Background: Approximately 24,000 Ontarians live in remote Indigenous communities with no road access. These communities are a subset of Nishnawbe Aski Nation (NAN), a political grouping of 49 First Nations communities in Northern Ontario, Canada. Limited information is available regarding the status of emergency care in these communities.Objective: We aimed to understand emergency response systems, services, and training in remote NAN communities.Design: We used an environmental scan approach to compile information from multiple sources including community-based participatory research. This included the analysis of data collected from key informant interviews (n=10) with First Nations community health leaders and a multi-stakeholder roundtable meeting (n=33) in October 2013.Results: Qualitative analysis of the interview data revealed four issues related to emergency response systems and training: (1) inequity in response capacity and services, (2) lack of formalised dispatch systems, (3) turnover and burnout in volunteer emergency services, and (4) challenges related to first aid training. Roundtable stakeholders supported the development of a community-based emergency care system to address gaps.Conclusions: Existing first response, paramedical, and ambulance service models do not meet the unique geographical, epidemiological and cultural needs in most NAN communities. Sustainable, context-appropriate, and culturally relevant emergency care systems are needed. In 2015, Canada’s Auditor General identified inequitable health services among remote First Nations communities, including severely under-equipped nursing stations and healthcare staff working beyond their scope of practice …an ambulance response service, and that is required. They make use of what they have. They’ve been lucky so far.”No formalised emergency service dispatch system. There is a lack of consistent, reliable and standardised communication. Many communities lack 911 services, cell services, reliable landlines, and street names or household identifiers. Often the communication system is unclear, requiring two or three different phone calls during times of emergency: “when there is an issue or emergency in a community, community members call at least two or three different numbers. At times, there is no 24 hours per day coverage, so the calls go unanswered, and it is then the responsibility of the community members to get the sick or injured person to the nursing station.”Turnover and burnout in volunteer teams. Some communities have volunteer-run EFRTs that support pre-nursing station care; however, there is high volunteer turnover where the team is dispatched often: “being called repeatedly at 3 am, 4 am, or 5 am is draining for volunteers, and if there is too much demand, the team turns over frequently.”Challenges related to first aid training for community members. There is a wide variety in first aid training, providers, and curriculum. Urban-developed first aid training courses are not appropriate in communities without paramedical services. For example, “patient transfer is not covered in normal CPR and first aid training, which is a problem … [because] training usually assumes that there are ambulance and 911 services nearby”. Training in many remote communities is infrequent, inconsistent, or does not occur at all. Training is usually only 2–3 days long and is often only provided to staff, employees, or teams in a community: “there is no regular [first aid] training”, “first aid training is way too short”, and “trainers are from outside the communities [and] this is part of what makes it challenging”.Four themes emerged related to the issues surrounding emergency response systems and training in NAN communities :InconsiEmergency service dispatch system. Community members need access to an effective system of communication to access first responders in an emergency: “A 911 for the North is needed.” Since people frequently travel in, out, and between remote communities, one respondent indicated that “a standardised system is required that is consistent across communities”. Another critical element of an effective emergency dispatch system is reliability: “When there is an issue or emergency in a community, the members call at least two or three different numbers . At times there is not 24 hour per day coverage, so the calls go unanswered, so it is then the responsibility of the community members to get the sick/injured person to the nursing station.”Support for volunteers. Existing volunteer emergency response teams need to be trained, equipped, and supported to enhance continuity to prevent burnout and turnover: the life expectancy of a team member is directly proportional to the call volume”, and “turn-over is problematic since the new people start at square one again.” One respondent summarised the challenge facing the use of EFRT programme: Most people dedicate themselves to the training and find the long-term commitment far too extensive, or find this is something they pursue as a career and leave to acquire the education needed to become a member of the medical field. In our region, emergency response teams will have cycled out a complete membership after 2 years with the exception usually of one or two people who are truly committed and suited to emergency work.”In summary, “The proper support and coordination of a team is required to ensure any measure of longevity”. Volunteer emergency care positions must be supported by paid professional or paraprofessional roles.Reliable and responsive transportation. There needs to be a safe, reliable and timely transportation system for patient preparation and transition to the nursing station or health centre. “Each community should have an emergency transport vehicle or ambulance.” In addition, the transport system may need to include “boat, motor, skidoo and sled for winter”. Considering the geographical context of large tracts of wilderness surrounding remote communities, one respondent summed this need succinctly: “safe transfer to a vehicle and safe transport to the nursing station.”Context-relevant system infrastructure. The emergency response system needs to be adapted and standardised for small remote communities, and this requires infrastructure funding and support for resources, training, and equipment. One respondent stated: “Each community should be outfitted with the resources (equipment and people) necessary to be able to respond to emergencies in the community.” Patient transition to the nursing station and health centres needs to reflect the reality of the community context with strong working relationships between nurses and first responders: “There should be a strong working relationship and system in place with the nursing station so the transition occurs smoothly and effectively.”Training that is reliable and context appropriate. Training needs to be longer than 3 days, more frequent, and more consistent: “There needs to be consistency in trained people that are able to respond to emergencies” and “regular refresher courses in the communities as a preventative measure, perhaps once a year to keep people fresh and up-to-date”. The curriculum needs to be adapted to deal with relevant critical health emergencies and adjusted to non-urban contexts without typical emergency response systems: “First aid & CPR deal with physical health, but communities need mental health first aid as well to deal with abusive situations, suicide and situations involving drugs and alcohol.” Community members should be encouraged to participate in training because they are a valuable first response resource in each community as “training is key and this includes training for lay community members”.Five themes emerged related to identifying the essential elements of an effective emergency response system for a remote NAN community :EmergenRepresentatives of this roundtable included an interdisciplinary group of 33 partners including 16 (48%) representatives from First Nations governance and community organisations, seven (21%) representatives from Ontario Provincial and Canadian Federal governments, seven (21%) representatives from nursing and paramedical services, and three (9%) representatives from non-governmental organisations.www.nosm/cbec [Representatives confirmed the accuracy of results from the informant interviews and interpreted these results to identify improvement opportunities for NAN communities. There were two main outcomes from this meeting: (1) a shared vision for the future of emergency medical services in NAN communities; (2) guiding principles central for implementation of the vision. The shared vision is: “people in remote and isolated First Nation communities should have access to excellent community-based first response emergency care” . The sixosm/cbec .Table 5.The literature search yielded 53 citations, four of which met inclusion criteria. Two news articles stated the need for improved emergency response from First Nations leaders ,20. The Strength & Spirit Campaign to develop and deliver existing and novel Red Cross programmes and services to better meet community needs [We could not locate significant amounts of publicly available information for the majority of programmes and services. Those that could be located provided no novel information. Documents from professional correspondence revealed that the Canadian Red Cross developed a partnership with Moose Cree First Nation in 2012 called the ty needs .Existing emergency response systems, efforts, and programmes are inadequate in NAN communities. Given the small population sizes and a variety of other contextual, historical, and geographical factors, many communities do not have 911 services or other essential emergency prevention and response systems. There are several programmes and services that address pre-nursing station care; however, the operation of these programmes is heterogeneous and fragmented. Many existing programmes depend on volunteers for operation, leading to burnout, turnover, and unreliable care. These challenges often place the burden on community members to transport patients to the nursing station; however, there is also lack of equitable, frequent, and effective training opportunities to ensure that lay responders are adequately prepared to manage the medical emergencies that occur in rural and remote NAN communities.Themes related to issues in emergency care that were identified from interviews with NAN health leaders included limited capacity, services, formalised dispatch systems, and contextually appropriate models of emergency medical service delivery. The expansion of conventional ambulance, first responder, and first aid programmes in these isolated and remote First Nations may not meet the unique geographical, epidemiological, and cultural needs of communities . StandarInnovative, sustainable, and community-based innovations in emergency health services delivery are urgently needed. Local First Nations emergency response stakeholders agreed that “people in remote and isolated communities should have access to excellent community-based first response emergency care”. Possible benefits for a community-based emergency care model include reduction in morbidity and mortality, the building of safer and more resilient communities, more local health knowledge and leadership, enhanced emergency response and crisis management capacity, enhanced community ownership and self-determination of health services, and economic development for remote communities . In the There are limitations to this study. Most of the data were based on interview responses and were not subject to verification from other community experts. Informants were responsible for up to eight First Nations communities, and this increased the challenge of accurately recalling or describing local contexts; however, many informants did take the time to research their answers. This increased the overall accuracy of the results reported, and therefore the results most likely provide a reliable assessment of local services and resources. Individual quotations may not be representative of overall trends or perceptions, but given that our respondents were legitimate representatives of a regional First Nations governance organisation, we feel that they represent credible perspectives. The passive phase of the project was conducted nearly 3 years after the active approach, so local circumstances may have changed in the intervening years; however, secondary sources did not identify any evidence that there has been improvement since the time of the interviews in 2013.Emergency response systems, efforts, and programmes are grossly insufficient in NAN communities. As these communities operate in isolated and remote contexts, the expansion of conventional ambulance or first responder programmes may not be an appropriate nor realistic solution. Remote communities are the most vulnerable, and transformation in health care to improve equity is needed. It is therefore paramount that novel, sustainable and community-based innovations are developed, particularly those addressing pre-nursing station care. The results of this paper can empower NAN communities with the information to advocate for improved emergency services and systems, which will then result in healthier, stronger, and more resilient communities.


Behaving efficiently  is central to animals' adaptation to their environment. Much evolutionary biology assumes, implicitly or explicitly, that optimal behavioural strategies are genetically inherited, yet the behaviour of many animals depends crucially on learning. The question of how learning contributes to optimal behaviour is largely open. Here we propose an associative learning model that can learn optimal behaviour in a wide variety of ecologically relevant circumstances. The model learns through chaining, a term introduced by Skinner to indicate learning of behaviour sequences by linking together shorter sequences or single behaviours. Our model formalizes the concept of conditioned reinforcement (the learning process that underlies chaining) and is closely related to optimization algorithms from machine learning. Our analysis dispels the common belief that associative learning is too limited to produce ‘intelligent’ behaviour such as tool use, social learning, self-control or expectations of the future. Furthermore, the model readily accounts for both instinctual and learned aspects of behaviour, clarifying how genetic evolution and individual learning complement each other, and bridging a long-standing divide between ethology and psychology. We conclude that associative learning, supported by genetic predispositions and including the oft-neglected phenomenon of conditioned reinforcement, may suffice to explain the ontogeny of optimal behaviour in most, if not all, non-human animals. Our results establish associative learning as a more powerful optimizing mechanism than acknowledged by current opinion. TypicAssociative learning is acknowledged to contribute to adaptation by enabling animals to anticipate meaningful events  and to respond appropriately to specific stimuli  ,17. Assolearn to behave optimally, as it requires perfect knowledge of the environment and extensive computation. Conditioned reinforcement, on the other hand, is computationally simple as well as taxonomically widespread, suggesting that optimal behaviour may be learned rather than inherited )2.To highlight connections to associative learning theory, behavioural ecology and reinforcement learning, we present our model in successive steps. We first consider a standard model of associative learning without conditioned reinforcement. This model can optimize single behaviours but not behaviour sequences. We then add conditioned reinforcement, obtaining our chaining model. Lastly, using ideas from reinforcement learning, we show that chaining can optimize sequences of behaviour in a similar way to dynamic programming.S has a primary reinforcement value, uS, which is genetically determined and serves to guide learning towards behaviour that promotes survival and reproduction. For example, a state corresponding to the ingestion of food would typically have positive value, while a state representing harm to the body would have a negative value. States that describe neutral conditions, e.g. waiting, are assumed to have a small negative value, corresponding to the time and energy expended while in the state. The animal's goal is to choose its behaviour to maximize the total value collected. To begin with, we do not assume any innate knowledge of the environment beyond the ability to recognize a number of biologically relevant situations such as pain and the ingestion of food, which are assumed to have suitable uS values. Hence, the appropriate behaviour must be learned.Our general framework is as follows. We consider an animal that can find itself in a finite  number of environmental states, among which transitions are possible. For example, states may represent spatial locations, and state transitions movement from one location to another. We assume that the animal can perceive without ambiguity which environmental states it is in (see §(c) and appendix A.3 for discussion, and for a model that does not require this assumption). By choosing its behaviour, the animal can influence transitions from one state to the next. Transitions can be deterministic  or stochastic . Each state 2.1.m behaviours . One behaviour (peck) leads to a food reward (tasting the fruit's sweet juice); all others have no meaningful consequences. We can imagine the animal as attempting to estimate the value of each behaviour, in order to then choose the one with highest value (this notion will be made precise below). Suppose the animal is in state S, chooses behaviour B and finds itself in state S′. Note that, in general, a state S may be followed by a number of states S′, either because the environment is not deterministic or because the animal does not always use the same behaviour B when it finds itself in state S. Hence S′ does not represent a fixed state, but rather whichever state follows S on a particular occasion. Let vS→B be the value estimated by the animal for choosing behaviour B in state S, and uS′ the primary reinforcement value of S′. A simple way of learning useful estimates is to update vS→B as follows after each experience:vS→B is the change in vS→B, and αv is a positive learning rate. The meaning of equation , while at the same time leaving some room for exploring alternative behaviours . A simple way to address both concerns is the so-called ‘softmax’ rule, which specifies the probability of behaviour ehaviour ,53.2.2.l actions in order to reach a reward. Equation . Such ‘The view that self control is learned based on a genetic predisposition for waiting is consistent with the observation that self-control correlates with absolute, but not relative brain size . The latdv means a smaller reward than expected, whereas a positive dv indicates a larger reward. The usual role of differences such as dv in animal learning theory is to drive learning  for aggressive behaviour will make aggression more likely when dv<0, i.e. when an expected reward is omitted.  This assumption is consistent with the observation that larger violations of expectations trigger more pronounced responses )


Cumulative evidence indicates that NO/cGMP inhibition would make a difference in vasoplegia treatment. Unfortunately, methylene blue (MB) is the only compound we currently have that can be used for this purpose. The effects of MB are apparent only in the case of nitric oxide (NO) up-regulation, and it is not a vasoconstrictor per se. Blocking the cGMP system “releases” the cAMP system in a kind of “crosstalk,” facilitating the noradrenaline vasoconstrictor effect , 2.I recently wrote an editorial opinion suggesting this approach as an unexplored therapeutic frontier for the pharmaceutical industry. MB is the oldest drug infused in humans, is cheap, and is not patented for industrial use, but the medical literature insists that it has not been the subject of any sizeable clinical trials, even considering its safety at low doses. However, it is mandatory to use it early, not as rescue therapy .Studies suggest that MB has a potential role in protecting the microcirculation. In an experimentally induced septic shock model in rats, only the combination of norepinephrine (NE) and MB restored mean arterial pressure to control levels by the end of the 3-h experiment. Intravital microscopy demonstrated better microvascular integrity in the presence of MB, and severe damage to animals that were infused with only NE . TherefoLevy and colleagues wrote an excellent review article about the “past, present and future” of vasoplegia treatment and presented some concerns about MB use . Not con


The use of ‘brain training’ games is often regarded as relating to wider ideals of self-improvement and youthfulness. Hence, use is intertwined with discourses of ‘active’ ageing. This paper analyzes how the use and users of brain training games were configured in the UK media, from 2005 to 2015, and examines how notions of active ageing relate to these representations. Game users were rarely constructed solely as gamers, and were more often presented as prudent individuals focused on a serious goal. This configuration related to assumed and enjoined motivations for brain training; specifically, users were commonly framed as seeking to enhance cognition and limit/delay cognitive decline. Scientific evidence about brain training was often deployed to explain how games might work; sometimes, however, it was used to undermine the utility of games and assert the significance and cognitive health-benefits of other activities. A minority of texts explicitly critiqued ideals of self-improvement, arguing that game playing was important for its own sake. Yet, even the pleasure associated with gaming was occasionally instrumentalized as a mechanism for ensuring prudent life choices. The analysis casts fresh light on how debates around health, ageing, and science correspond to configurations of technology uses and users. It presents evidence of the widespread cultural circulation of enjoiners regarding self-care and healthy ageing within British society. However, the paper also provides indications of the limits to such imperatives: discourses of pleasure co-exist with and perhaps supplant logics of prudence in (accounts of) practices ostensibly aimed at ageing ‘well’. •This article analyses UK newspaper coverage of brain training games from 2005 to 2015.•It interrogates how the uses and users of brain training games are configured.•It examines these configurations against a backdrop of active ageing and self-care.•Scientific evidence is drawn on in coverage to support and to refute brain training.•Coverage links to responsibilization but challenges it through a discourse of pleasure. Notably, ‘active ageing’  hasComputerized ‘brain training’ games are devices or software that purport to improve cognition. Promoted as one way to ameliorate the (cognitive) ageing process, games often focus on enhancing arithmetic and cognitive processing skills (e.g. memory) . ThroughNature Reviews Neuroscience noted that the cumulative evidence for generalised or transferred effects on cognition resulting from one trained skill was weak , for instance, partnered in 2015 to test the effectiveness of brain training . The focIn the UK, the traditional news media has engaged extensively with brain training games (e.g. we located 336 items between 2005 and 2015 across six newspapers). In it, issues like enhancement, ageing, fun, and health are diversely conceptualised and discussed. Such reporting at once undergirds and propels societal engagement with brain training, and is the focus of our analysis. Specifically, we analyze how writers in UK newspapers imagine and articulate the users of computerized brain training games, and the uses to which games are put.As Smirnova argues, “it is important to interrogate those various media outlets that perpetuate and reify various codes related to “the will to health”” : 1239. B1.1Within discourses of active or healthy ageing, efforts to pursue health are actions to which moral worth adheres . Such puThe concept of ‘functional age’ has become increasingly important as a measure complementing or even replacing chronological age . MoreiraThe brain, as well as its functions (i.e. cognition), is increasingly interpolated within discourses on ageing  as “someScholars like Katz and Peters , 349 hav2Our analysis is informed by science and technology studies (STS) insights regarding how (imagined) technologies, users, and practices are co-configured  and tabloids  were included. Search terms were, first, ‘brain training’, and, then, combinations of ‘game’, ‘improve’ and ‘brain’. Searches were restricted to items published from 1st January 2005  until 31st December 2014. The ten-year period examined produced a manageable yet meaningful sample. Mentions of ‘brain training games’ were less frequent from 2011 onwards, with just 15 articles published in 2015, which thus represented the end-point for our analysis  marketed as a means of enhancing cognition (n = 336 articles). Even when brain training games were mentioned largely tangentially, the article was included in the analysis since we regarded casual mentions as important in playing a role in configuring game uses and users. Items were more often found in broadsheets than tabloids (220 versus 116 items). Data were organised using Nvivo. A combination of deductive and inductive approaches were used within our constructivist analysis: we interrogated the data with particular ideas in mind, based on the literature , as well as taking cues from grounded theory approaches which are more orientated towards the location of unanticipated themes. Initial coding stayed close to the meaning of the specific fragments of text, which meant first distinguishing between sometimes similar-sounding codes such as ‘exercising one's brain’ and ‘mental workout’. This produced over 240 codes, with similar codes then grouped into 18 broad categories to make better analytic sense of the data . We ultimately focused on three key issues containing much of the data mapped to the original 18 themes: the configuring of uses; the configuring of users; and, science and self-care. For instance, ‘the configuration of uses’ contains many of the metaphors and descriptions of brain training use, as well as notions like enhancement.In what follows, we first examine the various kinds of uses assumed and anticipated for brain training games. Next, we analyze how users of brain training games are configured in the media as, especially, prudent and reflexive. The focus in the proceeding section turns to how evidence for brain training games was employed in journalists' accounts. The Discussion returns to the diverse discourses shaping the rhetorical machinery configuring technology users. We attend especially to ambivalences in the imaginaries of uses and users of brain training games, and the debates around health, ageing, and science that these propel. Throughout the article we largely refer to those writing in newspapers as ‘journalists’, although some might be better considered ‘commentators’. We do not regard journalists as a homogeneous group, and have borne authorship in mind during our analysis, as well as where in newspapers the items analyzed were situated.2.1Independent interview with Ryuta Kawashima (i.e. Nintendo's ‘Dr Kawashima’) of Tohoku University noted, brain training “games are more than just a fun way to learn: they could, in fact, provide a revolutionary new way to treat dementia” . Brain training games were sometimes heralded for their effects on users' cognitive skills , with the benefits of this enhanced functioning portrayed as extending to other areas in life. As one Sunday Times  piece put it: “By training your brain, you're making a commitment to maintain your intelligence, and by doing that, you're likely to be open to new ideas, possibilities and inventions.” The use of brain training games, then, did not just develop cognition or arrest its decline – it enhanced subjectivity more broadly.The backdrop to many articles on brain training games was often that these were a form of entertainment that could potentially have serious benefits. As an Guardian, 31/03/07, Guardian Weekend).The exercises, based on brain-scanning research, are designed to activate as many regions of your prefrontal cortex as possible, strengthening neural connections and even creating new ones. This is all just neuroscience-speak for the weird sensation - it actually feels almost like a literal stretching of the mind - you get when you attempt one of Kawashima's favourites, the Stroop test. .After four days of 20 min doing the dual n-back [a brain training game], I have no idea if it's working, but it's definitely hurting. Sadly, that's probably a good sign, and it's one thing on which researchers do tend to agree: if intelligence can be boosted by brain games - a very big if - they almost certainly won't be enjoyable ones. Unless the task involved keeps getting harder, so that you never quite feel you've got the hang of it, there's no way you'll get more intelligent. . Yet, a similar understanding of revivification was nevertheless put forward in the same article, with a scientist quoted to reinforce the point:Sunday Times, 16/11/08, Features).So your brain may be rotting, but there should, in theory, be something you can do to keep it reasonably fresh. The important concept here is “brain plasticity”, the ability of the brain to change and adapt. “We are literally remaking our brains,” writes [Nancy C.] Andreasen in The Creative Brain, “- who we are and how we think, with all our actions, reactions, perceptions, postures, and positions - every minute of the day and every day of the week and every month and year of our entire lives.” .'If you lead a full and active life, take new interests and learn new skills, you can increase the number of connections between your brain cells,' says psychologist Susan Blackmore. 'It really is a case of use it or lose it.'  as being used for enhancing citizens' brains and their selves, and to arrest or stave cognitive decline see . By usin2.2Daily Mirror, 25/06/07, News).Many articles provided a narrative of the rise of brain training as occurring first in Japan, then in the UK. Nintendo's marketing strategy was noted in at least 24 (primarily broadsheet) items. Responding to promotional campaigns, some articulated similar stories about actress Nicole Kidman's role advertising the Nintendo DS system. The marketing move was said to be aimed at promoting “the console's appeal beyond its traditional young male audience” . The Nintendo Wii console and its portable DS system gradually appeared as suggested family pastimes or presents, such as for “Mums”  and “Grandparents” . While teenage boys were anticipated to enjoy more vivid games like ‘Mortal Kombat , older relatives would apparently take (a more serious kind of) pleasure in gentler gaming experiences like brain training.Accounts of the popularity of brain training often underscored the ‘new’ users employing them, and of computer games more generally; for instance, by claiming 2007 “was the year computer games burst out of the geek's bedroom and into the living room” .Nintendo DS games have been marketed as “brain training” – focusing on a serious purpose rather than play. Although research has shown that the Wii Fit isn't as effective as going to the gym, and there's little evidence that brain training can help slow mental decline, the “training” packaging helps to sell these games to a demographic that might be unwilling to buy something purely for fun.  users of brain training games were not necessarily ‘traditional’ gamers.Times, 06/05/06, Times Magazine Features).You've sorted your gym membership, your personal trainer and your Botox. But how can you hope to retain that sparkle of youth unless you've signed up for a decent brain-fitness regime? As mortality looms for the Baby Boom generation, businesses are piling in to market new mental-stimulation programmes that claim to slow the brain's rate of decline. From computer gaming to publishing, the new “brain training” promises to enhance mental agility and stave off dementia, using the latest neuroscience to stretch thinking power. At a time when we have ever-increasing expectations of our senior years, it's a compelling sales pitch. .One of the commercials explains that the brain-training machines are “inspired by the research of Dr Kawashima”. What a brilliantly opaque, advertising-style sentence. The elderly target's subliminal mind inhales “research” and “doctor”, so she comes away thinking this is a development akin to the discovery of penicillin. But if you actually think about it, the words “inspired by” mean almost nothing at all. I could perform a contemporary dance inspired by the research of Dr Kawashima and that wouldn't stave off Alzheimer's either.  described how:Guardian, 31/03/07, Guardian Weekend Pages).The first time I subjected myself to Dr Ryuta Kawashima's brain-ageing technology, I learned that I had the brain of a 51-year-old. I mean no disrespect to 51-year-olds when I say I found this alarming. I was planning on waiting a couple of decades before turning 51. All of us are in cognitive decline from early adulthood onwards. But how come I'd jumped so far along the road so quickly? I was jet-lagged, I protested. But Kawashima - who's a real person, but who appears in the Brain Training computer program as a disembodied bouncing head - just chuckled. He chuckles a lot, no doubt because he possesses the brain of a 20-year-old, which is what he says we should all be aiming for.  the ‘brain age’ calculated by the Nintendo ‘Dr Kawashima’ game. A popular trope was journalists' disclosure of ‘alarm’ regarding their own brain age, followed by a personal story of using the game, and reflections on the experience. For example, Oliver Burkeman . Across the news items analyzed, users were commonly imagined to be older than ‘traditional’ gamers; however, younger people too were framed as wanting to enhance their cognition or to stave off decline (or simply to relax). They were generally presented as having awareness of the negative aspects of ageing, comprehension of some of the neurocognitive research giving support to their concerns, a desire to respond to these worries earlier in the life-course, and the necessary capabilities - both resources and will - to act in ways that would ameliorate (the effects of) aging. In this context, the optimizing effects of brain training in earlier life buttressed the brain against decline at a later point.Users of brain training games were frequently configured as sensible, future-thinking, and reflexive, employing games for rational ends. While a discourse of self-care was apparent both in tabloid and broadsheet newspapers, it was particularly emphasized in the latter, with tabloid newspapers more likely to mention celebrities such as tennis player Andy Murray playing brain training games (e.g. Guardian article at the beginning of this section)  self ever earlier in life . Simultaion) cf. . In what2.3Times, 29/09/07, Features). An article in The Times employed a neurobiological idiom when explaining the (in)famous Dr Kawashima's perspectives on brain training as a means of preventing, or at least slowing, cognitive decline. As in some other media items, this framed the potential users of brain training not as specifically older adults, but adults in general:Times, 15/02/07, Features).[Dr Kawashima] claims to have devised a series of exercises that increase delivery of oxygen, blood and amino acids to the prefrontal cortex, the region of the brain that makes up much of the frontal lobe, which is responsible for creativity, memory, communication and self control. The programme is designed for those suffering from forgetfulness, difficulty remembering names, how to spell words or express thoughts, or who wish to work on creativity, memory skills, communication and slowing the mental effects of ageing. That would be all of us then.  stated: “The Nintendo DS is a technological jewel. But it is charlatanism to claim that it is a scientific test”. Ambivalence and cynicism were evident in 2006 and 2007, albeit less emphasized, but scepticism was particularly present in 2009 (with at least 15 references to a lack of evidence) - and in 2010 (12 references), when the BBC and a team of researchers tested the effectiveness of brain training. Ultimately, the games failed; as one Daily Mirror  piece put it: “People who used the brain training games fared no better than others who surfed the internet for a similar amount of time on sites such as Wikipedia.” Dementia specialist Clive Ballard, of King's College London and the Alzheimer's Society, was quoted in the Daily Mirror and the Daily Mail, for instance, as stating that “staying active by taking a walk, for example, is a better use of our time”. . Quotes such as these underline, as well as dash, hopes that brain training can act as a means of enhancing cognition in the present in order to arrest or limit its decline in the future.However, both broadsheets and tabloids commented too on the lack of scientific support for game use as a means of extending cognitive skills or limiting decline. As one researcher quoted in Guardian, 04/01/14, Guardian Weekend).You might feel inclined to stick to brain games instead, on the rationale that even if they don't work, they can't do any harm. But that position's arguably misguided. Your time is finite, and every hour you spend wrestling with the dual n-back is one you could have spent doing any of the more mundane things that will certainly promote brain health: doing sufficient physical exercise, getting enough sleep, and preparing and eating healthy food. “Live a good clean life, get proper sleep and you'll be at the peak of whatever your potential performance is,” James Thompson suggests. .This all feels to me like pouring cold water, unnecessarily, on a harmless new fad that gave hope and purpose to people who felt their mental skills might be fading. Rushing to publicise the narrow, negative findings is mean-spirited and cynical. It's not like they were advocating a better way, they were just telling people not to do something fun. “Thought you were staving off the Alzheimer's with your silly little machine, did you, Grandpa? Ha! Think again, you hoodwinked old fool.”  articles explicitly addressed this in relation to scientific evidence, although engagement with the topic of fun and enjoyment in general was more widespread in the media items examined. We discuss it here as a negative case; i.e., a pattern in the data that diverges from the overall pattern. For instance, in the following quote commentator Victoria Coren asserted that publicising research demonstrating no cognitive benefits from brain training elided the pleasures of gaming:Guardian, 07/08/10, Guardian Weekend pages). Such prose can be read as an alternative means of perceiving the effectiveness of brain training games, as well as a different way of looking at (evidence-based) self-improvement. Pleasure in this context propelled self-care, but was also important per se.Oliver Burkeman similarly wrote that “Since it feels so true, “brain exercise” makes people feel happier”. He concluded: “the best ways to care for your brain are probably physical exercise, good diet and sleep; but happier people are surely more likely to make those choices. . A configuration of prudent use, orientated towards self-care, was commonly (but not exclusively) apparent throughout the years 2005–2015, and in both broadsheets and tabloids. This was somewhat more emphasized in the first five years, with later years increasingly focused on the (lack of) efficacy of brain training. Any pleasures assumed to be elicited through game use were largely articulated within more dominant tropes in which users were constructed as concerned primarily with the worthy pursuit of cognitive health and enhancement. This finding supports studies of gaming technologies that have shown that adult game use might not be regarded as age-appropriate , and henWith the use of brain training presented as relating to a desire to maintain or even enhance cognition, game users were largely presented as individuals who valued their cognitive skills and had the desire and will to better them – or to arrest or limit their decline. Such people might not normally buy games, but were sufficiently focused on self-care and improvement to engage with brain training despite the association of gaming with entertainment. Similar representations of self-care and improvement were apparent within the media accounts of cognitive health, decline, and optimization analyzed by other social scientists, including outside the UK . The cogPractices of self-improvement were propelled through metaphorical language presenting the brain as a kind of muscle  significance for people's sense of self . ConnectThe media items examined also provided illustrative cases of journalists deploying irony or sarcasm regarding self-improvement generally and/or brain training specifically. Such commentaries again highlight the cultural availability and significance of scripts around self-improvement into which brain training can be plotted, as well as the extent that these can be subject to resistance. One of the main points of critique for broadsheet commentators related to the joylessness of self-improvement for its own sake. For instance, some writers argued that there was nothing wrong with having fun through brain training, and more generally the presumed enjoyment of playing games on occasion served as a backdrop to the articles we examined. However, fun was itself sometimes seen as self-care too. By instrumentalizing pleasure as a means of legitimizing it, the dominance of enjoiners to age actively and healthily is underscored even as they were seemingly resisted .to justify gaming, but to justify it as something other than pleasure, escapism or entertainment” (Millington : 429 hasainment” : 142. Heainment”  of these4Accounts of brain training commonly emphasize brain plasticity and the related possibilities of cognitive enhancement  and the Broer and Pickersgill contributed equally to this article, and hence should be considered joint first authors.


When standard optimization methods fail to find a satisfactory solution for a parameter fitting problem, a tempting recourse is to adjust parameters manually. While tedious, this approach can be surprisingly powerful in terms of achieving optimal or near-optimal solutions. This paper outlines an optimization algorithm, Adaptive Stochastic Descent (ASD), that has been designed to replicate the essential aspects of manual parameter fitting in an automated way. Specifically, ASD uses simple principles to form probabilistic assumptions about (a) which parameters have the greatest effect on the objective function, and (b) optimal step sizes for each parameter. We show that for a certain class of optimization problems , ASD is capable of minimizing the objective function with far fewer function evaluations than classic optimization methods, such as the Nelder-Mead nonlinear simplex, Levenberg-Marquardt gradient descent, simulated annealing, and genetic algorithms. As a case study, we show that ASD outperforms standard algorithms when used to determine how resources should be allocated in order to minimize new HIV infections in Swaziland. E = f(x), by manually adjusting parameters in the vector x. e.g., 10%) of the initial parameter values. xi is found to reduce E, the probability that xi in the future increases; conversely, if changes in xi are not found to improve E, the probability that xi decreases , esp, espe.g.e.g., , neuronae.g., –6, or dee.g., . However,  is an n-element vector of parameters. There are 2n possible directions j to step in: an increase or decrease in the value of each parameter. Associated with each parameter xi are (a) two initial step sizes: xi, respectively  onto p, thereby choosing a direction j ∈ (1…2n) and a corresponding parameter i = ⌈j/2⌉ ∈ (1…n), where ⌈·⌉ denotes the ceiling operator. The algorithm then evaluatesδ(i) is an n-element vector such that δi = sj and 0 otherwise. Then:At each step If xi → xi + sj;The new parameter value is adopted: The error is updated: sj is increased: sj → sj ⋅ sinc (where sinc > 1);pj is increased: pj → pj ⋅ pinc (where pinc > 1), and p is renormalized such that ∑p = 1.Otherwise:x and error E are not changed;The parameter vector sj is decreased: sj → sj/sdec (where sdec > 1);pj is decreased: pj → pj/pdec (where pdec > 1), and p is renormalized as above.sinc, sdec, pinc, and pdec. In general, the smoother and more linear the objective function is, the larger the learning rates should be; the choice of sinc = sdec = pinc = pdec = 2 has been found to work well for both simple test cases as well as optimizing complex epidemiological models, although values from approximately 1.2 to 3 were found to have broadly similar performance. In addition to these metaparameters, three initial value vectors need to be specified: the initial parameter vector x0, step sizes s , and probabilities p .The algorithm thus has four metaparameters: s and p after each iteration, the algorithm learns which directions are most effective to step in and by how much . This, combined with the stochastic choice of which parameters to modify on each iteration, resembles the way in which humans (imperfectly) perform Bayesian decision-making in situations such as N-armed bandit problems [By modifying problems .i.e., Δx) and/or improvements in the objective function  are below a given absolute or relative threshold  for a given number of iterations .The criteria for terminating the algorithm can be specified in the same way as for traditional optimization algorithms. The most common choices for termination are when changes in parameter values  with pseudorandom choices of x0. The use of multiple starting points helps achieve the balance between “exploration and exploitation” (exploring the entire feasible region of parameter space versus exploring the most promising subregions), which is critical for efficient global search [To circumvent the problem of local minima, the method may be used with Monte Carlo initialization . In thisl search . This isl search , we founρ, where ρ is a function of the change in error; e.g., Another approach for circumventing the problem of local minima is a probabilistic step acceptance process, similar to that used in simulated annealing or the Metropolis-Hastings algorithm . Here, iNote that in the limit of infinite iterations, the basic ASD algorithm will not almost surely converge to the global optimum, since the step size will asymptotically converge to zero if the algorithm is in a location of parameter space such that its step size in all dimensions is smaller than the size of the local minimum’s basin of attraction. However, the algorithm will almost surely converge to the global optimum if probabilistic step acceptance is implemented . Formally, multiple initializations do not suffice to almost surely converge unless they are infinite in number. However, in practice, depending on the smoothness and monotonicity of the objective function, multiple initializations typically allow the exploration of global parameter space (and thus convergence) more efficiently than probabilistic step acceptance.p and uniform initial step sizes s can easily be relaxed. However, due to the adaptive nature of the algorithm, even silly initial choices of p and s will be corrected, as long as all pj and sj are nonzero. In general, choices of sj or pj that are too small are more problematic than ones that too large, since the latter will be corrected with each iteration that fails to improve the objective function.In some cases it may be desirable to allow assumptions about the scale or relative importance of parameters to be incorporated, in which case the assumptions of uniform priors pj by a fixed amount after each successful iteration, the change in pj (Δpj) can be a function of the change in the objective function E (ΔE), such that a larger ΔE results in a larger Δpj, as in simultaneous perturbation stochastic approximation [E at step k is proportional to both |Ek − min(E)| and the ratio of the step size to the characteristic scale of each parameter, and since in general neither of these quantities are known, the constant of proportionality between Δpj and ΔE cannot typically be estimated a priori. One can partially circumvent this problem by comparing the current ΔE to its previous values; however, more weight would need to be given to more recent values, since ΔE tends to decrease as the algorithm converges on a solution.To incorporate additional information about the change in the objective function, rather than updating the probability ximation . Howevern-parameter problem, modifying a single parameter at each iteration results in a learning rate of 1/2n on average for each parameter; in the limit where all possible combinations of parameters are considered, the learning rate would be 1/2n2. While manageable for small numbers of parameters , this quickly becomes intractable as the number of parameters grows. Conversely, if multiple parameters are modified simultaneously, the probabilities of all modified parameters could be updated simultaneously; this approach is likely to be most effective in very high-dimensional systems where the function E is nearly flat with respect to many of the dimensions, in which case varying parameters one by one may be time-consuming. The superior performance of simulated annealing compared to ASD for small numbers of function evaluations in the 10-parameter Rosenbrock’s valley problem discussed below is likely due to this effect.The assumption of local linearity can be relaxed by varying multiple parameters on a single iteration. However, assuming a separate probability is stored for each parameter combination, this reduces the learning rate; for an Finally, although only loosely inspired by Bayesian principles, the ASD algorithm could potentially be adapted to implement them more rigorously. While a more formal Bayesian approach may be desirable in certain situations, in general it is difficult to determine whether new information should be used to update the existing distribution, or whether the system is in a sufficiently dissimilar part of the parameter space that information from much earlier iterations is no longer relevant. Nonetheless, for certain problems, additional capacity for adaptation may be beneficial. For example, as shown below, the basic implementation of ASD described above performs poorly in cases where the objective function is dominated by nonlinear parameter interactions, as in the classic version of Rosenbrock’s valley; for this particular problem, an algorithm that was capable of learning nonlinear parameter combinations would be far more efficient.Here we compare ASD to four standard optimization methods: the Nelder-Mead nonlinear simplex algorithm , Levenbesinc = pinc = sdec = pdec = 2, initial step sizes sj of 20% of the parameter values in x0 , and uniform initial probabilities pj . MATLAB’s default metaparameters were used for the other four algorithms, except that the initial temperature of the simulated annealing algorithm was set to be equal to 10 ⋅ 〈|x0|〉 following manual exploration of metaparameter space, since the default choice of 100 did not generalize well across problems of different scales. Indeed, one of the major disadvantages of this type of algorithm is its sensitivity to the values of its metaparameters [For ASD, we used metaparameters rameters .To test this suite of algorithms, we used original and modified versions of the two classic optimization problems used for illustrating the simplex algorithm :x = . The optimum is at x = .Rosenbrock’s parabolic valley :x; the remaining 8 parameters do not contribute to the objective function. The starting point is at x = . The optimum is at x = , where ω1 … ω8 can be any real numbers.A modified 10-dimensional version of Rosenbrock’s valley, with the functional form as given in N-dimensional:xq is a vector of length N/4 (and note that vector operations are performed pointwise). The starting point is at N/4 times. The optimum is at x =  = . For example, if N = 4 , then x0 =  and xopt = ; if N = 8, then x0 =  and xopt = . Here, we used 4, 12, 20, and 100-dimensional versions of Powell’s function.A 4-dimensional Powell’s quartic function, modified to be The results from applying each of these algorithms to each of the three test problems is shown in inefficient, since its assumption of local linearity is violated by the shallow, curved valley . With the modified 10-dimensional version of Rosenbrock’s valley, ASD is the most efficient algorithm over most of the first several hundred function evaluations, as shown in As shown in During the descent into the shallow curved valley , the most efficient algorithms were ASD and simulated annealing; within the valley , the simplex algorithm was by far the most efficient. Hence, these examples illustrate that in optimization problems where some parameters are significantly more important than others, ASD has significant advantages. In contrast, for problems in which all parameters have equal importance, as in the original Rosenbrock’s valley problem, other algorithms have superior performance.For the 4-dimensional Powell’s quartic function, the nonlinear simplex method was again the most efficient, followed by ASD. For the 12- and 20-dimensional version, ASD was most efficient for 60–1700 and 250–4400 function evaluations respectively , after which the simplex method was most efficient. For the 100-dimensional version, the Levenberg-Marquardt method was most efficient for the first 1000 function evaluations , but ASD was the most efficient algorithm for larger numbers of function evaluations. In practice, algorithms are not run for a fixed number of function evaluations, but rather until they satisfy a given stopping criterion, which is usually defined in terms of the change in the relative or absolute error. Specific choices for these criteria depend on the problem at hand, but for illustrative absolute error tolerances of 99.9% or 99.99%, ASD was the most or equal-most efficient for all cases except the 2D version of Rosenbrock’s valley.increases over time (due to its adaptive step size), whereas for the latter, and for other algorithms, it decreases . In thehiv.optimamodel.com.In contrast to the foregoing theoretical discussion of error minimization for analytical functions, here we describe the practical application that ASD was designed for: finding the allocation of resources across different HIV prevention and treatment programs that minimizes new infections . To do tIn brief, the model describes HIV transmission and progression in a number of interacting subpopulations (14 in this case), including female sex workers, men who have sex with men, and general males and females in different age groups. The model incorporates parameters describing the sexual behavior, injecting behavior, HIV testing and treatment rates, and sexual and injecting partnerships of each population, as well as basic clinical parameters such as HIV transmissibility and disease progression rates. The model was based on to behavioral and surveillance data provided by the Swaziland Ministry of Health and UNAIDS. Further details are provided in . In addix being optimized consisted of the budget allocations across 9 different HIV prevention, testing, and treatment programs. Thus, the optimization problem had a dimensionality of 9 . The initial budgets for different programs varied by over three orders of magnitude: from US$40,000 per year for prevention programs for men who have sex with men to US$45 million per year for antiretroviral treatment. To evaluate the objective function, the budget for each program was first converted to one or more model parameter values via a nonlinear cost-outcome function, which in turn were used in the nonlinear dynamical epidemic model. The cost-outcome functions and epidemic model are described in detail in 3) of evaluations become wearisome.To optimize the allocation of Swaziland’s HIV budget, we assumed that spending on particular HIV programs produces changes in corresponding behavioral parameters or testing and treatment rates . The objective being minimized was the number of new infections over the period 2015–2020, subject to the constraint that total funding was held constant for the last year in which full budget details were available (2014). The vector This particular optimization problem has three notable aspects. First, despite the complexity and nonlinearity of the model, in almost all cases the objective function decreases monotonically as funding to any of the programs is increased—the only exception being HIV testing and counseling programs, in which case diagnosing more people with early-stage HIV infections without simultaneously increasing funding for antiretroviral treatment prevents some people with late-stage HIV infections from accessing treatment. Second, the country’s current HIV budget allocation, which is used as the initialization for the algorithm, is the product of considerable deliberation among numerous stakeholders and experts who have typically had the goal of allocating funds optimally. Thus, in most cases funds are already reasonably well allocated, and hence the initial starting point is expected to lie relatively close to the global optimum. Third, in situations where this is not the case, optimal solutions in very distant parts of parameter space are unlikely to be feasible given political and logistical constraints. Each of these three factors reduce the probability and/or importance of there being a difference between locally and globally optimal solutions.As shown in This paper presents a simple optimization method inspired by the process of manual parameter fitting that is capable of outperforming traditional algorithms for certain classes of problems. The algorithm is most effective for problems with moderate to large dimensionality (≥5 dimensions), which corresponds to the case in which there are enough parameters that different parameters are likely to have substantially different overall contributions to the objective function. Indeed, the relative uniformity of parameters in the simple test functions used here  does not necessarily reflect certain real-world situations in which some—or even most—of the objective function’s parameters may have little influence on its value. In such situations, as with the real-world example of HIV budget allocations, ASD is especially effective, as it is able to adapt to those parameters  that produce the greatest improvements in the objective function. An example of this is provided in e.g., by sampling points from a hypersphere of radius equal to the current step size), and are thus unable to obtain information about individual dimensions. In addition, they typically require additional function evaluations to calculate the optimal step size, whereas ASD updates step size automatically on each iteration. ASD also has some similarities with tabu search [Within the taxonomy of optimization methods, ASD is a stochastic, derivative-free, direct search method . Thus, u search , which uThis study has two main limitations. First, we chose the four algorithms to compare against ASD based on their popularity, as evidenced by their inclusion in MATLAB’s Optimization Toolbox and Python’s SciPy module. However, as noted above, many other optimization algorithms exist, some of which significantly outperform these more traditional methods for particular problems—especially those that are non-convex, multi-modal, and/or have many local minima—as shown in the comprehensive review by Rios and Sahinidis . Since AAs noted above, ASD has already been used successfully in the real-world applications of optimizing the allocation of HIV budgets, as well as calibrating various models—of HIV epidemiology, spiking neuronal network activity, and neural field dynamics—to experimental data. In the HIV budget optimization example shown above, standard optimization methods (including the four compared against ASD in this paper) were found to require an unpleasantly large number of function evaluations to obtain acceptable solutions. This led the authors to resort to manual parameter fitting until ASD was developed. It is our hope that this algorithm may be able to free other researchers from similar unpleasantries.S1 Appendix(PDF)Click here for additional data file.


The role of the school nurse is complex with many possible elements identified by previous research. The aim of this study is to understand perceptions of the role of the school nurse in order to support school nurses in the delivery of health education.The study used an inductive, qualitative research design involving semi-structured interviews and focus groups. Participants were recruited from four NHS trusts across England and final sample size was thirty one school nurses. Three focus groups and two interviews took place in person, and three interviews were over the phone. Data was thematically analysed.School nurses described six main themes. Four themes directly related to the school nurse role: the main roles of a school nurse, school nurses' role in health education, prioritisation of workload and activities, and community work. A further two other themes related to the delivery of health education: the school nursing system and educational resources.The role of the school nurse in England is very diverse and the school nurse role in health education is primarily to advise and support schools, rather than to directly deliver education. The study identified that tailored public health educational resources are needed to support school nurses. The UK Department of Health states that school nurses have a significant role in co-ordinating and delivering public health interventions for school-aged children . School School nurses have been recognised as the leaders in delivering services identified in the Healthy Child Programme from 5 to 19 years . School This study aims to understand the role of the school nurse from the perspective of the school nurse, using qualitative research methods, in order to better support school nurses in the delivery of health promotion and education.Four NHS trusts across England were chosen to include views of school nurses working in different contexts  Table . School National Research Ethics Committee approval was not required as the study only involved staff. Local approvals were received from each NHS trust involved in the study. The localities have been kept anonymous to maintain participant anonymity. Participants gave written informed consent for participation in the research, audio recording and the publishing of anonymised quotes.The interview/focus group topic guide was developed by the lead author (BH), reviewed by the other authors, and piloted with school nurses Table . The guiSemi structured individual interviews and focus groups were facilitated by BH who is an experienced qualitative researcher, registered nurse and researcher for the e-Bug project, Public Health England. Both individual interviews and focus groups were conducted in this research project in order to enrich the data; interviews enabled individuals to speak more openly outside of the group situation, whereas focus groups enabled snowballing and stimulation of ideas. All three focus groups and two interviews took place in person, and three interviews were conducted over the telephone. Interviews and focus groups took place at suitable venues for the participants, i.e. a meeting room in a doctor’s surgery. Two interviews lasted between15-30 min, 3 interviews lasted between 40–50 min and the three focus groups lasted between 45 to 60 min. During the focus groups, a second researcher (VY) was present to record notes, assist BH with collecting consent, and observe the group. Interviews and focus groups were audio recorded, transcribed verbatim by a third party transcription company, and checked for accuracy by BH. No new themes emerged from the later interviews and focus groups at which point data saturation was reached and data sampling was considered complete .Interview and focus group participants were also asked to complete a questionnaire that gathered details about work experience and their role, and half of the participants completed this questionnaire. Characteristics are summarised in Table Inductive thematic analysis was conducted based on Braun and Clarke’s (2006) methodology for thematic analysis . NVivo sA subset of the data (one focus group and two interviews) were analysed by a second researcher (MH) who is an experienced qualitative researcher. The analysis was discussed and the researchers agreed on emerging themes prior to developing a thematic framework. The framework Fig.  was thenThirty one school nurses participated from four English NHS Trusts Table . Half ofSix overarching themes emerged from the data. Four themes directly related to the school nurse role: the main roles of a school nurse, school nurses' role in health education, prioritisation of workload and activities, and community work. A further two other themes related to the delivery of health education, and included the school nursing system and educational resources.School nurses in this study described their work to improve the health of children, young people, families and the community. This included understanding community needs through a local or school health needs assessment, or public health profile; caring for anyone aged 0 to 19 years, though usually 5 to 19 years, regardless of whether they are in school and leading in the delivery of the Healthy Child Programme . School ‘stretched’, and reported being over burdened with work and under resourced. School nurses in this study found it difficult to fit in all they were commissioned to do. At the time of this study, in 2014, safeguarding or child protection , we do the School Nursing degree, so our view is very much public health and preventative and not just treating the outcomes.” SN1, Urban, InterviewSchool nurses described that they advised and supported schools with their PSHE education. Some participants, usually school nurse assistants, delivered health education sessions such as assemblies or classroom talks. School nurses signpost schools to resources and services, including specialists such as anaphylaxis or asthma lead, or diabetic nurses. Other aspects of the school nurse role that were identified in this research included running clinics, conducting drop-in sessions, making and responding to referrals, delivering immunisation sessions, supporting students with sexual health needs, conducting health screening sessions including the National Child Measurement Programme , support“We can advise, and we liaise and support, but we don’t actually carry out the teaching”. SN1, Rural, Interview“That used to be quite a big part of our role, we’d go in and do, yeah lots of health promotion work. But now we don’t have teaching time with anybody at all.” SN1, Rural, Interview“We tend to do, in the high schools and the upper school and colleges, health events rather than…going into the classroom.” SN7, Rural, Focus Group“I think it [health promotion] is very important for them, we’re lucky, I can’t speak for all schools but I know for the schools we have they value what we do in terms of health promotion because sometimes teachers may feel that … they don’t feel confident in that.” SN1, Urban, InterviewParticipants identified that they have historically played a major role in the delivery of health education in schools, but now the schools themselves are primarily responsible for delivering health education. Some described their main role in health education as supporting teachers, rather than delivering education themselves. School nurses reported delivering education on a range of topics including hygiene, sexual health, mental health and healthy eating in a range of formats such as assemblies and health fairs. Often the amount of health education that school nurses identified they are involved in is based on other commitments and how much capacity they have at certain times. However, school nurses describe that they are always educating, promoting health and sharing key health messages opportunistically.School nurses reported that they prioritised their work according to the needs of the young people in their communities. Nurses collaborated with schools to negotiate priorities and develop a school health profile. Some school nurses described that they linked priorities to the broader public health outcomes that contribute to overall public health.School nurses prioritised tasks daily as they had a very diverse role, were short staffed and their time was limited. A priority for school nurses is supporting schools, especially with the delivery of health education and signposting resources.“It also depends on the local need; you’ve got to understand your population, what are the issues, what are the public health issues for your area? … One area maybe dental care is an issue, another area maybe it’s not an issue, so you can’t actually put a blanket service for everything because each area and population is different, so it’s got to tailor to the public [in that area]”. SN8, Rural, Focus Group“I think basically we have to prioritise to meet the needs of the young people, so no, depending on how many referrals we get. Safeguarding of course is number one on our priority list, then once we prioritise we see the young people.” SN2, Rural, Focus Group“I think that’s [public health topics] important… especially how germs are spread and colds and flu and it’s very important. “SNA2, Rural, Interview“I think they [public health topics] are essential. I think it’s very important that the message gets across and hopefully for the children then to take it back to the parents”.SNA1, Rural, InterviewParticipants reported that priority health education topics included hand hygiene, tooth decay and oral health, sexual health, smoking, mental health, obesity and healthy eating. Some were seasonal, for example hand hygiene was reported as a key priority in the autumn when flu, coughs and colds are widespread.‘multi-agency work’ and referring children, young people and families to appropriate services and community support . School nurses described that they managed stakeholder relationships, supported parents, liaised with schools and maintained good relationships with teachers. Some school nurses indicated that certain schools require nurses to accommodate and be flexible towards the school regarding health education, for example meeting the time and subject requests from schools for health education talks. School nurses in this study identified that good relationships with schools were essential to allow them to access students more easily, as nurses experience barriers when trying to offer school health services. Barriers mentioned included schools prioritising academic lessons or examinations over health services being offered, teachers not having time or interest, and schools not prioritising certain health issues .“Sometimes you find that schools often gate keep and don’t want you to get involved”. SN1, Rural, Focus Group“Yeah, yeah. It’s working in partnership really, multiagency working, all the different agencies together to support the family.” SNA1, Rural, Interview“I think they [schools] always welcome somebody from the outside to come in and deliver [health] messages like that.” SN1, Rural, Interview“I think that’s what’s changed…15 years ago…everybody went in and taught contraception, or, or went and taught puberty, or whatever the school identified what they needed. Whereas now we’re looking at the health needs of the local community, looking at that, school as a community and actually the wider community as well, as a whole.” SN8, Rural, Focus GroupSchool nurses reported undertaking School nurses identified changes to their role that have taken place in recent years, including changes in team structure, priorities and commissioning. Commissioning is constantly changing, and nurses are only commissioned to offer certain services.“I think we’re under resourced, I think that’s always been that, hasn’t it?” SN, Rural, Focus Group“Some things we’re commissioned for, some …things like sexual health, like puberty we’re not really [commissioned to do], we can’t support schools with puberty. We can support the teacher and give a little bit of answering questions but we can’t really take the class for puberty [talks]”. SNA2, Rural, Interview“And I think the big challenge is that we’ve been commissioned to provide what’s in that service specification, and it’s that we deliver that and we don’t go delivering things because nobody else is out there to do it, and I think that is a big challenge, because I think you do get pulled in to lots of different things, but it’s making sure that we’re focussed on what we should be doing.”SN1, Urban, InterviewSchool nurses also identified many challenges they face such as lack of time, lack of capacity, technological barriers and financial barriers. Many nurses involved in this research reported that they could offer a better service if they had more resources in terms of funding, materials and human resources. However, nurses believe they deal with challenges proactively and are very valuable.“As I said at the meeting really, we’re very good at making our own resources up. Like the healthy lunchbox, I’ve made myself a healthy and an unhealthy lunchbox up. And we do have books we can get from the British Heart Foundation, places like that, but often it’s collecting bottles of drinks and then putting on how much sugar would be in there. So it is…very much about making our own resources.”SNA1, Rural, Interview“Having a resource where the lesson plan is written out clearly…is good because you need something that is structured, because you’re talking in front of groups of people. With children in school … you need to ensure there’s an aim, there’s an objective, that there’s an evaluation in place at the end of the lesson. So you need something structured and you need the correct resources as well, so that is very important.”SN1, Urban, Interview“Even if we’re not actually delivering, using the resource [e-Bug] ourselves, we’d want to be able to, we could be promoters [of them].”SN, Rural, Focus Group“Probably just support really, and knowing that, even if they were delivering the message, that they’ve got resources they can call upon or people they can call upon, and somewhere that they can actually turn to … if they need that bit of extra support or extra guidance.”SNA1, Urban, InterviewSchool nurses indicated that they are short on educational resources, finances to access resources, and human resources to deliver education. Some school nurses stated they use old or outdated resources, make do with what resources they have, and that they borrow resources from other health professionals . Many nurses mentioned a resource library where they used to access resources, however many of these libraries do not exist anymore . Most school nurses identified that they make their own resources and tools for teaching. School nurses stated that they are in need of health education resources like the e-Bug resources developed by Public Health England, and some described the need for standardised resources among teams or regions.This research identified that the role of the school nurse in England is very diverse. School nurses’ role in health education has shifted over time from directly delivering health education to advising and supporting schools with health education, as well as signposting resources to teachers. School nurses described that they are in a unique position to have a direct impact on the health and wellbeing of children, young people and their families.As indicated in other previous research , we foun‘stretched’ as a profession. Increased time pressures on school nurses are influencing their capacity to directly deliver health education [In 2013 the Department of Health identified that there were only 1,200 qualified school nurses in England . In 2012ducation . This reThe ‘Our School Nurse’ report by the British Youth Council  outlinesThe aim of our research was to identify the school nurse role related to health education in order to better support school nurses, for example by developing tailored educational resources around hygiene and infections. Results show that most school nurses are involved in health education to some degree, whether in a supportive, advisory or signposting role or through directly delivering education. Our research indicates that the amount of health education that school nurses deliver is determined by local priorities and capacity of the school nurse team. Further research could identify the priorities of each locality in England in order to determine the capacity in which school nurses can focus their time on health education.Through this research, school nurses identified that they are in need of health educational resources to assist in their work. These resources could either be used by school nurses, school nurse assistants, or they could be signposted to schools and teachers by the school nursing teams. Priority resources needed for school nurses include hand hygiene, oral health and sexual health which are currently freely available via the European project e-Bug operated by Public Health England , 25. ResA strength of the study was the use of qualitative methods of enquiry to enable comprehensive consideration of the role of the school nurse in the delivery of health education. This study used qualitative methods, interviews and focus groups, which brought synergism, snowballing of ideas and stimulation of participants. However, the convenient nature of the sample could limit transferability of the findings. The topic guide ensured that interviews and focus groups covered similar subjects, and all research was conducted by one researcher (BH) with a background in nursing. This study involved a wide range of school nurses from different educational settings and locations. Data analysis was robust with double coding by an experienced second researcher on a subset of the data, which enhanced the trustworthiness of the findings. In addition, results from our questionnaire Table  indicateThe findings provide a range of opinions from a diverse group of school nurses, and provide insight into the varied role of the school nurse in England. This work assists in clarifying the role of the school nurse, by those who undertake the role, especially related to health education and promotion.The role of the school nurse in England is very diverse and their role in health education is primarily to advise and support schools, rather than to directly deliver health education. The study identified that school nurses can be better supported by having educational resources available to signpost to, enabling school nurses to dedicate more time to their other responsibilities. Addressing understaffing issues would also assist school nurses in their diverse role.


The process of giving birth is very stressing for the mother. Meanwhile, maternity ward staff’s lack of awareness of mothers’ fears make mothers feel lonely and helpless. This study aimed to explore women’s perceptions of labor support during vaginal delivery.This exploratory qualitative study used qualitative content analysis to explore Iranian mothers’ experiences of labor support. Data were collected using observations and semi-structured interviews with 25 individuals. The participants were recruited through a purposive sampling method.Three categories, including “involvement of the spouse in the labor process”, “asking for a companion during labor”, and “mother’s self-care to cope with labor pain”, emerged during data analysis. These categories were merged to form the main theme of “trying to comply with the labor process”.Women believed that the presence of a companion, e.g. their husband, a family member, or a doula, during labor helped them better deal with the labor process, particularly when they felt lonely. Health care providers are expected to consider the needs of mothers and try to provide holistic support for mothers during labor pain.It seems that some mothers adopted particular coping strategies without receiving any relevant training. It is noteworthy that although mothers may make every effort to minimize their pain, health professionals should also practice medical approaches to help them through the process of labor. Childbirth is a unique complex, multidimensional, mental-cognitive experience and a major crisis in a woman’s life , 2. It hFollowing the changes in treatment approaches and family structure and the reduction in the admission time during the recent years, focus on supporting mothers during pregnancy, labor, and breastfeeding has increased . During Support has numerous effects which can be explained through two well-known models. According to Hoff Meyer (1991), two hypotheses, namely the buffer model and the main effect model, can describe continuous support –10. The Studies have confirmed the beneficial effects of support provided by the midwife and caregiver , 12–16. This exploratory qualitative study aimed to explore Iranian mothers’ experiences of labor and labor support.This study was a part of a doctoral dissertation which used qualitative content analysis to explore the process of Iranian mothers’ support. Content analysis is a systematic approach which provides new knowledge and insight into a particular phenomenon. It leads to valid inferences from data and is suitable for examining the experiences and views of people towards the issue of interest –23. IranPurposive sampling continued until data saturation occurred. In order to ensure maximum variation, we tried to select the participants who had maximum diversity in terms of age, education, work experience, and social class and were able to provide the greatest amount of information regarding support in labor and delivery rooms "The sample size was increased to eliminate the possibility of fake saturation , 25. TheThe interviews were recorded using a digital recorder and transcribed verbatim shortly afterward. The participants were then provided with the transcripts and asked to confirm their accuracy. Field notes were taken before, during, and after the interviews in order to record the details of the interview context. Moreover, since observation is appropriate as a complementary method to collect data and explain the behaviors, the first researcher collected data through observation by spending 50 hours in the labor environment .SimultanA variety of methods were used throughout the study to ensure the trustworthiness of the collected data. In order to verify the credibility of the data and codes, member check was performed to see if the extracted codes matched the participants’ views. For this purpose, the participants were provided with five drafts of the interviews and asked to verify if the researchers had actually presented their real perceptions and experiences. Moreover, peer debriefing was used to ensure credibility, i.e. the extracted codes and categories were reviewed by two expert supervisors and two PhD students. Moreover, allocation of sufficient time to the interviews, transcription of interviews immediately after their conduct, and simultaneous data collection and analysis enhanced the credibility of data. Furthermore, immersion, prolonged engagement in data collection and analysis, and providing field notes helped the trustworthiness of data.The study was approved by the Ethics Committee of Mashhad University of Medical Science  in 2014. Official permissions were also obtained from relevant authorities before entering the fields of study for both observation and interview. Moreover, all the participants signed an informed consent form after they had been provided with details on the study objectives and ensured about not only data confidentiality and anonymity, but also their right to withdraw from the study at any time (without their decision affecting their course of treatment).Overall, 1680 codes were extracted from the interviews (70–195 codes from each interview). After eliminating redundant codes, the number of codes was reduced to 1200. Afterward, similar codes were merged into primary categories which were then abstracted to three main categories including “involvement of the spouse in the labor process”, “asking for a birth companion during labor”, and “mother's self-care to cope with labor pain”. These categories formed the main theme of “trying to comply with the labor process” .The presence of husbands during childbirth is accepted throughout the world. The involvement of the spouse during labor not only exerts some medical effects , but also promotes responsible parenthood and father-child bonding.Women in this study believed that their spouses could play a major role in reducing labor pain. Meanwhile, based on their characteristics, the spouses showed different reactions toward the stress they encountered. They even expressed feelings that they had never experienced.He (my husband) was very encouraging and gave me a special energy. He was joking around a lot. He said it was nothing and it would pass, God willing. He said that the second and third deliveries would be easier!”, recalled participants #12 (a 25-year-old housewife who had recently given birth).“Women are sensitive to any acts and words from their spouses. Therefore, any satisfying actions from the spouse’s side will have a positive effect on women. When experiencing labor pain, women need to receive emotional support through hear empowering words and being touched and kissed.“… He told me that he loved me so much because I was going through all that pain because of him. It was enough for me that he was holding my hand. He was telling me about the good days that we had together…”, recalled participant #11 (a 23-year-old housewife who had given birth to her second child three years before the study).Accompanying their wives through labor pain was a very distressing experience for men and evoked negatives emotions (such as fear of unknown consequences) among some fathers.“At first, he was stressed, but it was too short because he was frightened, too. When we were leaving, he told me not to panic. He really made me calm.”, said participant #16 (a 33-year-old woman).My husband was stressed when he realized that I was going to give birth. I’m usually very quiet when I am in pain. I didn’t say anything because I saw he was stressed.”, reported participant #17 (a 23-year-old housewife).“According to the participants, although maternity wards did not allow a companion in the delivery room, the presence of women’s husbands or mothers in the waiting room or being allowed to make a short contact with them could give women comfort and reassurance and made them feel loved.During my first delivery, my father, my father-in-law, my mother, my sister-in-law, and everybody were praying for me behind the door of the delivery room. This makes you calm and relaxed, you know, when you think that there are people there for you. When you go in there , you feel very lonely, but when you hear them, it gives you a wonderful feeling.”, commented participant #12 (a 25-year-old woman with a history of two deliveries).“Interestingly, the participants were not willing to have their mothers accompany them in the delivery room as they thought that their mothers would be so stressed seeing them suffering from labor pain.“I wanted my husband to be with me, because I knew that my mother would get anxious and suffer even more than me. I didn’t want her to be there at that moment, because I knew that she would panic.”, said participant #1 .All I worried about was that nobody was there for me. I mean all of it, that loneliness, it was very depressing! Although there was another patient in my room and I wasn’t alone in the room, I felt like there was nobody there! I had a very bad feeling. But I’m happy because of the moment of birth. I think that a baby is a fruit of love, the result of passion. I really wanted my husband to be there when I got out of that delivery room, but he wasn’t.”, mentioned participant #18 .“Such feelings of the participants were also confirmed by their mothers. In fact, the relatives present in the waiting room expressed overwhelming feelings. The mother of a participant (a 55-years-old retired teacher), who seemed very anxious when they brought her daughter to a private hospital for vaginal delivery, said:“I think, you know, someone who is going to give birth is so stressed herself and the other person who accompanies her is stressed, too. So I 'm afraid that my daughter gets more anxious when she sees my anxiety.” (participant #19).This scenario was a little different for husbands. Since they saw themselves supportive of their wives, they decided to return their wives’ kindness by acting like them during labor.“When I am upset about something, she usually puts her head on my shoulder and then I feel relaxed. I suppose that if I could be with her at these moments, it would be good for her. It would make her feel that somebody was supporting her and help her better manage her stress….”, stated participant #6 (a 35-year-old husband).The self-care and self-learning practiced by mothers during labor originated from their previous experiences or any information they obtained through regular trainings. In their attempts to cope with labor pain, our participants tried to adopt various strategies such as distracting themselves from labor pain, being prepared for the following contraction, measuring the duration of pain, using relaxation techniques during contractions, and believing in the superiority of the divine power over human abilities.Honestly, when I arrived at the hospital, I knew that I had a tough job ahead. So, I tried to be calm and manage my stress. I kept telling myself that I had to pass this stage and that I had to do my best to overcome the difficulty of labor.”, recalled participant #17 (a 23 year-old housewife who had just given birth to her first child).“It gives you a good feeling to talk to your baby when you’ve got pain. I suppose there is more pressure on my baby than me, because he moves in all directions in that small uterus. He is under more pressure, I think. So, I was more concerned about my baby than about myself. Another thing is that I counted my contractions as if I liked them.”, said participant #11 (a 23-year-old woman) when she was discussing her method of dealing with labor pain.“However, in some cases, the pain became dominant and the mothers’ strategies were not effective. The mothers tried to find somebody to comfort or encourage them.I always thought that I had to go through all these alone and that nobody would be there for me. This made me very upset. I thought that neither my mother nor my husband was allowed to be there. I wished that at least someone was there to understand what I said, to listen to me and to hear my groans, to understand me and reassure me that it was going to be over soon. I was looking for these words! These things could highly affect my confidence.”, declared participant #12 (a 25-year-old woman) about her need for a supportive and reassuring companion during labor.“Another issue expressed by the mothers was their understanding of the achievements of labor and their expression of feelings at the moment of birth. Almost all mothers who gave birth through vaginal delivery expressed their feelings of pride and satisfaction. Although some participants had unpleasant feelings and experiences during labor, they were generally satisfied with their ability to do a great job.“I was happy. I was happy that I became a mother even though I knew it was a difficult responsibility. My baby was born. I was very happy. Everything seemed to be perfect and excellent. No problem came to my mind at that moment or maybe I’ve just forgotten my thoughts.”, said participant #17 (a 23-year-old housewife).As another strategy to deal with labor pain, mothers tried to concentrate on their babies and giving them their maternal love.“But I’m happy because of the moment of birth. I think that a baby is a fruit of love and the result of passion. I really wanted my husband to be there when I got out of that delivery room…”, stated participant #18 (a 34-year-old primiparous woman).When mothers’ strategies did not work due to the severity of pain, our participants sought a comforting and encouraging person.“I had always thought that I have to go through all these alone and nobody would be there for me. This made me very sad. I was looking for someone to tell me that it was nothing and that it would be over! These things could highly affect my confidence.”, recalled participant #12 (a 25-year-old mother).This exploratory qualitative study aimed to investigate mothers’ experiences of labor support. Three main categories, including the “involvement of the spouse in the labor process”, “asking for a companion during labor”, “mother’s self-care to cope with labor pain”, emerged during data analysis. These categories were then combined into a main theme: “trying to comply with the labor process”.When a woman goes through labor pain, her husband can provide her with great support by discussing his feelings. Kharesheh et al. (2010) compared women who received support from their relatives during labor with a control group . Although the length of labor was similar in the two groups, those supported by their family needed lower amounts of analgesics and had a more pleasant experience during labor . In a clIn this study, the husbands used calming and encouraging words and behaviors to help their wives relax during labor. Similarly, in their study of women’s approaches toward labor pain management, Klomp et al. (2014) identified three main themes, including preparation, support, and decision-making and control. Their participants highlighted the significance of the presence and support of their husbands, family members, or friends during labor. In fact, even if they did not talk, their presence helped mothers relax and regain their calmness. mothers could better deal with labor pain in the presences of their husbands or family members, and of course a professional health care provider ,35.Bäckström and Wahn (2011) performed a content analysis and emphasized the role of environmental conditions of the labor ward on fathers’ willingness to be engaged in the process of labor . Such en“Asking for a companion during labor” emerged as the second category in this study. Based on the World Health Organization’s recommendations, midwives should facilitate the presence of a companion during labor. However, it is important for the mothers to trust these companions and feel comfortable around them. Therefore, husbands, friends, and relatives are good choices . In IranDiniz et al. (2014) emphasized the role of companions in preventing negative feelings in women and suggested that companionship during childbirth had to be accepted as a new policy in developing countries . AlthougThe findings of this study showed that mothers employed coping strategies like self-care and self-learning to deal with labor pain. Their practical strategies often originated from the maternal instinct or their previous experiences. Escott et al. (2004) explained that mothers used breathing and relaxation techniques and counted the duration of pain in order to cope with labor pain. Most women learned these strategies from their previous experiences . LikewisWhile our participants had not received any training, they had developed employed some self- care strategies, such as talking to their baby, to cope with labor pain. Likewise, Escott et al. (2011) reported that in order to relax and reduce pain, mothers tried to talk to their babies during the pain. In addition, our participants considered labor pain to be purposeful, i.e. it led to the birth of the baby and development of a sense of motherhood. Therefore, they coped with it and described it as pleasant and enjoyable. Mothers in this study also used adaptation and using positive words and thoughts as other strategies to deal with pain. Moreover, they really longed to enjoy the presence of an encouraging person during labor. Similar findings were reported by Escott et al. ,32.Whitburn et al. (2014) indicated that mothers overcame their fears by mentally accepting the pain and preparing themselves for the next contraction. They concluded that women’s use of their own experiences of labor pain had an important role in their understanding of pain and led to better pain management . Lally eWomen apply various strategies to cope with labor pain. Since they felt lonely in the delivery room, they were eager to have a companion during labor. However, despite the significant role of spouses, they were not allowed in the delivery room. Therefore, women had to develop strategies, some of which they had not learned before, to deal with labor pain. It is noteworthy that although mothers may make every effort to minimize their pain, health professionals should also practice medical approaches to help them through the process of labor. Moreover, the critical role of the husbands in calming women should be considered by the labor team, particularly midwives. Finally, health policymakers are expected to pay more attention to this issue and provide holistic support for mothers during labor pain.This paper gives a deep insight about labor support in Iran’s clinical settings which is presented for the first time. It can promote a new vision for health care professionals and midwives to get familiar with basic preferences and needs of women in labor. Furthermore, it can provide a new chance for Iranian men to get more involved during labor and normal delivery. Also, it has developed a framework for some quantitative and qualitative studies that enrich our findings and contributes to knowledge.