The discovery of a form of chronic, low-grade systemic inflammation (“metaflammation”) linked with obesity, but also associated with several lifestyle-related behaviours not necessarily causing obesity, suggests a re-consideration of obesity as a direct cause of chronic disease and a search for the main drivers—or cause of causes. Factors contributing to this are considered here within an environmental context, leading to the conclusion that humans have an immune reaction to aspects of the modern techno-industrial environment, to which they have not fully adapted. It is suggested that economic growth—beyond a point—leads to increases in chronic diseases and climate change and that obesity is a signal of these problems. This is supported by data from Sweden over 200 years, as well as “natural” experiments in disrupted economies like Cuba and Nauru, which have shown a positive health effect with economic downturns. The effect is reflected both in human health and environmental problems such as climate change, thus pointing to the need for greater cross-disciplinary communication and a concept shift in thinking on prevention if economic growth is to continue to benefit human health and well-being. Obesity is currently pandemic, as are many of the chronic diseases often associated with this  . Howevereconomic growth, which is the rate of increase in the market value of traded goods and services as measured by Gross Domestic Product (GDP), and which is widely used as the measure of progress throughout the world, and economic development (which can include desired improvements in renewable resources and nontangible assets such as literacy levels and access to heath care).) Although of undoubted benefit to human health and well-being in the early stages of development [In the current paper, which is proposed as a forum for a broader discussion in prevention, this argument is extended to consider the role of economic growth—beyond a point euphemistically defined as a “sweet spot” —as a sigelopment , economielopment  of develelopment . This noelopment , which aelopment , 11 is dsudden death is more common in those who are naturally fat than in the lean” [Obesity has been associated with ill-health since the days of Hippocrates who said that “.. he lean” . Recent he lean”  and morehe lean” . Yet whiThe discovery of a form of low-grade, systemic inflammation, since called “metaflammation” , associaIn contrast to the large  acute defensive reaction of classical inflammation, “metaflammation” is characterised by a small (~3-4-fold), but chronic and systemic rise in proinflammatory markers , many ofA table of factors causing pro- and anti-inflammatory responses based on research evidence is shown in per se, which are the link with disease outcomes [From outcomes . It is aTo cover the spectrum of causality, classical epidemiology typically involves investigating not just the cause of a disease, but the cause of that cause . Based oAs stated above, the dichotomy between pro- and anti-inflammatory stimuli shown in There is ample evidence to support the notion that while economic development is generally positively associated with human health , this isOf course, this has not always been the case, and hence to be comprehensive, any proposition of a link between economic growth and health needs to be dynamic. Growth has unarguably been positively related to human longevity and health overall, as witnessed by the big improvements in longevity in developed countries since the industrial revolution . In deveThe recent work by Tapia Granados and others , 24 has Other support for the developing adverse effects of development, beyond a point, is gained from studying the situation in reverse. Cuba, for example, was forced into economic decline after Russia's withdrawal in 1989 resulting in a 1000 kcal/day average decrease in food intake. The following decade was characterised by an improvement in many aspects of chronic disease; overall mortality decreased by 20%, obesity was halved, and deaths from heart disease reduced by 35% and stroke by 18% . Only caFrom a different perspective, negative developments in environmental degradation, such as manifest in climate change, also point to diminishing returns from unlimited growth. Studies on carbon and other greenhouse gas emissions, for example, show a highly positive association between atmospheric concentration of these and economic fluctuations , as mighAn awareness of the convergence of health, climate, and macroeconomics gives rise to a need for consideration of all three phenomena.It would be naive to propose the above argument as a reason to cease economic growth, or even revert immediately to a nongrowth, or steady-state economy. However, growing environmental, and health issues—as well as the often-unrecognised link between the two—make it important to place the issue on the prevention agenda. Consideration of the consequences of unfettered growth (both economic and population growth—which helps to drive this), which were raised in the 1970s , but theImmediate actions, which are within the realm of political possibility, such as carbon emissions policies, both corporate and personal, need to be expedited by health and environmental experts, without ignoring the long-term as well as short-term economic consequences. Corporate carbon policies are already on the statutes in many countries in one form or another and, if properly instituted, might be expected to have an impact not only on the environment, but on health, through the increased cost of energy-dense, and hence fattening, processed foods . Yet corGrowth beyond maturity is either obesity or cancer” [In classic economic terms, body fat is an investment in the future. This yields healthy dividends —to a point, just as all good investments. But beyond this point, diminishing rates of returns begin to decrease the value of further investment. Body fat, to a level probably defined by individual genetics, is a necessary and healthy source of reserve energy. Recent findings suggest that while fat stays in the fat cells, for which they are designed, this is not a cause for concern. Only when lipid intolerant nonadipose organs are not protected against lipid “spillover” during sustained energy surplus does it become a problem . In adva cancer” . And whi cancer” ). Howeve


Common sense [CS], especially that of the non-scientist, can have predictive power to identify promising research avenues, as humans anywhere on Earth have always looked for causal links to understand, shape and control the world around them. CS is based on the experience of many individuals and is thus believed to hold some truths. Outcomes predicted by CS are compatible with observations made by whole populations and have survived tests conducted by a plethora of non-scientists. To explore our claim, we provide 4 examples of empirical insights  into causal phenomena predicted by CS: (i) “humans must have a sense of time”, (ii) “at extreme latitudes, more people have the winter blues”, (iii) “sleep is a cure for many ills” and (iv) “social networks affect health and disease”. While CS is fallible, it should not be ignored by science – however improbable or self-evident the causal relationships predicted by CS may appear to be. Numerous books and reviews have been devoted to the topic of common sense, henceforth abbreviated CS -4. Unsuris CS? Can it be defined? It may not come as a surprise that Nobel Prize laureates such as Albert Einstein and George Bernard Shaw have emphasized the value of CS. According to Einstein, CS is in and by itself a discipline, which should not be taken for granted. He asserts,If CS were not an important asset  it should not exist. From every part of the world, in every society, examples of CS abound, but what exactly “Common sense invents and constructs no less in its own field than science does in its domain.” think is probably true does turn out to be true  then little progress has been made. If a hypothesis which most think is improbable turns out to be true then a scientific revolution occurs and progress is dramatic.”Although on the surface the “relationships” presented by the non-scientists’ CS may seem rather straightforward, deeper scientific investigation may reveal the counter-intuitive processes Horrobin  refers tThe non-scientist’s CS differs considerably from that of the scientist. For one, the CS of non-scientists, and how it is used and applied, is not infused with vested work and career interests, but rather has been developed, shaped and put under scrutiny by a large population. Indeed, much of the CS of populations is the result of powerful tests by many individuals of hypotheses in both time and space. In this vein, the non-scientists’ CS is the result of evolutionary steps or refinements along the way by the masses and across generations. Therefore, the CS of populations ultimately benefits from what has been coined “group intelligence” and “group creativity” .There are, of course, interfaces between a non-scientist’s and a scientist’s CS. After all, scientists are, as a tiny (but at times powerful) minority, part of the CS evolutionary process within populations. In principle, they can persuade their immediate environment and, ultimately, whole populations if there are CS errors which need to be corrected. To achieve this end, scientists must want to share, write and speak about “scientific” truths so that non-experts understand them . In realHorrobin  declares“It’s also true that 'popularizer’ is a pejorative term among scientists generally. A popularizer is somebody who explains what the issues are in ways people can understand. I think that it’s ridiculous that scientists don’t respect such people. In any other field, explaining to a congressional committee why what you’re doing is exciting and wonderful would be considered a service to the field. In science, you’re treated almost like somebody who has betrayed the secret club” or benefit from “chronobiologically active radiation” ) sometimes are shared between neighbouring communities, but often also differ between one community or geographic region and another . In our Accepting that CS of non-scientists can be beneficial to the scientific community, the following conclusions are warranted: Non-scientists should not only be viewed as sources of information, but as full-fledged collaborators in the research on CS and its potential for scientific exploration. CS is built on observations and powerful tests of hypotheses made by large populations. Put differently, scientists should pay attention to non-scientists’ CS observations, explanations and predictions, because usually they have survived a plethora of tests and have undergone numerous variations and refinements. This is particularly true with regard to folk-medicinal practices and views on health-promoting behaviours.While non-experts certainly differ from experts in their background and training to observe and test, this should not necessarily be viewed as a negative or knock-out criterion . Importathat causal links predicted by the non-scientist’s CS are valid, then we should a forteriori use CS convictions for preventive purposes if there are means to do so.As one practical consequence of the predictive power of the non-scientist’s CS we may want to use CS convictions of causal relationships in everyday life regardless of whether scientific explorations into its nature have already been made or not ,111. To that A is associated with or causes B. However improbable, on the one hand, or self-evident, on the other, one or more CS convictions might appear in a researcher’s view and elucidation of how A relates to B could be the next big thing in science. In order to seek clues of what is important for the public and what should be studied with some priority, it is time to try to identify causal links that are worthy of rigorous investigations with an emphasis on the non-scientists’ CS. Surely, this cannot be worse than being exclusively led by scientists, whose vision may be obscured by vested interests. Indeed, as evinced by the examples presented in this paper, the non-scientist’s CS may do much better. A very recent study [With regard to innovative science, researchers should watch out for the non-scientists’ CS suggesting nt study , in whicThe authors declare that they have no competing interests.TC Erren started this work as a visiting scholar at the UC Berkeley in 2010; M Koch assisted with the literature survey in Germany and together with TCE prepared the first draft; VBM-R added information and completed the manuscript. All authors read and approved the final manuscript.


Most households in the United Kingdom have Internet access, and health-related Internet use is increasing. The National Health Service (NHS) Direct website is the major UK provider of online health information.Our objective was to identify the characteristics and motivations of online health information seekers accessing the NHS Direct website, and to examine the benefits and challenges of the health Internet. We undertook an online questionnaire survey, offered to users of the NHS Direct website. A subsample of survey respondents participated in in-depth, semistructured, qualitative interviews by telephone or instant messaging/email. Questionnaire results were analyzed using chi-square statistics. Thematic coding with constant comparison was used for interview transcript analysis.2                        2 = 6.35, P = .04). Prior consultation with a health professional was reported by 44.9% (346/770), although this was less common in younger age groups (<36 years) . Participants aged 16 to 75 years  were recruited for interview by telephone (n = 23) and instant messaging/email (n = 3). Four major interview themes were identified: motivations for seeking help online; benefits of seeking help in this way and some of the challenges faced; strategies employed in navigating online health information provision and determining what information to use and to trust; and specific comments regarding the NHS Direct website service. Within the motivation category, four concepts emerged: the desire for reassurance; the desire for a second opinion to challenge other information; the desire for greater understanding to supplement other information; and perceived external barriers to accessing information through traditional sources. The benefits clustered around three theme areas: convenience, coverage, and anonymity. Various challenges were discussed but no prominent theme emerged. Navigating online health information and determining what to trust was regarded as a “common sense” activity, and brand recognition was important. Specific comments about NHS Direct included the perception that the online service was integrated with traditional service provision.In total 792 respondents completed some or all of the survey: 71.2% (534/750 with data available) were aged under 45 years, 67.4% (511/758) were female, and 37.7% (286/759) had university-level qualifications. They sought information for themselves , someone else , or both . Women were more likely than men to seek help for someone else or both themselves and someone else (168/509 vs 61/242, χThis study supports a model of evolutionary rather than revolutionary change in online health information use. Given increasing resource constraints, the health care community needs to seek ways of promoting efficient and appropriate health service use, and should aim to harness the potential benefits of the Internet, informed by an understanding of how and why people go online for health. In the United Kingdom, in 2009, 70% of households had Internet access . With thThe National Health Service (NHS) Direct website is the main health advice and information website for patients and the public in the United Kingdom. It was launched in December 1999, and in 2009, there were 18 million visits to the website, compared with 1.5 million visits in 2001 . At the There is limited information describing how and why people use online health information, or the effect of this on health status, although this literature base is growing -11. In tA combination of questionnaire survey and semistructured interviews was used. A self-administered, open, cross-sectional survey of visitors to the NHS Direct website was undertaken using a link placed on the home page of the website. It was therefore a web-based opt-in survey of a convenience sample. Cookies prevented multiple submissions from one computer. Consent was given by participants entering an email address to be sent the link to the survey. There were no incentives to participation. The questionnaire had two aims: first, to identify the characteristics and motivations of users of the website; and second, to recruit potential participants for a qualitative interview study. The questionnaire included 15 questions (one question per screen) covering demographic and health status characteristics, reasons for using the website, and questions related to information-seeking behavior. There was no adaptive questioning or manipulation of item order. In the final part of the survey, the respondents were asked for consent to be contacted at a later date for an interview. The questionnaire was developed based on previous work. The instrument is included as an online appendix.Interview participants were selected by maximum variation sampling with respect to demographic and health status characteristics of gender, age, ethnicity, those seeking help for acute and chronic illnesses, and those seeking help for themselves or for others. To minimize recall bias, while allowing sufficient time for participants to act on the information they had found, interviews were conducted within 1 to 2 weeks of use of the site. These semistructured interviews were undertaken via telephone, email, or instant messaging. Interviews were conducted by two interviewers, who were members of the research team (JP and NI). Anonymized interview transcripts were used for analysis. We used open-ended questioning and determined the order of questioning by the direction taken by each interview participant. Each interview usually began with a brief description of the interviewee’s last visit to the NHS Direct website and went on to explore their online health-related information needs and their information-seeking behavior under the following headings: motivation for using the NHS Direct website, the NHS Direct website itself, facilitators and barriers to online health seeking, role of the Internet compared with other sources of information, and consequences of using online health information. Demographic characteristics of each participant were also recorded . The interview topic guide is included as an online appendix. Survey and interview data were held in password-protected files on password-protected computers. NHS ethics committee approval was obtained for both elements of this study. Questionnaire results were analyzed to provide summary descriptive statistics and cross-tabulations for which chi-square statistics were calculated to examine differences in proportions by demographic characteristics. No statistical corrections such as weighting were used, but nonresponders to individual questions were excluded from the analysis of those questions. All interview transcripts were read by three investigators , who familiarized themselves with the data through reading and reflection, and each independently undertook open coding of all transcripts . ConstanA total of 792 respondents completed at least part of the survey accessed via the homepage link. Results are presented as a proportion of the total number of responses to each question . As can be seen from 2                    2 = 6.35, P = .04; 33% of women, 168/509, versus 25.2% of men, 61/242, reported seeking information for someone else or for both themselves and someone else). There was a significant difference by age group for women, which was predominantly due to a higher number of women in the 56- to 65-year-old age group reporting looking for help for someone else compared with women in other age bands . There was no difference by age group for men . Regarding reasons for seeking help, 69.8% (545/781) reported looking for information for their own health issue, while 22.0% (172/781) reported looking for information for someone else . These proportions differed by gender, with women more likely than men to report seeking help for someone else . Users in younger age groups (<36 years) were less likely to report having had prior consultation with a health professional before using the website ; 35.9% (143/398) of those aged up to 35 reported having consulted prior to using the website, compared with 53.9% (186/345) of those over 35. Of all respondents, 47.5% (366/770) reported seeking help for a new health issue, while 19.6% (151/770) reported seeking help for a long-standing issue; 17.1% (132/770) reported seeking help for both new and long-standing issues, and 15.7% (121/770) for neither. The commonest category of user was a person who reported seeking help for a new health issue, regarding their own health . A total of 44.9% (346/770) reported having already consulted a health professional  about the problem for which they were using the NHS Direct website, and 6.1% (47/770) had previously consulted the NHS Direct telephone service about the issue they were currently looking up online. There were no significant differences in this previous consultation behavior by gender  participants aged 16 to 75 years were recruited from a total of 265 who had indicated their willingness to take part in an interview on the questionnaire. They were interviewed either by telephone (n = 23) or by instant messaging/email (n = 3). Twenty-one described their ethnicity as white British, and five belonged to other ethnic groups. At the time of recruitment the participants were looking up information for themselves (n = 15), for someone else (n = 10), or for both themselves and someone else (n = 1). The participants rated their health as very good (n = 2), good (n = 6), fair (n = 14), bad (n = 1), or very bad (n = 3). Participant characteristics are summarized in The range of health topics searched for was broad, with the most popular being musculoskeletal problems (6/26), mental health problems (3/26), and dermatological problems (3/26).Themes were identified under the following headings, framed by the questions used in the interview topic guide: the motivations for seeking help online; the benefits of seeking help in this way, and some of the challenges faced; the strategies employed in navigating online health information provision and determining what information to use and to trust; and finally, specific comments regarding the NHS Direct website service. These will be discussed in turn.Within the category of motivations, four concepts emerged through the thematic analysis: the desire for reassurance; the desire for a second opinion to challenge other information; the desire for greater understanding to supplement other information; and perceived external barriers to accessing information through traditional sources .“sometimes you just want your fears eased” . In general, this online search for reassurance and relief from anxiety was not said to replace other forms of seeking help; rather, it was seen as an adjunct to other sources of help and information, not a substitute for them, thereby providing an extra layer of information but not necessarily altering consulting behaviors. As Interviewee 19 put it:One prominent reported motivation for seeking online health information was reassurance, often at the time symptoms appeared and prior to consultation with a health professional. As one participant stated Interviewee 19, a 48-year-old manI think I probably followed a course of action I would have taken anyway.For the most part, the interviewees in this study reported seeking health information from official health websites that gave authoritative health information, and not from other users. This was not surprising given the route of recruitment through their use of the NHS Direct website. Even so, among the participants in this sample a few participants did report seeking nonprofessional “peer-to-peer” information. In these cases the motivation was again reassurance – wanting to know that the person was not alone in what they were experiencing. This was illustrated by Interviewee 17:Interviewee 17, a 49-year-old womanI’ve gone to a menopause site that specializes in that [peer-to-peer interaction]. There are lots and lots of contributors over several years and I search for that, have a read and see what other people think and then I’ve posted on that and said“Look, I don’t have what people classically call flushes”... I just have it at night. What do other people think? And then lots of people come on and say“Yes, that’s perfectly normal. That’s what I’ve experienced and this is not unusual. People do have...”...so quite often I get reassurance that I’m not an odd one out from this.bother” their doctor with a problem that might be trivial. Interviewee 13 described how reassurance over a bloodshot eye eliminated the need for a general practice appointment.A few examples of the Internet providing “demand management” for primary care or emergency services were identified. Sometimes participants described the motivation of not wanting to “Interviewee 13, a 66-year-old womanIt looks as if you should do something about it. I looked it up again on the website and it said “there’s nothing to worry about,” you know...it normally goes off on its own and it doesn’t need a trip to the doctor’s so again, it saved the trip to the doctor and it saved a lot of worrying.However, while 13 interviewees talked about accessing the NHS Direct website as one of their first actions to find out information about symptoms, in most cases they did report going on to seek help from traditional health service sources, albeit sometimes with less urgency or less anxiety. This was the case whether they reported seeking help for themselves or for someone else. Furthermore, half the interviewees also stated that they would tend to see a professional as a first point of call if they had a health problemInterviewee 9, a 32-year-old womanAs I say, it didn’t make me do anything that I wasn’t already contemplating, but I guess it gave me the answer to the question that I was looking for and then the peace of mind that it wasn’t becoming an emergency I guess and that we should stick with it.Where demand management appeared to be occurring in practice, this was usually explained by the avoidance of barriers to accessing traditional health services, such as difficulties in getting an appointment or in travelling to one.Interviewee 10, a 25-year-old womanIt used to take two hours and two bus journeys to get to the doctors...It’s easier to use than to get down to the doctor’s...It’s the time and the money...you know – those kinds of factors and then all the problems with getting appointments as well.The desire for a second opinion following initial advice received from a heath professional was another reported motivation. Participants described the Internet as a way of accessing specialist knowledge, which they could use to challenge the advice given during their consultation. As in the example below from Interviewee 21, this challenge was an explicit response to not believing the health professional. At other times, illustrated by a quote from Interviewee 5, this was more about becoming fully informed on the range of divergent professional opinion.Interviewee 21, a 59-year-old manThey were telling me that treatment would be such and such and I thought“well I don’t believe that and I’ll use NHS Direct to see whether they can give me some information.”Interviewee 5, a 55-year-old womanWell, when you go to the doctor you’ve only got his opinion haven’t you? I mean I’m sure he’s basing it on knowledge and research and things like that, but I just wanted to see other opinions about it.The next motivation described by participants was also related to researching information prior to or following a consultation, but was not motivated by a desire to challenge. Instead the reported motivation was to seek clarity and confirmatory information in greater depth. This could be characterized as “homework” to support informed decision making, which could be done at the individual’s own pace. As Interviewee 20 explained:Interviewee 20, a 62-year-old manIt [the Internet] is excellent for a slower time study of information that my doctor hasn’t fully explained.Interviewee18, a 46-year-old womanI was really looking to substantiate a little bit more about the treatment options that I was given by the GP.“in your own time                        ...                        at your own pace” . This was contrasted with issues in accessing traditional health services.Interviewees volunteered a range of benefits of online health information seeking. These reported benefits clustered around three theme areas: convenience, coverage, and anonymity. The convenience of online health encompassed the ease and speed of access, at any time, and from any location, especially from home. Access could be Interviewee 24, a 58-year-old womanYou can go on it any time of the day quite honestly, whereas you can’t get your doctor any time of the day, or they have to ring you back and then you’re sitting either waiting or...you know.Interviewee 25, a 41-year-old womanIt’s quick and it’s direct. It’s there in front of me every day and every evening.“make an informed decision” in conjunction with her specialist, about treatment for fibroids, having sought information online. The benefit of coverage related to the wide range and depth of health information available on the Internet, and access to specialist medical knowledge. This access to esoteric medical knowledge was highlighted by Interviewee 4 (a 59-year-old woman):In their responses, interviewees recognized that the Internet played a role in allowing them to become informed consumers, better able to share decisions with their health care provider. For example, Interviewee 18 (a 46-year-old woman) reported being able to Interviewee 4, a 59-year-old womanIt’s [the Internet] the perfect tool for finding out something that you need to know about and you probably don’t have the information unless you’re a medic.Confidentiality was the third area that emerged from the interviews as a key valued benefit for Internet health users. This encapsulated both the anonymous nature of online identity and the ability to use the Internet privately from any location. This could be of particular value for conditions that were more personal or stigmatizing.Interviewee 22, a 20-year-old womanConfidentiality...you’re not speaking to someone about health issues. I mean for someone that has a lot more of a personal problem and they didn’t really want to discuss it with someone it’s ideal.“there’s always the worry of misdiagnosing something, or reading something into it” ; (3) confusion caused by the sheer volume of information, which was sometimes perceived as being “confusing” and “daunting”; and (4) sometimes criticism of health-related Internet use for its “impersonal” nature, which lacked the quality of face-to-face contact, and which could not replace a real consultation.Interviewees also discussed some of the challenges of health-related Internet use but no prominent theme emerged. The issues raised included (1) inaccurate information leading to harmful health decisions, which was reported as more of a theoretical problem, rather than by anyone with direct experience; (2) misuse of accurate information, leading to inappropriate self-diagnosis: “there’s a lot of crap on the Internet                        ,                        ” as Interviewee 21 (a 59-year-old man) put it – but they used common sense to avoid this. For Interviewee 1, the Internet provided her with:Throughout the interviews, participants explained the strategies employed in navigating online health provision and determining what information to use and to trust. They reported finding NHS Direct Online either by using a search engine , or by going directly to the uniform resource locator (URL) once they were familiar with it. Choosing a site was regarded as a common sense activity by interviewees. They were well aware that the Internet could be a source of misleading information – Interviewee 1, a 59-year-old womanA vast range of information from the idiotic to the academic, so I’ve got a vast range of information and it’s on tap so to speak. It’s up to the individual to adjudicate whether the information is relevant, or whether it’s valid...I do have enough common sense to evaluate what I see...I keep repeating that you need to use your discretion when you read...I would say that it could be a dangerous thing, on the other hand but I think the majority of people do have common sense.“wild women from Minnesota                        ,                        ” and Interviewee 5 explained:Several participants expressed negative views regarding peer-to-peer sources of health information, related to concerns about its trustworthiness. For example, Interviewee 4 (a 59-year-old woman) was concerned that the information may be written by Interviewee 5, a 55-year-old womanHow do you know if they’re trustworthy? No, I wouldn’t do that at all. I don’t particularly like these chat rooms anyway...Because I don’t know them. No, I don’t want to talk to people I don’t know about things really. I think it could be quite dangerous...Perhaps I’m being cautious but that’s how I think.“You tend to trust the NHS don’t you?” . Interviewees often contrasted this inherent trustworthiness of the NHS brand with their views on commercial health websites, particularly those produced by pharmaceutical companies:“Brand recognition” was reported as very important to the interviewees in navigating the health Internet. Interviewees reported choosing sites that had “real-world” branding, that is, an identity that they recognized from their offline experiences. The importance of the brand in establishing that a site was trustworthy was a very strong theme across the interviews. The NHS brand in particular was seen by respondents as giving the website the valued qualities of being impartial, reliable, and up-to-date. As one interviewee put it Interviewee 3, a 44-year-old womanI thought the NHS one probably has no axe to grind...Whereas if it’s related to a drug company or somebody with herbal medicine and all of this sort of thing, I think they tend to be more biased, whereas the NHS is not trying to sell you something.“trying to sell something” and partly the lack of local or cultural relevance for some of the information.A further interesting finding regarding which sites were valued and used was the low esteem in which North American sites were sometimes held as reported by our British participants. This was partly due to a perception that US sites had commercial aims and were therefore seen as Interviewee 25, a 41-year-old womanThe thing about the NHS online is that you know you’re looking at genuine stuff. The answers that you’re going to get are absolutely spot on and you can rely and trust them, whereas if I just Google something I may end up on an American site or something. I wouldn’t feel confident that the information I was looking at was absolutely right.“I would hope that it ties in with the NHS generally, so it seemed to be the sensible place to go                        .                        ” Interviewees had an expectation that there would be some connection between their use of a virtual health service and the care they received from the physical counterpart. Furthermore, they felt that, because they were NHS patients, using the NHS website was the “right thing to do,” because of this perceived integration across online and traditional services.As would be expected given the route for recruitment, respondents made many comments about specific aspects of the NHS Direct website; for example, wanting further information on specific topics. Over and above these individual remarks, two broad issues concerning the NHS Internet service were present across the interviews and had generic relevance to health-related Internet provision. The first of these was the perception that the NHS Direct website was integrated with the real-world NHS service. As Interviewee 4 (a 59-year-old woman) put it Interviewee 1, a 59-year-old womanSince we are under the NHS system, it would be logical for me to go first of all to the NHS Direct to see what the NHS’s take was...As far as I’m concerned, if the NHS Direct website is offering this information then it should make it uniform all through the NHS...I specifically used the NHS website because we live in an NHS world and where better than to get it straight from the horse’s mouth?The second broad issue of generic relevance related to feedback about the clarity and simplicity of design of the NHS Direct website, in terms of the language used and the architecture of the site.Interviewee 22, a 20-year-old womanIt’s got clear information and there’s enough there, but not like reels and reels that you get that you struggle to understand it and it’s very well broken down into sections as well I think, so like very specific for children and adults.Together with the issue of the NHS brand, which was described above under navigation strategy, the clarity of the site and the perceived link with the real-world service were the principal reasons reported for valuing the NHS Direct site in particular as a source of online health information.The survey findings with respect to the age, gender, and educational status of online health seekers add to the accumulated evidence of several studies over the last decade that have shown that being female, being younger, and having a higher level of educational attainment are all associated with more frequent health-related Internet use ,19-23. THaving established the characteristics of the users of the site, we undertook in-depth qualitative work to explore in detail their motivations and attitudes. In 2003, the lead author (JP) wrote a review paper that summarized the benefits and challenges of health-related Internet use . In TablThe majority of online events were related to real-world consultations, whether as preparation for them or as a search for further information afterward ,32,33. TSome theoretical benefits and challenges were not prominent in these interviews. The “green” potential of the Internet to reduce travel, but at the same time possibly reduce physical activity and lead to social isolation or depression , was notBecause this was an opt-in survey accessed via a weblink, it was not possible to calculate a response rate for the questionnaire. There were also design issues with the website during the survey period, which meant that the link to the survey was not always clearly visible to users. This affected the overall response and the number of individuals consenting to be interviewed in the second stage. To minimize social desirability bias, the researchers made it clear to interviewees that the researchers were independent of the NHS Direct organization, but those volunteering for interviews may still have been a particular population who wanted to relate their experiences with NHS Direct, good or bad. More women than men were interviewed due to having very few male volunteers. Interview methodology of this type, asking people to report how and why they used a particular source, may reflect attitudes rather than actual behavior, for which direct observation may be preferred. Nevertheless, questions were designed to focus on the most recent actual use of the Internet for health, rather than rely on hypothetical questioning. The participants were users of the NHS Direct website and were therefore not necessarily representative of the overall population of online health information seekers in the United Kingdom. However, the NHS site is the most popular health information site in the United Kingdom, and the demographic profile of respondents was similar to that of non-UK-based studies.Given increasing resource constraints, the health care community needs to seek ways of promoting efficient and appropriate health care use, which should include consideration of how Internet health information is provided and used, and how traditional NHS services and online services can be best integrated. The study findings support a model of evolutionary rather than revolutionary change in health information use, with real-world trusted brands being used online, in conjunction with traditional consultations. It will be interesting to see whether in time, particularly as the younger “Internet generation” ages and eHealth literacy increases in all age groups , Interne


Despite its clinical importance, the issue of subjective sleep quality in children remains unexplored. Here we investigate, in school-aged children, the prevalence of bad sleep perception and its relationships with sleep habits and daytime functioning, to provide hints on its possible determinants. Subjective sleep perception, sleep habits, and daytime functioning were studied through a questionnaire survey in a sample of 482 children (6–12 yrs.). Being “bad sleeper” was reported by 6.9% of the sample. Compared to the “good sleepers”, these subjects displayed shorter sleep duration on schooldays, longer sleep latencies, and a more pronounced evening preference, beyond more frequent insufficient sleep. Though no differences emerged in sleepiness, bad sleepers showed higher impairments in daytime functioning, indicated by more frequent depressed mood and impulsivity. These distinctive features might be very important to precociously detect those children who are possibly more vulnerable to sleep disturbances and whose sleep-wake rhythms evolution should be paid particular attention thereafter.“The good people sleep much better at night than the bad people.Of course, the bad people enjoy the waking hours much more”Woody Allen Good sleep is extremely important for all aspects of health and wellbeing in humans.But what exactly does “good sleep” mean? A first basic distinction should be made between those characteristics that can be considered “objective” indicators of sleep quality and the subjective perception of sleeping well.The latter is extremely important in itself since subjective sleep complaints, which are the most frequent reason for seeking medical help, are not necessarily concordant with what objectively measured, as highlighted by a number of studies, conducted both in normal , 2 and pIn children, the first question that still requires a definite answer is how many of them believe their sleep is good. In fact, data on the prevalence of good sleep perception are scarce over the whole life span.Most of the available data concerns the adult population: in 2005, the USA National Sleep Foundation  reportedIn their classical paper on subjective sleep quality in aging, Buysse and colleagues  found thAs for younger populations, data on subjective sleep quality perception are even scarcer. Despite a number of surveys in children and adolescents reporting a high prevalence of sleep problems, such as night awakenings , nightmaBoth in the clinical and the experimental fields , optimalActually, subjective determinants of sleep quality perception have been only occasionally studied in the adult individual. Among sleep features it seems that sleep continuity  and the However, there is very little systematic knowledge on factors underlying sleep satisfaction judgments both in children and in the elderly and on whether these determinants might exhibit age-related differences. Indeed, only one recent work by Zilli and coworkers  was carrFinally, daytime functioning in children has been investigated in relation to objective measures of sleep or self-reported sleep habits and problems: in these studies, a number of sleep features such as degree of fragmentation , sleep dThus, aims of this study are:(1) to determine the prevalence of sleep satisfaction in a sample of children in Southern Italy;(2) to investigate how dissatisfied children differentiate from satisfied ones as far as sleep habits, subjective evaluation of sleep characteristics, circadian preference, vigilance levels, and daytime functioning are concerned.The survey has been carried out from May to June 2009 in three public Elementary Schools, respectively located in S. Nicola La Strada (Caserta), Naples, and Pomigliano d'Arco (Naples). These schools were randomly selected from the list of all Elementary Schools in Campania, a wide region of southern Italy.Headmasters of the selected schools were first contacted through a formal letter, introducing the research and the professionals involved. For those who positively answered, all the procedures, instruments, and aims of the study were explained in a further meeting, extended to teachers and parents' representatives. A final meeting served to illustrate the study to all children's parents and to collect their informed consent.Four hundred eighty-two students were recruited for the study, the only exclusion criterion being the presence of a diagnosed cognitive or learning disorder.The instrument used in the study is the School Sleep Habits Survey –34 in itquestions assessing sleep habits on both schooldays and weekends: three of these are open questions, addressing sleep duration and bedtime and rise time in hours and minutes; two others, investigating the reasons for going to bed and rising at a given time, are multiple choice questions with seven predetermined answers;one question on habitual sleep latency, consisting of a single forced-choice item with six response categories ;vis a vis with someone else”, “travelling on public transports”, “watching a show”, “watching television or listening to music”, “reading or studying”, “during a school test”, “sitting in class”, “working at the computer”, “playing a videogame”). Respondents had to choose among four ordinal alternatives, ranging from “no difficulty staying awake” to “struggling to stay awake but falling asleep”. A global vigilance score was then obtained by summing up scores at all of the nine items;a context and vigilance scale, composed of nine items assessing the ease of staying awake in different situations . The answers are graded on a five-point scale, ranging from “never” to “always”;a sleep-wake behavioural problems scale, made up of 17 items which assesses, over the last two weeks, how often the subjects have experienced some sleepa morningness-eveningness questionnaire (MEQ), composed of ten items assessing circadian preference to discriminate subjects in morning types (M-types), intermediate types (I-types), and evening types (E-types).Finally, an item about sleep quality perception (“Do you consider yourself as a good or a bad sleeper?”) was added to the original Italian version of the questionnaire , as wellQuestionnaires were administered by an experimenter, in presence of the teachers, during school hours. In view of the subjects' young age, the experimenter remained in the classroom throughout the administration procedure, being available to answer any question arising during the questionnaire completion. He was specifically instructed to provide standardized answers, which included question rephrasing and examples.After descriptive statistics, the global sample was split in two groups (“good sleepers” and “bad sleepers”), based on the answer to the question assessing overall subjective sleep quality. The prevalence of good and bad sleepers was calculated for the total sample, for males and females separately, and, to detect age-related differences, within two different age groups: 6–8 and 9–12 years.Good and bad sleepers were then compared for the following dependent variables:sleep habits, that is, sleep duration in minutes, bedtime and rise time—all variables reported for schooldays and weekends—plus the differences between schooldays and weekends (Δ-SD/WE) in bedtime, rise time, and sleep duration;sleep latency;sufficiency of sleep;circadian preference, calculated by summing up scores at the ten questions (lower scores being associated to a higher degree of eveningness);vigilance, calculated by summing up scores at the nine questions ranging from 1 to 4, so to have a maximum score of 36 and a minimum score of 9;sleep-wake behavioural problems, calculated by summing up scores at the seventeen questions ranging from 1 to 5 (higher scores corresponding to lower degrees of problems).U-test was used for all cardinal variables.For comparisons, nonparametric Mann-Whitney Chi-square test was carried for all binomial variables, as well as for analysis of frequency distribution of chronotypologies.Furthermore, Pearson's analysis of correlation was carried between the overall sleep-wake behavioural problems score and sleep habits measures.N = 482). However, seventeen questionnaires had to be excluded for aberrant values. Thus, the final sample for data analysis included 465 children . The questionnaire was correctly filled by all children  or across genders .To the question about global sleep quality, 6.9% of the sample answered to be “bad sleepers”, whereas 90% answered to be “good sleepers”, and 3.1% did not answer . Bad sleP = 0.025) and weekends (P = 0.027). Furthermore, sleep duration is significantly shorter in bad sleepers compared to good sleepers in schooldays (P = 0.028). No significant differences were found in either rise time or sleep duration between bad and good sleepers during schooldays and weekends.U = 6937.0, ns), rise time , and sleep duration .Also, the two groups did not significantly differ in the Δ-SD/WE of bedtime . Moreover, bad sleepers report more frequent insufficient sleep .Sleep latency is significantly longer in bad sleepers .As shown in U = 4088.5, P = 0.003), with bad sleepers more frequently displaying an evening preference.Significant differences were found in MEQ global scores between good and bad sleepers  or in any of the items composing the scale.No significant differences between bad and good sleepers were found either in the context and vigilance global score , displayed in A significant difference emerged between bad and good sleepers at the sleep-wake behavioural problems global score  and weekends , whereas it was not significantly correlated with bedtime , sleep duration , or Δ-SD/WE measures .In addition, the global score in the overall sample showed significant correlations with rise time both in schooldays  could be questioned, this is not the first study concerning sleep habits that used self-reports in this age group , 44, 45.A first major result of the present survey is the rather low percentage (6.9%) of school children claiming to be bad sleepers. We did not find any comparable data in the literature, since in the few studies on the same age group administering a question on subjective sleep quality, this question was part of a sleep log, thus referring to a specific night instead of assessing the subjective perception of habitual sleep –44.Regarding sex, no difference in the percentage of bad sleepers was detected between males and females, at variance with data on adolescence, showing that subjectively assessed sleep quality indicators are better in girls than boys , and witAs for age differences, the prevalence of subjectively reported bad sleep in our group of children is lower than the one previously found both in adults –11 and oIn our sample, bad sleepers' sleep duration was lower than that of good sleepers on schooldays. Also, they reported insufficient sleep more often than good sleepers and longer sleep latencies, as well as delayed sleep onset time on both schooldays and weekends.Furthermore, the bad sleepers group displayed a higher global score on the sleep-wake behavioural problems scale. In particular, it is noteworthy that bad sleepers reported significantly higher scores at the items “have done something dangerous” and “have felt sad and depressed”, suggesting a somehow more impulsive attitude and a tendency to depressed mood.Both the previously mentioned data about sleep features and the presence of a poorer daytime functioning compared to good sleepers might be explained by looking at chronotypologies through the morningness-eveningness questionnaire results. In general terms, we have detected an equal frequency of evening and morning types in the total sample—slightly above 10%, similar to the one of the adult population—and no differences between our two age groups, which range from elementary schoolchildren (6–8 years) to prepubertal children (9–12 years). This suggests that the high frequency of eveningness, often observed in adolescence , 46, is However, what is most interesting for our purposes is our data concerning a clear evening preference for bad sleepers. This result is consistent with Giannotti and coworkers' finding  of a higOn the other hand, no difference emerged between bad and good sleepers' scores on the context and vigilance scale. Though in contrast with the negative influence of sleep disturbances on daytime sleepiness, described in most of the literature , thMoreover, in a very recent meta-analysis on children's sleep and cognition, after publication bias correction—a necessary step in the meta-analytic process—total sleep time and sleep efficiency displayed no correlation with daytime sleepiness, whereas the relationship between sleep and behaviour was indeed significant .In light of these results, we can trace two hypotheses on the determinants of poor sleep perception in our bad sleepers group. On one hand, it is possible to consider their sleep quality judgments as the result of objectively worse sleep features, which would on their turn influence mood and impulsive attitudes though not impacting perceived alertness. If this is the case, sleep duration and latency are possibly the main determinants, as confirmed by the finding that bad sleepers report perception of insufficient sleep and difficulties falling asleep more frequently than good sleepers, similarly to what observed in the elderly .Yet, these differences might be negligible although significant, and bad sleep perception could be the consequence of additional factors other than sleep itself. In the first place, as proposed by some authors , 54, sleThis alternative view might also provide an answer to the aforementioned question on the increase in the prevalence of poor sleep perception occurring from adolescence onward. The main factor interfering with judgments on sleep quality would actually be perceived wake quality, which is often dramatically worsened at that age as a result of many factors, including modified life styles and more challenging social and work demands.On the basis of our evidence, it would be hazardous to privilege or discard any of these two major hypotheses, which are likely to be not mutually exclusive and to interact in determining children's poor sleep judgments, as it was shown to happen in insomniac adults as well , 54.In conclusion, the subjective perception of sleep characteristics and daytime behavioural features seems quite peculiar in the group of children reporting themselves as bad sleepers. This observation is of great clinical interest, in that it strongly suggests a possibility to set specific strategies aimed to screen and precociously detect those subjects who might be more vulnerable than others to sleep disturbances over the life span.


Well-trained experts in pearl grading have been thought to evaluate pearls according to their glossiness, interference color, and shape. However, the characteristics of their evaluations are not fully understood. Using pearl grading experiments, we investigate the consistency of novice  and expert participants’ pearl grading skill and then compare the novices’ grading with that of experts; furthermore, we discuss the relationship between grading, interference color, and glossiness. We found that novices’ grading was significantly less concordant with experts average grading than was experts’ grading; more than half of novices graded pearls the opposite of how experts graded those same pearls. However, while experts graded pearls more consistently than novices did, novices’ consistency was relatively high. We also found differences between the groups in regression analyses that used interference color and glossiness as explanatory variables and were conducted for each trial. Although the regression coefficient was significant in 60% of novices’ trials, there were fewer significant trials for the experts (20%). This indicates that novices can also make use of these two factors, but that their usage is simpler than that of the experts. These results suggest that experts and novices share some values about pearls but that the evaluation method is elaborated for experts. Pinctada fucata martensii) have superior luster and impressive iridescence. In addition to these two features, their size, roundness, and the existence of scars or pocks are the key features inspected by farmers, traders, and craftsmen, who are collectively addressed as “experts” Pearls are known as jewels from the bottom of the sea. Their mystique from being produced by shellfish and their lustrous iridescence has attracted many people worldwide. The pearls produced by Akoya pearl oysters  and proteins like conchiolin. Calcium carbonate is an ingredient of both the nucleus and nacre; the former is calcite crystal, whereas the latter is aragonite crystal. The thicknesses of the aragonite crystal and the protein membrane are approximately 300–500 nm and 10 nm, respectively. Thus, the thickness of a nacreous layer is in the range of the wavelength of visible light  and eleven novices  participated in the experiment. All of them were males and had normal or corrected-to-normal vision. The expert participants included five pearl oyster farmers with more than 20 years of experience in the field; two pearl marketers with more than 15 years of experience; and one scientist who had been studying improvements in the health of cultured pearls in order to raise the quality of the pearls generated in pearl oyster farming for five years. All experts worked in Toba, Mie Prefecture, Japan. Although there are no national qualifications or licenses concerning pearls in Japan, in this study, experts are considered to be individuals who had learned about pearls from masters of the field, had been handling pearls in their work as professionals for a long period, and who were recognized as full-fledged experts by other experts.The novice participants included ten scientists affiliated with Toyohashi University of Technology as assistant professors, associate professors, and professors and one university clerk. All of them were unfamiliar with pearls in both their research activities and daily life and were unaware of the purpose of the experiment. After the experimental procedure was explained, all participants gave written informed consent before the experiment began. This study was approved by the Committee for Human-Subject Studies at Toyohashi University of Technology.We used 20 Akoya cultured pearls that had been labeled A-rank and B-rank. We got them from the trader in Kobe, a major center of pearl circulation (These pearls we used were labeled by some experts in Kobe other than our expert participants). All pearls used in the experiment were approximately 8 mm in diameter. The pearls were arbitrarily placed into two sets, with each set consisting of five A-rank (“good”) pearls and five B-rank (“fair”) pearls. Although Toyota and Nakauchi In the device for qualifying pearls, a pearl is illuminated from the opposite side of the surface from where the camera is placed, and a transmission image is captured. The intensity map of the transmission image is calculated using both white and very narrow band light (around 520 nm). The device then calculates the intensity gradient with eccentricity using weighted coefficients; the resulting value is a quantitative measurement of interference color The illumination we used had the same spectral pattern as sunny afternoon light, ranging from 370 nm to 780 nm (SERIC Ltd. SOLAX XC-100AF). We intended to imitate the lighting conditions under which experts look at pearls. We used two lamps and a diffuser to illuminate the desk; the distance between the lamps and the desktop was 100 cm. The illuminance on the desk was 109 lx.The experiment was conducted in the cargo space of a truck that had been modified for use in psychological experiments, called Mobile-Labo . Mobile-The task was to evaluate ten pearls, which were randomly placed on a black desk mat, according to their goodness. The novices were not given any instruction about how experts grade pearls; they evaluated pearls according to their own subjective criteria or preference. On the other hand, the experts were asked to evaluate pearls according to their professional criteria. Although the experts group included participants with different profession and this could cause the diversity of criteria in this group, the economical relationships between their works were very close. For example, marketers selected and bought pearls selected by farmers. If there were great differences between their evaluations, the commercial transactions would never be established. That is, we regarded the difference in their criteria derived from the difference in their profession as allowable. Although roundness and the existence of scars or pocks also affect the goodness of pearls, the participants were asked to ignore these aspects. They were allowed to look at the pearls while changing viewing positions or moving their heads, but were not allowed to pick up the pearls.The participants observed and compared ten pearls, and then sorted the pearls by subjective rank order of goodness. After the participant declared that the ordering was complete, the experimenter (who sat next to the participant) checked the identification codes and recorded the rank order. The participants repeated this task five times for each set, alternating between sets. In total, the participants repeated this task ten times. They were not given any feedback about their ordering during the experiment.F = 5.786, p = 0.022); however, novices’ concordances did not differ between pearl sets  = 0.725, p = 0.399). Although the differences among individuals were significant in both groups, the interaction was significant only in the novices  = 4.933, p<0.001). That is, all experts evaluated both sets roughly equal from the point of view of concordance, on the other hand, the evaluations of some novices differed between pearl sets  = 2.832, p = 0.012, d = 1.39).To compare the results between novices and experts, we first calculated the expert participants’ average ranks for each pearl. Hereafter, these averaged ranks are referred to as the “reference rank” (or Ref-rank in W) as an index of participants’ consistency across five repeated rankings for each pearl set. Thus, we calculated two W values for each participant. Participants’ within-subjects consistency was thus the average of the Ws  = 2.449, p = 0.025, d = 1.22). Secondly, we calculated Spearman’s rank correlation coefficients (ρ) between the pairs of trials for each pearl set. That is, 20 separate ρ coefficients were calculated for each participant. The averages of the ρ coefficients are shown in U test again revealed that the experts’ consistency was statistically higher than that of novices  = 19, p<0.05). The significance was confirmed after a z-transformed comparison of the correlation coefficients  = 2.519, p = 0.045, d = 1.24).Next, we compared the consistency of rank orderings between these two groups. Consistency referred to the similarity in rank orderings between sets of pearls within each participant. First, we calculated Kendall’s coefficient of concordance (f the Ws . These ap = 0.08 ∼ 0.18).Finally, comparisons were made between subjective grading and pearls’ optical properties. To examine whether the rank orderings were explained by the physical properties of the pearls, we carried out four regression analyses for each trial; three simple linear regressions and one multiple regression, in which optically measured interference color and glossiness were used as explanatory variables. Although a single multiple regression with two variables would have sufficed, we wanted to demonstrate to what extent each parameter  could explain each trial. Thus, we conducted three simple regressions as well. First, we performed separate simple linear regressions with interference color  and glosIn this study, we found that the average rank ordering of novices was significantly less concordant with the standard ranks than that of experts. Indeed, more than half of novices showed a concordance rate lower than 0.5 . Thus, their rank orderings were apparently the opposite of the standard ranks for experts in the field, suggesting that the experts’ method of evaluating pearls or pearliness is not used by novices who had not been given any instructions about how to evaluate pearls.Thus, novices could be divided into two groups; those whose rank orderings showed the same tendency as the standard ranks, and those whose rank orderings showed the opposite tendency. In other words, novices may use the same criteria as experts for evaluating pearls, but they utilize these criteria differently.Interestingly, experts’ average concordance was not very high. This suggests that experts’ evaluations were not identical. One possible reason for this was that they were unaccustomed to experimental settings such as ours. Although our experimental procedure and environment were designed to imitate the conditions in which experts usually engaged in their daily work, some residual differences might have affected their performance. For example, their work task may be to categorize large numbers of pearls in A-rank, B-rank, or C-rank, while in our experimental task, experts had to rank individual pearls. Thus, the difference between categorization and rank ordering could have been larger than expected. The other candidate should be the variety or complexity of the pearl evaluation. We took five factors into consideration; size, roundness or shape, the existence of scars or pocks, interference color, and glossiness. We controlled the former three factors in choosing pearls and instructed participants to ignore them, and we tried to explain the rank orderings by optically measured interference color, and glossiness (the latter two variables). However, experts might have examined other factors that we had not considered. For example, one expert had a rank-ordering tendency that was opposite that of the other experts. In addition to the factors we had considered, he might have strongly depended on other factors that we did not consider, which would have caused his results to differ from the reference rank.We should note that there seems to be no absolute scale of pearl beauty, as is the case for music Both experts and novices showed sufficient consistency in their rank orderings of pearls. However, their consistencies were not equal; the experts’ consistency was significantly higher than that of the novices. In addition, during introspection after the experiment, most of the experts noticed that only two sets of pearls were presented repeatedly. On the other hand, none of the novices said that they noticed this. This indicates that the experts were superior in terms of consistency. This could also indicate a better recognition of the pearls by experts. This could be explained by a better attention to specific pearls’ physical features, that novices did not notice, and that experts would have used in their judgment.A series of regression analyses did not fully support the previous findings that experts use both interference color and glossiness in their judgments In this paper, we investigated how experts and novices evaluate pearls, although this problem had already been investigated in different ways


This paper queries the notion that young people overestimate peer substance use, asking whether there is robust evidence that such misperceptions are widespread and whether the phenomenon may have been exaggerated in the research literature.An examination of the research literature was conducted, focusing mainly on studies published since 2000. Some analyses of relevant data on cannabis use from a Norwegian youth survey were also undertaken.The research in question is characterized by many weaknesses, including low response rates and widespread use of convenience samples, as well as the presence of contextual factors and the use of assessment tools that may have created a bias in favour of ‘demonstrating’ that youth overestimate peer drinking or drug use. Moreover, in some cases, the apparent tendency to hold such misbeliefs may reflect the reality. Further, although most studies conclude that the modal tendency is to overestimate, high levels of underestimation of peer substance use have been reported. There is also suggestive evidence that many youth may have no pre-existing beliefs when responding to items on the issue. Results from the Norwegian youth survey added to this picture.Young people's tendency to overestimate peer drinking and drug use has been exaggerated, while the uncertainty surrounding the evidence in question has been understated. In 1963, Bruun & Hauge , and theet al. , participants estimated that their peers drink about double the amount reported by the participants’ , p. 525)et al.  reported25et al. et al. .The social norms theory was developed in this context ,16,17. AThe social norms theory and approach prevention have been questioned for various reasons –21. HoweThis paper is based mainly on an examination of the research literature. Electronic databases were searched using key words such as ‘norms’, ‘perception’, ‘alcohol’ and ‘drug’ and additional publications were found in the reference lists of identified papers. Priority was given to studies published in peer-reviewed journals since 2000. Studies focusing solely on perceived injunctive norms were excluded.n = 2830) and to the senior high school students  (n = 11 158) in the sample. Details about the survey are reported elsewhere [The empirical analyses were based on data from a survey that was carried out in 2005. The target sample comprised all junior and senior high school students in 16 Norwegian municipalities. There were 89 such schools in the municipalities, of which 85 took part in the survey (response rate: 87%). The analyses were confined to the 15–16-year-olds own drinking or drug use. Under-reporting may also occur because the respondents conceal the truth intentionally, for instance, because they are suspicious about the confidentiality of their responses [Indeed, the notion that respondents are inclined to understate their alcohol consumption and to give false negative responses to questions on drug use has generally been supported –26. Suchesponses . Howeveris a social desirability bias in survey data on college drinking, implying that the observed consumption level is likely to be deflated [Most studies on misperceived drinking norms are based on samples of students in their late teens or early 20s, but whether the tendency to under-report varies with age is unknown. However, according to Borsari & Muellerleile , the phedeflated .Sample representativeness is another basic issue. Ideally, studies aimed at measuring actual prevalence rates should be based on representative samples with response rates close to maximum. However, as reported in Borsari & Carey's  review oBorsary & Carey's  meta-anaTo ensure comparability between data on ‘actual’ and perceived norms, it is evidently essential that the respondents are representative for the reference group in question. This may not be the case when the comparison target is ‘your friends’. It is possible that a population of students and the corresponding population of ‘students who are somebody's friends’ overlap substantially, but friendship ties are not necessarily symmetrical. In one recent study, more than 20% of those who had been nominated as ‘my best friend’ by a schoolmate did not reciprocate the relationship . MoreoveIf young people who have many friendship ties also tend to drink a great deal, observed self–friend discrepancies with respect to drinking may reflect an actual state of affairs. Several studies indicate that this is, in fact, the case –44. For All the studies above rely on the respondents' self-reported friendship relations or lack of them, but a more crucial issue is whether there is a positive correlation between the number of people who perceive the same person as their friend and that person's extent of substance use. A national survey of US secondary school students revealed that this was indeed the case with respect to drinking, but the number of received friendship nominations was unrelated to cannabis use . HoweverWhile it may be difficult to give correct information about one's own drinking, it is undoubtedly harder to estimate others'—notably when the ‘others’ refer to a distal social group. If taken seriously, the items used to assess these perceptions require a substantial amount of cognitive effort. Thus, even for the brightest respondents, it is no small challenge to give reasonably accurate answers to questions such as ‘How much alcohol, on average, does a typical student at your university drink each day of a typical week?’ or to caIn their meta-analytical study, Borsari & Carey  speculateach separate day in a typical week, respondents may infer erroneously that daily drinking is common—otherwise, the question would have been framed differently. These kinds of questions might also mislead the survey participants to believe that they are supposed to estimate the consumption level only among the drinkers. Moreover, when making judgements under uncertainty, the respondents may assume that the values in the middle range of the response scale reflect the average or the usual frequency in the population [In addition to a high level of complexity, the perceived meaning of the DNRF items and other similar items may be problematic. Thus, when asked about other students' average alcohol consumption on pulation ,53.The ‘typical student’ is probably the most common reference group in studies on perceived drinking norms. How this term is interpreted is evidently essential. From the researchers' perspective, it is synonymous with the average student but it is generally well established that the numerical meaning of vague quantifiers such as ‘typical’ or ‘usual’ may not be perceived as intended ,55. For et al. [Numerous studies on cognitive aspects of survey methodology have demonstrated that the questions may shape the answers –56. Thiset al.  revealedet al.  showed tP < 0.0001).Unclear questions may also yield high rates of missing data, but item non-response is often not reported in studies on self–other differences with respect to substance use. Moreover, almost none of these studies have offered ‘I don't know’ as a response option. Wechsler & Kuo's  nationalThe social norms theory ,16,17 anet al. [et al. [Many studies have only reported the mean values for the key measures, implying that information about the prevalence of norms misperception and apparently correct responses is unavailable. Some of the studies that provide such information suggest that it may be common to underestimate peer drinking ,57–60. Fet al. , while FData from the Norwegian youth survey added to the picture. The senior high school students in the sample were asked to consider all same-aged students in their municipality and to report on a pre-coded scale the percentage that they believed had used cannabis. Fourteen per cent reported personal use of the drug, but a solid majority (67%) assumed that the prevalence was somewhere between 0% and 10%. Fewer than one in five (18%) believed that the prevalence exceeded 20%, implying that the occurrence of ‘correct’ answers was 15%.As in other surveys, the above findings may have been affected by methodological limitations, but it should be kept in mind that full cohorts of students were assessed, that the response rate was high (87%) and that the question on peers' cannabis use was simple and presumably easy to understand. However, the results from this study and from other similar studies should never be taken at face value, among other things because they depend critically on characteristics of the key variables. The more finely graded the response scale for these variables, the lower the occurrence of ‘accurate’ perceptions and the higher the occurrence of apparently misperceived norms. In a sense, the magnitude of the ‘problem’ may thus be a matter of choice.Some studies on perceived drinking norms have asked the respondents directly whether they believe that others drink more or less than themselves e.g. ,9,11), b,11, b9,1et al. [However, when respondents compare themselves with others or when they are likely to infer that such comparisons will be made, their responses may be affected by a self-serving bias. In other words, a social comparison context may promote individuals' tendency to see themselves as ‘better’ than other people or, alternatively, others may be seen as ‘worse’ than they otherwise would have been. Melson et al.  pursued The findings above raise serious concerns about the research literature on misperceived norms in relation to substance use. The title of Melson and co-workers'  paper ilAccording to both literature reviews ,5,6 and Several limitations characterize this research, including low response rates and widespread use of convenience samples, as well as the presence of contextual factors and the use of questionnaire items that may have created a bias in favour of ‘demonstrating’ that youth overestimate peer substance use. Conversely, although most studies conclude that the modal tendency is to overestimate, high levels of underestimation have also been observed. There is also suggestive evidence that young people do not necessarily possess preformed beliefs when responding to questionnaire items about peer substance use. Data from the Norwegian youth survey added to this picture.In some cases, results that have been taken as evidence of exaggerated drinking norms may well reflect real differences—between individuals and their perceived friends, or between the survey participants and the average co-student. In other cases, what Borsari & Carey  referredAnother suggestion for future research is to examine the respondents' comprehension of the questions that have been applied in previous research. How the commonly used term ‘the typical student’ is perceived stands out as particularly important. Evidently, whether—and if so, to what extent—young people believe ‘the typical student’ drinks more than themselves depends critically on their perceived meaning of this term. It is also possible that different subgroups of youth tend to interpret the same words and item formulations differently, and that this in part may explain why the extent of overestimation as well as magnitude of the observed self–other differences varies with the respondents' personal drinking level e.g. –10,38).,38.10,38et al. [The issue raised by Melson et al.  should aet al. , p. 1083


Frontiers in Human Neuroscience, 6:87). In that paper we introduced a new socially interactive, laboratory-based task, the Deceptive Interaction Task (DeceIT), and used it to measure individuals' ability to lie, their ability to detect the lies of others, and potential individual difference measures contributing to these abilities. We showed that the two skills were correlated; better liars made better lie detectors  and this ability seemed to be independent of cognitive (IQ) and emotional (EQ) intelligence. Here, following the Focused Review format, we outline the method and results of the original paper and comment more on the value of lab-based experimental studies of deception, which have attracted criticism in recent years. While acknowledging that experimental paradigms may fail to recreate the full complexity and potential seriousness of real-world deceptive behavior, we suggest that lab-based deception paradigms can offer valuable insight into ecologically-valid deceptive behavior. The use of the DeceIT procedure enabled deception to be studied in an interactive setting, with motivated participants, and importantly allowed the study of both the liar and the lie detector within the same deceptive interaction. It is our thesis that by addressing deception more holistically—by bringing the liar into the “spotlight” which is typically trained exclusively on the lie detector—we may further enhance our understanding of deception.This Focused Review expands upon our original paper (You can't kid a kidder": Interaction between production and detection of deception in an interactive deception task.  Besides being a topic of enduring fascination to laymen, deception has stimulated a vibrant field of scientific enquiry across numerous distinct research disciplines including (but by no means limited to) philosophy, psychology, economics, criminology, and in recent years, neuroscience. Despite this long, inter-disciplinary tradition, doubt appears to exist as to the possible future direction of deception research. This doubt has largely been due to discussions of the utility (or futility) of laboratory-based deception research , and therefore this response bias could account for the increased accuracy for truthful statements over deceptive ones. The inadequacies of these blunt percentage accuracy figures are discussed and a potential solution proposed in a later section describing our Signal Detection Theory analytic framework.The first of these meta-analyses  the use of instructed lies, (2) the sanction of experimental lies, (3) low motivation experienced by participants, (4) low stakes for failure, and (5) limited social interaction.Participants recruited to act as liars or truth tellers are usually instructed to either lie or tell the truth upon experimental cues. The fact that an experimenter instructs the participant to lie or tell the truth is argued by some to remove the essence of deception by not giving the perpetrator the option to lie or tell the truth—that instead of lying, participants are merely following instructions , participants may not try as hard to effect successful deceit. Conversely, it is also argued that real-life deception may be less successful than in the lab because the greater motivation to successfully deceive in real life (due to the higher stakes for success and failure) may lead to a difficulty in effecting successful deception, a so-called “Motivational Impairment Effect” . Stimulus material in lie detection tasks is usually pre-recorded , thus permitting limited access to potentially useful cues to deception not portrayed by these media. It is worth highlighting that without a live audience, the performance of the Sender may also be impacted since a video camera gives no feedback or sense of social contingency. In this regard, researchers examining investigative interview strategies have maintained an important aspect of everyday deception by virtue of using socially interactive paradigms  with English as a first language participated in the study. All participants provided written informed consent to participate and for data to be collected. The local Research Ethics Committee  granted ethical approval for the study.Fifty one healthy adults  also completed the Wechsler Abbreviated Scale of Intelligence  to which participants responded “agree” or “disagree.” Responses to the Opinion Survey served as ground truth in the subsequent task  prizes would be awarded; one to the participant who was rated as most credible across all trials and the other to the participant who was most accurate in their judgments across all trials. Participants were required to make both truthful and dishonest statements relating to their answers on the prior “Opinion Survey,” with the objective being to appear as credible as possible regardless of whether they were telling a lie or the truth. Participants played the role of both “Communicator” (Sender) and “Judge” (Receiver), and their role changed randomly on a trial-by-trial basis, with topic being similarly randomized.On each trial, the experimenter presented one participant with a cue card, facedown, specifying a topic from the “Opinion Survey” and an instruction to lie or tell the truth on that trial. This indicated to all participants the Sender for the upcoming trial. At a verbal instruction to “go,” the participant turned the card, read the instruction, and then spoke for approximately 20 s, presenting either their true or false opinion and some supporting argument. After the presentation of the format of the task, a practice trial was conducted for all participants and the experimenter presented a verbatim example response from the piloting phase of the study. This permitted each participant to fully preview the requirements of both Sender and Receiver roles. Following each trial, Senders were required to rate whether they thought they had been successful or unsuccessful in appearing credible using a binary “credible” or “not credible” response scale. Simultaneously, Receivers rated whether they thought the opinion given by the Sender was true or false by marking “Truth” or “Lie” on their response form. Each participant completed 10 or 20 trials as Sender, half with their true opinion and half with their false opinion. Statistical analysis demonstrated that performance did not vary as a function of the number of statements produced and so this variable is not analyzed further. The 50:50 lie-truth ratio was not highlighted to the participants at any stage to prevent strategic responding in either the Sender or Receiver roles. Following the task, participants were asked to rate the degree to which they experienced guilt, anxiety and cognitive load when lying and when telling the truth, each on a 5-point Likert scale ranging from 1  to 5 (extremely).In deception detection experiments, researchers often wish to measure two aspects of performance: (1) the ability of receivers to discriminate lies from truths, and (2) the receiver's tendency to classify messages as true (truth bias). (1) Is typically measured as the percentage of messages that are correctly classified by the receiver (lies classified as lies and truths classified as truths). Greater than chance performance  is therefore indicated by a percentage correct score greater than 50%. (2) Is most commonly indexed as the percentage of truth classifications made ; scores greater than 50% therefore indicate a general truth bias. One limitation of measuring (1) using the percentage correct measure is that, when the proportions of lie and truth messages are unequal, this measure is not independent of (2). For example, suppose that a receiver has a general tendency to classify messages as truths. If a greater proportion of true messages than false messages are presented to the receiver, then the receiver will most likely score above 50% when the percentage of correct classification score is calculated, but this will be a false impression of their detection ability: their accuracy is confounded by their truth bias. This limitation of the use of the percentage correct measure in deception research has been noted by other researchers  can be defined as a “lie” classification to a lie message, and a “false alarm” (FA) can be defined as a “lie” classification to a truth message. d′ can then be calculated as the difference in the z transformed proportions of hits and false alarms ) – z(p(FA)). A positive d′ score therefore indicates a tendency to correctly distinguish lies from truths. The measure of bias, C, can be calculated as C = −0.5 × [z(p(H)) + z(p(FA))]. A negative value of C therefore indicates a truth bias, and a positive value of C indicates a bias to classify messages as lies.Signal detection theory is a well-established framework  and Credibility (the extent to which a Senders' messages as a whole tend to be rated as truthful), respectively. Sender Credibility, as indexed by C may be thought to be analogous with the “Demeanor Bias” mentioned previously. Full details of the analysis strategy and the interpretation of results can be found in Wright et al. (d′ and C) for each role was that it facilitated an analysis of the relationship between the measures across roles.Wright et al.  showed tt et al.  and Wrigt(50) = 7.060, p < 0.001, d = 1.226, Anxiety t(50) = 9.598, p < 0.001, d = 1.784, Cognitive Load t(50) = 9.177, p < 0.001, d = 1.421]. Also in common with previous studies  than when they lied  = −3.885, p < 0.001, d = 0.728]. Finally, task performance in the Receiver role was analyzed using conventional percentage accuracy rates and overall accuracy was found to be 54.1% (SD = 8.7%), not significantly different to the 54% reported previously  = 0.065, p = 0.950, d = 0.013] but significantly greater than chance . Fractional rates addressing accuracy for different types of statement showed a significantly lower mean accuracy for truths  than for lies . To compare any response bias in the Receiver role with findings from the literature, we calculated the number of statements of all types classified by Receivers as truthful and found it to be 46.7% (SD = 8.8%) a figure significantly lower than chance .In line with previous studies  =M d′receiver = 0.242, SD = 0.418; M Creceiver = −0.086, SD = 0.233; M d′sender = 0.272, SD = 0.509; M Csender = 0.097, SD = 0.256). Of principal interest is the fact that detectability in the Sender role (d′sender) and the ability to discriminate in the Receiver role (d′receiver) were significantly correlated . The only significant association with either measure of bias (Truth-Bias or Credibility) was a correlation between a Sender's confidence that they were believed and their Credibility measure, i.e., those that judged they were believed were more likely to be seen as honest independently of the veracity of their statements . Neither IQ , emotional ability relating to the self , nor empathy  correlated with d′receiver, Creceiver, d′sender, or Csender.Large individual differences were observed in all of the four performance measures analyzed using Signal Detection Theory (The relationship between the abilities to successfully produce and accurately detect deception was examined using a novel group Sender/Receiver deception task (DeceIT). This paradigm addressed widespread concerns around ecological validity in that it was socially interactive (rather than video-mediated) and sought to increase and maintain motivation in participants by introducing a competitive element with high-value monetary rewards. The reported results were comparable to patterns of results reported in the deception literature with regards to increased self-reported guilt, anxiety and cognitive load while performing the task (Caso et al., Interpreting the “deception-general” ability given the data currently available is very difficult. Deceptive skill was unrelated to IQ or self-report measures of self- or other-focused emotional intelligence. We tentatively suggest that it may be a product of practice or vigilance in everyday life through social learning (Cheney et al., To summarize, our recent discovery of a “deception-general” ability, conferring advantage to some individuals over others in both aspects of deception, is a potentially powerful interpersonal tool delivering a competitive edge for resources and social position. We have argued that our DeceIT paradigm and Signal Detection Theory based analytic technique provide the tools to finally turn the spotlight on the liar, a variable of interest in deception research whose time was long overdue. We have shown that DeceIT addresses a number of the methodological concerns around sanction, low stakes and social interaction highlighted above. We have further suggested that lab-based research is not distinct from the vast majority of real-world deception in terms of the penalty for being caught lying, we cite evidence describing real-world lies as being frequent and often of little consequence if discovered (DePaulo et al., We have promoted the adoption of SDT techniques in future research to index the performance of both Senders and Receivers, of liars and lie detectors. Although the SDT measures initially seem less transparent than traditional percentage accuracy scores, they capture all aspects of performance relevant for deception. One can gain independent measures of an individual's skill when deceiving, their credibility or demeanor bias, their ability to detect lies, and their degree of credulity, or truth bias. These measures are confounded in traditional percentage accuracy scores. Furthermore, percentage accuracy scores, but not SDT measures, are susceptible to biases induced through factors such as the proportion of lies and truths presented to participants during the experimental task.and within applied settings. An important element of this drive must be the broadening of research goals beyond that of lie detection, to include lie production ability, and the mechanisms of credibility and trustworthiness that contribute to it, leveraging all the tools, insights and theoretical advancement that interdisciplinary collaboration promises.Certain researchers, deeply ensconced in the field, may appear somewhat frustrated or urge a wholesale change of direction in deception research. However, in keeping with the idea that it is often “darkest before the dawn,” we promote a renewed vigor in deception research, both in the lab The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Working as part of a class-action legal settlement with DuPont, a science panel appointed by the Wood County Circuit Court recently announced the first “probable link” between perfluorooctanoic acid (PFOA) released into the environment from a DuPont manufacturing plant and disease in neighboring communities—specifically, pregnancy-induced hypertension (PIH).PFOA can be released into the environment during the manufacture of products such as Teflon™ nonstick coating. The chemical is present in an estimated 98% of Americans, with average blood serum levels of 5.2 ng/mL reported in the 1999−2000 National Health and Nutrition Examination Survey.In 2004 a settlement reached between DuPont and the plaintiffs established the C8 Health Project,Savitz, a professor at Brown University, explains that the panel originally envisioned using the C8 Health Project data and a literature review to report on potential health effects but soon realized that although animal studies have linked PFOA to tumor formation, neonatal death, impaired thyroid, and lipid abnormalities,In December 2011 the panel submitted to the court its first probable link reports on reproductive outcomes . For the PIH report, the panel relied on 6 studies examining either PIH or preeclampsia, a life-threatening condition for mother and fetus characterized by protein in the urine (proteinuria) combined with PIH. The panelists conducted 5 of the studies themselves, with collaborators.The studies were unable to distinguish between PIH with or without proteinuria because of the data available. Because women with preeclampsia by definition have hypertension, the panelists assessed only a link between PIH and PFOA. “There were a series of studies that pointed variably and modestly towards there being an association,” Savitz says. “There were different methodological limitations in each of them, but in looking at the aggregation of them, there really is a signal there.”Although it’s well established that PIH and preeclampsia can cause preterm birth and stillbirth, the panel concluded that the available data were insufficient to support a “probable link” between PFOA exposure and preterm birth or stillbirths/miscarriages, or birth defects, either. “We were careful not to claim that there is no impact [on these other PIH-related end points]—rather, that there is insufficient evidence to support a probable link,” says Fletcher, a professor at the London School of Hygiene & Tropical Medicine. “This may be due to clear evidence of no effect or insufficient power, and obviously the rarer the outcome, the more that low power will result in insufficient evidence to declare a link.”The C8 Health Project is one of the largest and most comprehensive studies of its kind to result from a legal settlement. “The agreement . . . resulted in, first, a very large and rapidly collected data set by a court-appointed survey group, and then significant additions to understanding the population science related to perfluorocarbon exposure by independent researchers,” says Alan Ducatman, chairman of community medicine at West Virginia University. “These socially reasonable outcomes help . . . everyone by adding to the science and being accountable to population needs. That is a credit to the settling parties.”The panel released 3 status reports in December, one with additional details on the reproductive outcomes,