to clozapine treatment.

It is fundamental, when undertaking research, to understand the discipline of Statistics—what it is, the key concepts and approaches, statistical tests and how to choose them, and how to write up your findings. Statistics can be used to summarise quantitative data and generalise findings. Types of variables will determine how they are analysed statistically; categorical variables may be dichotomous, nominal or ordinal, which are analysed in different ways, while interval/ratio variables for numerical data are analysed in the same way. Understanding the basics of how to present and interpret data is essential in any field of research.

In the previous article in this series ( Campbell, 2016 ), we looked at one method for generalising findings from a sample to a population, confidence intervals. In this article, we will look at the other method, hypothesis tests.

In a previous article in this series, we looked at Normal distributions and the concept of a normal range or reference range covering 95% of data values ( Campbell, 2016 ). In this article, we will look at a related concept that is one way of generalising from a sample to a population: a confidence interval.

The opportunity of an emerging smart city in post-disaster Christchurch has been explored as a way to improve the quality of life of people suffering Chronic Obstructive Pulmonary Disease (COPD), which is a progressive disease that affects respiratory function. It affects 1 in 15 New Zealanders and is the 4th largest cause of death, with significant costs to the health system. While, cigarette smoking is the leading cause of COPD, long-term exposure to other lung irritants, such as air pollution, chemical fumes, or dust can also cause and exacerbate it. Currently, we do know little what happens to the patients with COPD after they leave a doctor’s care. By learning more about patients’ movements in space and time, we can better understand the impacts of both the environment and personal mobility on the disease. This research is studying patients with COPD by using GPS-enabled smartphones, combined with the data about their spatiotemporal movements and information about their actual usage of medication in near real-time. We measure environmental data in the city, including air pollution, humidity and temperature and how this may subsequently be associated with COPD symptoms. In addition to the existing air quality monitoring network, to improve the spatial scale of our analysis, we deployed a series of low-cost Internet of Things (IoT) air quality sensors as well. The study demonstrates how health devices, smartphones and IoT sensors are becoming a part of a new health data ecosystem and how their usage could provide information about high-risk health hotspots, which, in the longer term, could lead to improvement in the quality of life for patients with COPD.

Objective To gain understanding of the first-hand experience of women prior to and following repair of a vaginal fistula, to determine the most effective support mechanisms. Design Qualitative phenomenological study using a series of in-depth semi-structured interviews at two time points: prior to fistula repair and 6 months post-surgery. Data were analysed thematically. Setting Three fistula clinics in three districts in Kenya. Population A purposive sample of 16 women suffering with vaginal fistula who were seeking fistula repair. Methods Thrity-two semi-structured interviews were conducted. Results The two main themes represented the women's journeys from social isolation to social reintegration. Women felt euphoric following fistula repair, believing that a ‘miracle’ had occurred. However, the ‘post-miracle phase’ demonstrated that the social and psychological impact of fistula leaves scars that are not easily healed, even when fistula repair is successful. Conclusion Women's experiences of living with fistula have an impact beyond that which can be repaired solely by surgery. The findings from this study support the need for more active psychological assessment in the management of women with fistula, and the role of targeted psychological support in any package of care given in the post repair phase. The format of this support requires further study. Engagement by health professionals with the wider community could raise awareness of the causes of fistula, and provide support for significant others who may also be feeling vulnerable. It is likely that the collaborative efforts from health professionals and community members will provide the most effective support. Tweetable abstract Fistula surgery alone is insufficient for women's physical, social and psychological recovery.

Application of intermedin/adrenomedullin-2 (IMD/AM-2) protects cultured human cardiac vascular cells and fibroblasts from oxidative stress and simulated ischaemia-reoxygenation injury (I-R), predominantly via adrenomedullin AM1 receptor involvement; similar protection had not been investigated previously in human cardiomyocytes (HCM). Expression of IMD, AM and their receptor components was studied in HCM. Receptor subtype involvement in protection by exogenous IMD against injury by simulated I-R was investigated using receptor component-specific siRNAs. Direct protection by endogenous IMD against HCM injury, both as an autocrine factor produced in HCM themselves and as a paracrine factor released from HCMEC co-cultured with HCM, was investigated using peptide-specific siRNA for IMD. IMD, AM and their receptor components (CLR, RAMPs1-3) were expressed in HCM. IMD 1nmol L(-1), applied either throughout ischaemia (3h) and re-oxygenation (1h) or during re-oxygenation (1h) alone, attenuated HCM injury (P

This nationwide study investigated the relationship between proximity to alcohol outlets (off-licence, on-licence, and other-licence) and two adverse outcomes; hazardous drinking and crime (common assault, non-aggravated sexual assault, aggravated sexual assault, and tobacco and liquor offences). After adjustment for important individual- and area-level factors, close proximity to alcohol outlets was associated with increased risk of hazardous drinking, with strong associations for on-licence outlets. Proximity alcohol outlets was also strongly associated with all crime outcomes, often with a dose-response relationship. Nationally representative New Zealand data showed that close proximity to alcohol outlets was associated with increased crime and hazardous drinking.

Chronic Obstructive Pulmonary Disease is a progressive lung disease affecting the respiratory function of every sixth New Zealander and over 300 million people worldwide. In this paper, we explored how the combination of social, demographical and environmental conditions (represented by increased winter air pollution) affected hospital admissions due to COPD in an urban area of Christchurch (NZ). We juxtaposed the hospitalisation data with dynamic air pollution data and census data to investigate the spatiotemporal patterns of hospital admissions. Spatial analysis identified high-risk health hot spots both overall and season specific, exhibiting higher rates in winter months not solely due to air pollution, but rather as a result of its combination with other factors that initiate deterioration of breathing, increasing impairments and lead to the hospitalisation of COPD patients. From this we found that socioeconomic deprivation and air pollution, followed by the age and ethnicity structure contribute the most to the increased winter hospital admissions. This research shows the continued importance of including both individual (composition) and area level (composition) factors when examining and analysing disease patterns.

Background There is no validated measure of positive mental well-being that is suitable for Deaf people who use a signed language such as British Sign Language (BSL). This impedes inclusion of this population in a range of research designed to evaluate effectiveness of interventions. The study aims were: (i) to translate the original English version of SWEMWBS into BSL and to test the SWEMWBS BSL with the Deaf population in the UK who use BSL; (ii) to examine its psychometric properties; and (iii) to establish the validity and reliability of the SWEMWBS BSL. Methods The SWEMWBS was translated into BSL following a six stage translation procedure and in consultation with the originators. The draft version was piloted with Deaf BSL users (n = 96) who also completed the CORE-OM BSL well-being subscale and the EQ-5D VAS BSL. Reliability was explored using Cronbach’s alpha for internal consistency and ICC for test-retest reliability. Validity was explored by using Kendall’s tau correction for convergent validity and an exploratory factor analysis for construct validity. Results The internal consistency for the reliability of the SWEMWBS BSL was found to be good and the test-retest one week apart showed an acceptable reliability. There was good convergent validity of the SWEMWBS BSL with the well-being subscale of the CORE-OM BSL and the EQ-5D VAS BSL. Conclusions The SWEMWBS BSL can be used with a Deaf population of BSL users. This is the first validated version of a BSL instrument that focuses solely on positively phrased questions for measuring mental well-being.

Aims and objectives\ud To explore the experiences of patients readmitted due to potential ischaemic heart disease symptoms within six months of primary percutaneous coronary intervention.\ud Background\ud Following myocardial infarction and primary percutaneous coronary intervention, some patients experience potential ischaemic heart disease symptoms that may lead to readmission. Symptoms may be related to cardiac ischaemia, reduced psychological health or a comorbid condition.\ud Design\ud A qualitative study involving semistructured, in‐depth interviews conducted once, mean 196 (50–384) days following readmission (at least six months following original ST‐elevation myocardial infarction and primary percutaneous coronary intervention). This is the qualitative part of a mixed methods study.\ud Methods\ud Participants were purposefully selected, and concurrent sampling, data collection and data analysis were performed. Data were organised using framework analysis; constant comparative analysis involving deduction and induction led to identification of cogent themes and subthemes.\ud Results\ud Twenty‐five participants (14 men, 27–79 years) experienced 1–4 readmissions; discharge diagnoses were cardiac, psychological, indeterminate, pulmonary and gastric. Three main themes emerged: (1) anxiety, uncertainty and inability to determine cause of symptoms, (2) fear of experiencing further myocardial infarction and (3) insufficient opportunity to validate self‐construction of illness.\ud Conclusion\ud Fear of dying or experiencing a further myocardial infarction led to patients seeking help at the time of potential ischaemic heart disease symptoms. Participants were anxious and lacked understanding regarding symptom attribution at the time of readmission and generally following their heart attack. Additionally, original heart attack symptoms were used as a comparator for future symptoms. Participants reported feeling well immediately after primary percutaneous coronary intervention but later experiencing fatigue and debilitation often linked to potential ischaemic heart disease symptoms.\ud Relevance to clinical practice\ud Increased education and information related to symptom attribution post‐primary percutaneous coronary intervention and postreadmission are worthy of exploration and may lead to increased understanding and reassurance for this patient group.

ObjectiveTo determine the reliability of anthropometric and body composition measurements in children with special needs.DesignObservational study.SettingSpecialist support schools (primary and secondary) in Manchester, UK.Participants53 children with moderate-to-severe learning disability; 30 non-standers (14 boys) and 23 standers (15 boys). Mean ages were 11 years (range 3–20) for non-standers and 12.4 years (range 8–19) for standers.MeasuresAnthropometric measures included: height/length, segmental measures, weight, skinfolds, body circumferences and body composition estimated from bioelectrical impedance analysis (BIA). These were measured twice, 2–4 weeks apart.Main outcome measuresReliability was assessed using the technical error of measurement (TEM).ResultsThe TEM for height and supine length was 0.55 cm for standers and 2.47 cm for non-standers, respectively. For non-standers, the TEMs for knee height and tibial length were 0.81 and 1.57 cm, respectively. The TEM for weight was 0.55 kg for standers and 0.75 kg for non-standers. For skinfold thickness, the TEM was smaller for non-standers than standers. The TEM for mid-upper arm circumference for standers and non-standers was 0.91 and 0.82 cm, respectively. The TEM for BIA in standers and non-standers was 34.7 and 54.1 Ω, respectively. Some measurements, including waist circumferences, were difficult to obtain reliably.ConclusionsAnthropometric and body composition measurements were feasible to obtain in children with special needs. However, the reliability of these measures differs between non-standers and standers and should be considered when choosing appropriate measures.

BackgroundImproving Access to Psychological Therapies (IAPT) is a National Institute for Health and Care Excellence-approved approach to intervention for depression and/or anxiety. This exploratory study sets the groundwork for comparing psychological therapies for Deaf sign language users experiencing anxiety and/or depression, delivered in British Sign Language (BSL) by a Deaf therapist with usual access through an interpreter within the IAPT national programme.Objectives(1) To explore the following questions: (a) is BSL-IAPT more effective than standard IAPT for Deaf people with anxiety and/or depression? and (b) is any additional benefit from BSL-IAPT worth any additional cost to provide it? (2) To establish relevant BSL versions of assessment tools and methods to answer research questions (a) and (b). (3) To gauge the feasibility of a larger-scale definitive study and to inform its future design.DesignA mixed-methods exploratory study combing an economic model to synthesise data from multiple sources; a qualitative study of understanding and acceptability of randomisation and trial terminology; statistical determination of clinical cut-off points of standardised assessments in BSL; secondary data analysis of anonymised IAPT client records; realist inquiry incorporating interviews with service providers and survey results.SettingsIAPT service providers (NHS and private); the Deaf community.ParticipantsDeaf people who use BSL and who are clients of IAPT services (n = 502); healthy Deaf volunteers (n = 104); IAPT service providers (NHS and private) (n = 118).InterventionsIAPT at steps 2 and 3.Main outcome measuresReliable recovery and reliable improvement defined by IAPT; Deaf community views on the acceptability of randomisation; BSL terminology for trial-related language; clinical cut-off measurements for the BSL versions of the Patient Health Questionnaire-9 items (PHQ-9) and the Generalised Anxiety Disorder-7 (GAD-7); a valid BSL version of the EuroQol-5 Dimensions five-level version (EQ-5D-5L); costs, quality-adjusted life-years and incremental cost-effectiveness ratios.Data sourcesIAPT service provider anonymised records of the characteristics and clinical outcomes of Deaf BSL users of BSL-IAPT and of standard IAPT; published literature.ResultsRandomisation may be acceptable to Deaf people who use IAPT if linguistic and cultural requirements are addressed. Specifications for effective information in BSL for recruitment have been established. A valid EQ-5D-5L in BSL has been produced. The clinical cut-off point for the GAD-7 BSL is 6 and for the PHQ-9 BSL is 8. No significant difference in rates of reliable recovery and reliable improvement between Deaf users of standard IAPT or BSL-IAPT has been found. Whether or not BSL-IAPT is more cost-effective than standard IAPT is uncertain.LimitationsThe small number of participating standard IAPT services who have seen Deaf clients means that there is statistical uncertainty in the comparable clinical outcome result. Clinical cut-off scores have not been verified through gold standard clinical interview methodology. Limited data availability means that whether or not BSL-IAPT is more cost-effective than standard IAPT is uncertain.ConclusionsThere is a lack of evidence to definitively compare reliable recovery and reliable improvement between Deaf users of standard IAPT and BSL-IAPT. Instrumentation and prerequisites for a larger-scale study have been established.Future workA prospective observational study for definitive results is justified.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

Background: Activity pacing has been associated with both improved and worsened symptoms, and its role in reducing disability among patients with long-term conditions has been questioned. However, existing studies have measured pacing according to unidimensional subscales, and therefore the empirical evidence for pacing as a multifaceted construct remains unclear. We have developed a 26-item Activity Pacing Questionnaire (APQ-26) for chronic pain/fatigue containing 5 themes of pacing: activity adjustment, activity consistency, activity progression, activity planning, and activity acceptance.\ud \ud \ud Objective: To assess the associations between the 5 APQ-26 pacing themes and symptoms of pain, physical fatigue, depression, avoidance, and physical function.\ud \ud \ud Methods: Cross-sectional questionnaire study design. Data analyzed using multiple regression.\ud \ud \ud Participants: A total of 257 adult patients with diagnoses of chronic low back pain, chronic widespread pain, fibromyalgia, and chronic fatigue syndrome/myalgic encephalomyelitis.\ud \ud \ud Results: Hierarchical multiple regression showed that activity adjustment was significantly associated with increased physical fatigue, depression, and avoidance, but decreased physical function (all Ps≤0.030). Activity consistency was associated with decreased pain, physical fatigue, depression, and avoidance, but increased physical function (all Ps≤0.003). Activity planning was associated with reduced physical fatigue (Ps=0.025) and activity acceptance was associated with increased avoidance (Ps=0.036).\ud \ud \ud Conclusions: Some APQ-26 pacing themes were associated with worse symptoms and others with symptom improvement. Specifically, pacing themes involving adjusting/reducing activities were associated with worse symptoms, whereas pacing themes involving undertaking consistent activities were associated with improved symptoms. Future study will explore the causality of these associations to add clarification regarding the effects of pacing on patients’ symptoms.

Objectives to identify what skin practices are important for the protection of baby skin in healthy term babies (0–6 months) and generate evidence-based conclusions to inform health professionals and parents. Design eleven databases were searched for all empirical quantitative and qualitative research published between 2000–2015 which explored baby skin care for bathing and cleansing, nappy care, hair and scalp care, management of dry skin or baby massage, for healthy term babies up to 6 months old. Papers not published in English were excluded. A total of 3062 papers were identified. Pairs of reviewers assessed all citations and extracted data independently. There were 26 included papers: 16 RCTs, 3 non-randomised experimental studies, 1 mixed-methods study and 6 qualitative studies. Primary and secondary outcome measures were analysed using meta-analysis or narrative descriptive statistics. Synthesis of qualitative data was not possible due to disparity of the evidence. Findings from the small numbers of studies with comparable data, there was no evidence of any significant differences between tested wash products and water or tested baby wipes and water. There was some evidence to suggest that daily use of full-body emollient therapy may help to reduce the risk of atopic eczema in high risk babies with a genetic predisposition to eczema; however, the use of olive oil or sunflower oil for baby dry skin may adversely affect skin barrier function. There was no evidence about hair/scalp care or baby massage. Qualitative research indicates that parents and health professionals believe that water alone is best. Key conclusions meta-analysis was restricted due to the lack of consistency of study outcome measures. Although there is considerable RCT evidence comparing the use of specific products against water alone, or another product, for bathing, cleansing and nappy care, the power of this evidence is reduced due to inconsistency of outcome measures in terms of outcome, treatment site or time-point. The development of a core outcome measure set is advocated for trials assessing skin care practices. Implications for practice this review offers health professionals best evidence available on which to base their advice. Of those studies with comparative outcomes, the evidence indicates no difference between the specific products tested and water alone; offering parents a choice in their baby skin care regimen. Protocol available: http://www.crd.york.ac.uk/PROSPEROFILES/28054_PROTOCOL_20151009.pdf

Recently, the role of a low-carbohydrate diet in diabetes management has generated interest with claims being made regarding its superiority over the traditional high-carbohydrate, low-fat dietary approach. This systematic review and meta-analysis evaluated the interpretation and effect of a low-carbohydrate diet in the management of type 2 diabetes. Randomised controlled trials were searched for which included adults with type 2 diabetes aged 18 years or more. The intervention was a low-carbohydrate diet as defined by the author compared to a control group of usual care. MEDLINE, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, ISRCTN, ProQuest and opengrey.eu were searched. Independent experts were contacted and reference lists of selected papers were checked. Results were analysed descriptively and meta-analyses were completed to include trials that presented data at 1 year. Eighteen studies (n = 2204) were eligible for inclusion within the systematic review. The definition of a low-carbohydrate diet varied. At trial end, the descriptive analysis suggested that the low-carbohydrate intervention arm (LCIA) may promote favourable outcomes in terms of HbA1c, triglycerides and HDL cholesterol. The LCIA demonstrated reduced requirements for diabetes medication, which may have reduced the observed benefit of dietary carbohydrate restriction on HbA1c. Seven studies provided data to be included in the meta-analyses at 1 year. The meta-analyses showed statistical significance in favour of the LCIA for HbA1c (estimated effect = −0.28%, 95% CI −0.53 to −0.02, p = 0.03; χ 2 = 13.15, df = 6, p = 0.03; I 2 = 54%), HDL cholesterol (estimated effect = 0.06 mmol/L, 95% CI 0.04–0.09, p

Few evidence-based, on-line resources exist to support home-based care of childhood long-term conditions.In a feasibility study, children with stages 3, 4, or 5 chronic kidney disease, parents and professionals collaboratively developed a novel Online Parent Information and Support (OPIS) application. Parents were randomized to an intervention arm with access to OPIS or a control arm without access. OPIS usage was assessed using Google Analytics. Parents in the intervention arm completed the Suitability Assessment of Materials (SAM) and User Interface Satisfaction (USE) questionnaires and participated in qualitative interviews.Twenty parents accessed OPIS with a mean of 23.3 (SD 20.8, range 2-64) visits per user. Responses from the SAM and USE questionnaires were positive, most respondents rating OPIS highly and finding it easy to use. Qualitative suggestions include refinement of OPIS components, enabling personalization of OPIS functionalities and proactive endorsements of OPIS by professionals.Implementation of OPIS into standard practice is feasible in the centre where it was developed. Suggested developments will augment reported strengths to inform ongoing testing in the wider UK network of units. Our design and methods are transferrable to developing and evaluating web-applications to support home-based clinical care-giving for other long-term conditions.

The synthetic biology lab module pClone is ideal for beginning students to conduct authentic research—inexpensive and easy to prep. Students clone and characterize promoters and share their results in research-grade databases with significant learning in the core concept of information and several core competencies described in Vision and Change., The Vision and Change report recommended genuine research experiences for undergraduate biology students. Authentic research improves science education, increases the number of scientifically literate citizens, and encourages students to pursue research. Synthetic biology is well suited for undergraduate research and is a growing area of science. We developed a laboratory module called pClone that empowers students to use advances in molecular cloning methods to discover new promoters for use by synthetic biologists. Our educational goals are consistent with Vision and Change and emphasize core concepts and competencies. pClone is a family of three plasmids that students use to clone a new transcriptional promoter or mutate a canonical promoter and measure promoter activity in Escherichia coli. We also developed the Registry of Functional Promoters, an open-access database of student promoter research results. Using pre- and posttests, we measured significant learning gains among students using pClone in introductory biology and genetics classes. Student posttest scores were significantly better than scores of students who did not use pClone. pClone is an easy and affordable mechanism for large-enrollment labs to meet the high standards of Vision and Change.