In recent years, many studies focused on the description and comparison of large sets of related bacteriophage genomes. Due to the peculiar mosaic structure of these genomes, few informative approaches for comparing whole genomes exist: dot plots diagrams give a mostly qualitative assessment of the similarity/dissimilarity between two or more genomes, and clustering techniques are used to classify genomes. Multiple alignments are conspicuously absent from this scene. Indeed, whole genome aligners interpret lack of similarity between sequences as an indication of rearrangements, insertions, or losses. This behavior makes them ill-prepared to align bacteriophage genomes, where even closely related strains can accomplish the same biological function with highly dissimilar sequences.Staphylococcus aureus and Mycobacterium bacteriophages, involving up to 29 genomes. Using these datasets, we prove that Alpha alignments are at least as good as those computed by standard aligners. Comparison with the progressiveMauve aligner – which implements a partial order strategy, but whose alignments are linearized – shows a greatly improved interactive graphic display, while avoiding misalignments.In this paper, we propose a multiple alignment strategy that exploits functional collinearity shared by related strains of bacteriophages, and uses partial orders to capture mosaicism of sets of genomes. As classical alignments do, the computed alignments can be used to predict that genes have the same biological function, even in the absence of detectable similarity. The Alpha aligner implements these ideas in visual interactive displays, and is used to compute several examples of alignments of Multiple alignments of whole bacteriophage genomes work, and will become an important conceptual and visual tool in comparative genomics of sets of related strains.https://bitbucket.org/thekswenson/alpha).A python implementation of Alpha, along with installation instructions for Ubuntu and OSX, is available on bitbucket (The online version of this article (doi:10.1186/s12859-015-0869-5) contains supplementary material, which is available to authorized users. The most abundant, and probably the most diverse, biological entities are bacteriophages, the viruses that infect bacteria. Helped by recent advances in sequencing, comparative studies –3 use doIn order to explore the relations between bacteriophages in the same cluster, it seems natural to turn to whole genome multiple alignments. One of the main features of whole genome aligners is that they take into account genome rearrangement events that scramble the order of large segments of chromosomes , the first aligner specifically designed for whole bacteriophage genomes. With the help of partial order structures, Alpha captures the unique mosaic structure of bacteriophage genomes, and provides an interactive graphical interface with the generated multiple alignment. We also give a detailed comparison between Alpha and progressiveMauve ,H[u..v]}, where s and u are the start positions of the match in the respective genomes, and t−s=v−u; it asserts the equalities G[s]=H[u],…,G[t]=H[v].A We next formalize the notion of homologous positions, defining what constitutes a ‘column’ of a multiple alignment, along the lines of J. Kececioglu’s original paper .pij denote position j of genome Gi. Two positions pij and pkl are equivalent if there is a match in Gi[j]=Gk[l], or if there is a sequence of matches that links Gi[j] to Gk[l] through a sequence of such assertions. The equivalence class of pij is denoted ⟦pij⟧, and we will refer to it as a column. The support of a column sp⟦pij⟧ is the set of genomes that have a position in the column ⟦pij⟧.Let anchor that is used in WGA, which corresponds to columns whose support is equal to Note that there is no requirement that a column span the complete set column graph is obtained by linking the different columns according to their order in each genome. Formally, it is the directed (multi)graph whose vertices are the columns ⟦pij⟧, and there are edges from ⟦pij⟧ to ⟦pkl⟧ for all genomes Gg that have positions pgs in ⟦pij⟧ and pg(s+1) in ⟦pkl⟧. An example of the construction is given in Fig. The functionally collinear with respect toLet In most WGA systems, collinearity is meant to represent sequences that ‘align well’. Classical collinearity is broken by pairs of dissimilar sequences, and is an indication of gene rearrangements, gains or losses, in most higher organisms. Functional collinearity, on the other hand, excludes rearrangements, but allows dissimilar sequences to be compared. Interestingly, both concepts have the same formal definition, but the use of the column graph is quite different from one application to the other.A necessary condition for a column graph to be functionally collinear is that each column have at most one position in a given genome, since the presence of two or more positions would generate a cycle. We have therefore the following definition:valid if, for each column ⟦pij⟧, both ⟦pij⟧ and sp⟦pij⟧ have the same number of elements.A set The most likely sources of invalid sets of matches are duplicated segments, and tandem repeats with a variable number of repeats, which may cause overlapping matches. Most WGA deal with these invalid matches by eliminating matches that are not unique in a genome, and by trimming overlapping matches that result from tandem repeats. Given the simple data structure that we use for the alignment graph – equivalence classes – we eliminate duplicated segments, and trim overlapping matches by post-processing the columns: any column that has more than one position for a genome is split into singletons.m for matches. In the m is set, and how it can be changed.Allowing the length of matches to be very small may cause misalignments, and may also create cycles in the column graph, due to random small transpositions. It is therefore wise to have a minimal length alignment graph, in which consecutive vertices with the same support are merged, as in Fig. When the column graph has no cycles, we use a condensed version, called the m. The parameter m is normally chosen as the minimum length such that there is no cycle in the graph. It is set by default at 15, but can be changed to any desired value. Large values of m are sometimes useful in initial explorations of a set of bacteriophages and small values can be used to refine alignments.Given a set of genomes omeTools , a suffim, constructs the column graph, and the alignment graph when possible. After initializing the graph, it uses the Union-Find algorithm [Mℓ is the total length of matches, and α is the inverse of the Ackermann function [The main steps of the algorithm underlying Alpha are described in Algorithm 1. It takes as input a set of matches of minimum length lgorithm  to constfunction .n is the number of genomes, yielding a complexity of Nℓ is the total length of genomes. Note that at most Nℓ new classes can be created by the splitting process.The third step visits all classes, determining whether they are valid. For each class, this determination can be made in Nℓ. Assuming the genomes are collinear, consecutive columns with the same support are then merged to give the alignment graph.In the fourth step, edges between consecutive columns are added to the graph, and it is checked for the presence of cycles that would indicate non-collinearity. This can be done in time proportional to Mℓ and nNℓ vary greatly depending on the data.The total complexity is thus m remain unaligned. In order to increase the compactness of whole genome alignments, we contract the vertices further with the following requirement:The vertices of an alignment graph are exact alignments, since all rows are equal. Regions that do not contain exact matches of length at least U,V) is contractible if U precedes V in the partial order, U and V have the same support, the support of every vertex between U and V is included in sp(V), and the lengths, in base pairs, of all segments that span from U to V are the same.The pair of vertices . Myco6 contains bacteriophage genomes {U2, Alvin, DD5, BillKnuckles, Perseus, Dreamboat}, a subset of Myco29 chosen for diversity within cluster A1. Some of the mycobacteriophage genomes were trimmed in order to automatically run the experiments with small values of m; transpositions at the end of the sequences cause Alpha to increase the value of m . Given the overall poor performance of Muscle, we chose the rule of the majority. Finally, for Region 6, there was a tie between the four aligners, and there was no decision.m, the minimal length of exact matches: it does not rely on thresholds, and does not maximize any score. Instead, it relies on the transitive properties of the equality relation to provide reliable anchors, and on the unique constraint imposed on bacteriophages who, before traveling, must pack their whole genome in a small suitcase.As the results of Table In the preceding section, we showed that Alpha alignments are sound, in the sense that they predict biological meaningful similarities. The next question is to evaluate to what extent Alpha captures all meaningful similarities.In order to do this, we compared Alpha with progressiveMauve , since iComparing partial order alignments stemming from two different aligners turned out to be a daunting task: an alignment proposed by one aligner can be broken into several alignments by the other, since alignments may involve different subsets of the input genomes. The most practical approach was to compare only alignments that included all input genomes from both aligners.S. aureus phages {phiETA3, phiNM2, phiNM1, B236}, with default parameters for progressiveMauve, and interactively setting m between 13 and 21 for Alpha. All alignments from both aligners were identified by their phiETA3 start and end positions, and further refined by whether they were identified by Mauve only, Alpha only, or both. This produced 70 blocks, available in the Additional file We used a dataset of four All blocks predicted by both aligners were considered as valid alignments. Furthermore, short blocks (less than 100 bp) that were predicted by only one aligner – mostly by Mauve – were considered as valid: they averaged 24 bp. Three of the remaining large blocks – two predicted only by Mauve, and one only by Alpha – were validated using protein alignments. Figure Seven alignments predicted only by Mauve, totaling 2803 bp, were suspicious. They correspond to the yellow and red rectangles of Fig. Example of the non-homolog case. This is the block labeled ‘x’ in Fig. Example of the homolog case . Mauve aligns phage phiETA, 8704-9129, with phage phiNM2, 8046-8468. The nucleotide alignment has 7 gaps, of lengths 2, 2, 1, 1, 3, 4, and 4. The corresponding blastp 142 aa alignment of annotated proteins YP_001004347:1-142 and ABF73110:1-141 has 58/142(41 %) identities, 92/142(64 %) positives and 1 gap. This is a rather good alignment of two distant homologs, but the Mauve alignment does not reflect the conservation of the two proteins.When one excludes Mauve misalignments – that is, considering the green and blue rectangles of Fig. The high rate of Mauve misalignments on bacteriophage genomes is problematic. More than 20 % of Mauve column alignments on this dataset are either random, or belong to nucleotide alignments whose gaps contradicts the corresponding annotated proteins alignments. It should be noted, however, that the Mauve algorithm uses Muscle to produce alignments between its own anchors, and the way Muscle introduces gaps in nucleotide alignments does not seem to be appropriate for bacteriophage genomes, as we already saw in the preceding section on validating Alpha gapless alignments.Overall, Alpha’s alignment strategy captures the essential features of bacteriophage genomes. Regions that are similar are detected, while more dissimilar regions are not aggressively aligned. Being a conservative aligner, Alpha relies on functional collinearity to predict distant homologs that should be aligned using amino acids translations, such as the variants in columns 2 and 4 of Fig. Due to their peculiar mosaic structure where similar functions do not correspond to similar sequences, bacteriophage genomes are not well-suited to traditional whole genome alignment techniques. On the other hand, they exhibit features that can be leveraged to obtain alignments, most notably functional collinearity, a low duplication rate, and the presence of long shared sequences.In this paper, we presented a mathematical model based on partial order graphs for performing multiple alignment of bacteriophage whole genomes, along with algorithms to operate on the model. Relying exclusively on the equality relation, the model is almost parameter free, greatly reducing the need to calibrate the aligner, yet delivers biologically meaningful results. The model has been implemented in the form of an interactive aligner that can perform multiple alignments of dozens of genomes and present the result in an attractive format.We also showed that Alpha, used on bacteriophage genomes, produces biologically meaningful alignments, while avoiding the high rate of misalignments of complex heuristics such as progressiveMauve.Our model supposes that all genomes under consideration are functionally collinear. This is often the case, but not always. Our program can detect when this condition is not satisfied – indicating the presence of rearrangements – but does not perform the alignment in such a case. A short-term goal is to extend our mathematical model and aligner to deal with rearrangements.Some bacteriophage genomes present in the online databases are well annotated, other are less so. Another goal is to extend the aligner in order to perform automated transfer of annotations using the generated alignments.Finally, while we focussed this study on Siphoviridae, we plan to test Alpha on more general viruse families in which horizontal transfer is widespread, and for which the collinearity property may hold.https://bitbucket.org/thekswenson/alpha).The code, along with installation instructions for Ubuntu and OSX, is available on bitbucket (


The first book on pediatrics in the Western world was published in 1544 AD by Thomas Phaer (1510–1560) – a truly assiduous Renaissance man of sagacity – physician, lawyer, poet, philosopher, and father of English pediatrics , 3. Prio2 vitamin D . , 4. 2, 4itamin D . Ricketsitamin D . The tweitamin D –11.Modern science will continue its hunt for understanding of renal disorders by looking at twenty-first century progress in cell biology, epigenetics, metabolomics, proteomics, pharmacogenomics, other “omics,” integrins, inflammasomes, autophagy, stem cells, biomarkers, and other examples of Research and Development –20. At tSimultaneous cognizance of diabetes from Areteus of Capadocia (81–138 AD – “melting away of flesh into urine”) and renal physiology over the eons have lead to twentieth and now twenty-first century research on diabetic kidney disease that will advance . Cross-oContinuous ambulatory peritoneal dialysis (CAPD) in children was identified in the 1970s and 1980s; its usefulness will be studied further now and well into this century – in relation to such issues as risk  and automated peritoneal dialysis (APD) . ChallenResearch will also advance issues that initiated the field of pediatric nephrology in the latter half of the twentieth century – including improved diagnosis and management of acute kidney injury (AKI), polycystic kidney disease, vesicoureteral reflux (VUR), and the NS . For exaThe current and future shortage of pediatric nephrologists necessitates steady, rejuvenated information on the pediatric kidney for primary care clinicians as they care for the child and adolescent with renal and genitourinary dilemmas and disorders –30. As nIt is easy for a non-nephrologist to become lost in the complexities of renal physiology, diagnosis, and treatment – i.e., to miss the forest for the trees. In this expression, one can see so many trees but not understand they are part of a vast forest and fail to appreciate the forest itself.As the primary care clinician consider the many details of pediatric nephrology (the “trees”) one can fail to appreciate basic concepts that they can manage (the “forest”) – as for example – effectively managing potentially benign but common conditions, such as transient proteinuria, orthostatic proteinuria, and microscopic hematuria without proteinuria. If one appreciates that the majority of kidney disease in children relates to hypertension, the primary care physician (PCP) can be energized to persistently and carefully monitor the blood pressure of all of his/her pediatric patients. Early diagnosis of hypertension and careful management of all these patients with the help of consultants is a vital and rewarding task of primary care clinicians and will prevent much renal disease in these pediatric patients. Management of dehydration is also a critical role of clinicians . It is iI’m always astonished by a forest. It makes me realize that the fantasy of nature is much larger than my own fantasy. I still have things to learn.Gunter Grass (1927–2015).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


L’Âge d’Homme, Tom Clegg & Thierry Crouzet L’Âge d’Homme, CP 5076, 1002 Lausanne (Suisse) 5, rue Férou, 75006 Paris (France). The concept that a ‘tipping point’ occurs when a behaviour or cultural norm reaches a threshold when sufficient knowledge, information, expectation and/or peer pressure is amassed is beautifully illustrated in this book, which tells the story of Dr. Pittet’s hand hygiene journey. Malcolm Gladwell popularized this idea in his 2000 best seller, “The Tipping Point: How Little Things Can Make A Big Difference” . In his Research demonstrating the efficacy of alcohol hand hygiene has been published around the world, starting in the 1970s and continuing through today—examples are from the UK -6, CroatBut an important lesson for the scientific community is that conducting and publishing rigorous research is not sufficient for reaching that tipping point which results in changed behaviour and culture. The publication in 2002 of CDC’s hand hygiene guideline , for exaThis book describes in colourful and rather dramatic (even evangelistic) terms the unfolding and evolution of Dr. Pittet’s work and contributions. It is not, however, a book for scientists seeking factual data. Rather it is a saga of a charismatic and committed individual who was in the right place at a tipping point and had a prepared mind and the passion to help make hand hygiene globally accessible and demonstrate its impact.There are problems with the book. First, it contains a number of factual inaccuracies and slight misinterpretations, and, with the exception of the usual nod to Semmelweis, provides little historical perspective or knowledge of the field. Examples of some of the more egregious inaccuracies are below:http://www.jhpiego.org/content/jhpiego-history), published a manual which was widely circulated throughout many countries of the world, particularly in lesser developed regions, which not only recommended alcohol-based products for hand hygiene but also provided a ‘recipe’ for inexpensive local production [– Stating that “No one had thought of distributing it  widely in hospitals” (p. 65) when alcohol-based products were used in a number of countries, and implying that HUG was the first place to make an inexpensive alcohol-based sanitizer in-house. In fact, a number of individuals and groups of care providers were teaching health care providers in lesser developed countries how to prepare alcohol hand hygiene preparations in their own settings. For example, in 1992 Jhpeigo, a global non-profit organization established in 1974 .http://www.cdc.gov/nhsn/). Reporting of infection rates is now mandatory in many states, albeit specific requirements differ by state, and The Centers for Medicaid and Medicare Services no longer reimburse hospitals for several potentially preventable healthcare-associated infections. Surveillance has been the cornerstone of much of CDC’s infection prevention and control efforts since the 1970s and has been continuous since then.Contrary to this statement, the US was one of the first countries to initiate and continue a national infection surveillance system, originally called the National Nosocomial Infection Surveillance system and continuing to current times as the National Healthcare Safety Network  provides emotion-packed anecdotes about puerperal sepsis and Semmelweis’ struggles . And the dramatic description of a nurse in 1997 (!!) being booed and ridiculed by attendees at the French Society for Hospital Hygiene when she discussed using alcohol for hand hygiene is beyond belief to this US nurse researcher. The ‘Geneva model of hand hygiene’ was labeled ‘a consecration’, and Pittet’s work was likened to religious fervor and faith.The writing style is just a personal preference, however, because the book does a great job of telling a meaningful, important, and moving story. Clearly the primary audience of this book is the lay public and the story telling style was entertaining and colourful. Just don’t use it for fact-finding! There was indeed a body of work on alcohol-based hand hygiene before Dr. Pittet began his journey, but his amazing and distinctive accomplishment has been to serve as the tipping point to globalize the importance of hand hygiene, conceptualize the practice in ways that are universally meaningful and accessible, and demonstrate its value. As Crouzet states:“Making a gesture as simple as cleansing one’s hands into an historic innovation certainly requires a special kind of personality, a connection to people and to the most ordinary ideas, an open mind combined with an innate goodness” (p. 100).All in all, this book accomplishes the monumental and worthy task of telling the story of hand hygiene and its role in reducing morbidity and mortality through the tipping point work of a Dr. Pittet, a visionary scientist and tireless humanitarian.


Over recent years, researchers have found evidence which indicates that the prevalence of postpartum depressive symptoms crosses cultural boundaries and is reported to be at least as high in non-Western countries as in Western countries. However, qualitative studies about new mothers’ experiences from non-Western countries, such as Bangladesh, are rare, particularly in rural areas. This study aims to describe the experiences and concerns of rural Bangladeshi mothers with postpartum depressive symptoms. Open narrative interviews were conducted with 21 mothers with depressive symptoms 2–3 months postpartum, consecutively selected from a longitudinal study about prevalence and risk factors of perinatal depressive symptoms. Inductive content analysis was used to analyse data and three themes emerged: family dynamics, living at the limits of survival, and role of the cultural context after childbirth. These themes were based on six categories and 15 subcategories. The findings show that troublesome family relationships, including intimate partner violence and violence in the family, influenced the mothers’ mental well-being. They and their families lived at the limit of survival and the mothers expressed fear and worries about their insecure situation regarding economic difficulties and health problems. They felt sorry for being unable to give their infants a good start in life and sad because they could not always follow the traditional norms related to childbirth. Thus, it is important to focus on the depressive symptoms among new mothers and offer counselling to those showing depressive symptoms, as the cultural traditions do not always alleviate these symptoms in the changing Bangladeshi society today. Maternal depressive symptoms around childbirth have long been considered as culture-bound and rare or non-existing outside the Western cultures Cox, . DepressIn a systematic review by Gavin et al. , the comIn high-income countries, childbirth is rarely a life-threatening event any longer  in Bangladesh and the Regional Ethical Review Board at Karolinska Institutet, Stockholm, Sweden (Ref. no. 2008/919-31).M=6.2 months) were approached, informed, and agreed to participate.Participants for the study were selected from a sample of mothers identified as having depressive symptoms 2–3 months postpartum in the longitudinal study, that is, having a score of 10 or more on the Edinburgh Postnatal Depressive Scale  who is bilingual read all the interviews in Bangla and controlled the English translation against the Bangla version. In case of a discrepancy in the translation between Bangla and English, it was discussed between the two bilingual authors (ZKN and HEN).The data were analysed using inductive content analysis  read through the English translations of the interviews several times to obtain a sense of the whole. One bilingual researcher (ZKN) read all the interviews in Bangla and another (HEN) read half of the interviews. For each transcript, the first author (ME) identified the meaning units related to the aim, marked them, and condensed the meaning units. The condensed meaning units were then abstracted and labelled with a code according to Granehielm and Lundman .To increase the credibility of the analysis, a bilingual anthropologist and the first author (ME) independently coded four interviews in English. The coding schemes for these four interviews were compared and found mostly to be in agreement. The first author (ME) then coded the remaining transcripts, drawing upon additional codes where required from the data. The various codes were then compared based on differences and similarities and sorted into subcategories and categories, that is, the manifest content  family dynamics; 2) living at the limits of survival; and 3) role of the cultural context after childbirth. We present the findings according to these three themes, six categories and 15 subcategories .MEPDS=11.8, EPDS range: 10–14), and most of them (except two) also during the third trimester of the pregnancy , were interviewed  Kabir, , but mos32 years, 3-para). Those women who were living in polygamous marriages, that is, in the same household with the husband's other wife said that they always quarrelled, mostly about the children and particularly if the children suffered from illness and needed medicine. The mothers reported having a good relationship with their infant. They said they loved the baby and were happy irrespective of whether they had a son or a daughter. However, some mothers reported that their babies had sleeping problems and that the baby had been crying at night for 2–3 months. Other mothers reported eating problems and these mothers were very concerned about their infants’ low weight.Although most women reported supportive relationships with their husbands and in-laws, they admitted that they also had fights and quarrels in the family: “There is always a quarrel in a family when money is needed” . “He could slap me, but then he would go out and calm down” . However, the intimate partner violence could be worse and one woman, whose husband already had one wife, said: “He just beats me … ever since this woman (the first wife returned after husband's second marriage) came, he can't stand the sight of me” .The women reported on intimate partner violence and that they were sometimes beaten by their husbands. However, in most of these cases they did not feel so bad about it: “He becomes angry and beats me, but it is no big deal!” .Even if there was no intimate partner violence, several women reported problematic relationship and sometimes violence in the family and that they were scared of other family members. For one woman, the violence from in-laws during the pregnancy was so bad that it was reported to the police. This mother said: “I am scared of them (the parents-in-law), they look at me threateningly, and they want to pick issues. When they come home, I stay in my room and don't go out” . Another mother left her husband before the birth of her daughter, due to violence from both her husband and in-laws during her pregnancy because they wanted more money as a dowry.The mothers also reported conflicts about inheritance in the families. In one family, the mother said that there was quarrelling and fights between her and her brother-in-law after her father-in-law's death because she thought her “brother-in-law will swindle her husband … because he is not too sharp”  and “not too much and not too little” . These families had their own land for cultivation. Mostly, the women's husbands did farming on others’ lands and several families did not have any steady income due to the husbands’ unemployment, irregular employment, or poor health, which made the husbands unable to work full time. The mothers spoke a lot about financial worries and that the families “suffer hardships” and “live hand to mouth” .All the women reported that their families were poor and had a difficult economic situation, except for two women who said they “had enough to eat, but not to sell” . Another mother said, “I have a big sorrow in my heart … I cannot look after my baby the way I would like to. I can't feed him properly. I have such pain in my heart for this” .The majority of the women expressed that they did not have enough to eat. With a single income, which most of the families lived on, the mothers had difficulties in properly feeding all: “It is difficult to depend on one person only in such a big family” .Pregnancy and childbirth were very insecure periods for these poor women and were associated with risk for the woman's life. Several mothers said that they had fear of dying during the delivery, and expressed fear for what would happen with the children if they died: “Who will look after them, love them if my husband marries again?”  several years ago, which still affected their lives through the husbands’ decreased ability to work full time, needing expensive medicine, and visits to the hospital and doctors. Those women who had lost their parents during childhood felt insecure as they did not have parents to look after them. The parental family seemed to be a secure base for the women, whom they could call upon or go to when things became problematic in their new families.The mothers with depressive symptoms reported poor physical health after birth. They felt weak and had no physical strength which they explained through loss of blood during delivery or as lacking calcium and vitamins. They complained about multiple health problems, such as stomach pains, chest pains, headache, dizziness, low or high blood pressure, jaundice, urinary problems, gastric problems, a tumour in the throat, and having trouble walking after childbirth. The mothers reported that they had lost weight, became thin, and lacked an appetite, and they related their health problems to worries for the children, for financial issues, and for not being able to give the children enough food or to raise and bring them up properly.30 years, 7-para). Some mothers said they had problems concentrating, they can't remember anything, and they had problems working properly and felt mentally weak. One mother said: “I feel sad in my heart”  and another said: “I have mental anxiety and depression. My husband has another wife, they show love for each other which makes me unhappy” .About their own mental health, the mothers talked about worries and tension in their lives and that “things are running in their heads” and they “can't stop worrying about everything” . One infant was described by his mother as blind and not interested in other people. It was the mother's first child after a very complicated delivery and she felt very sad: “I am more worried now about the baby …. If my baby stays healthy, I will be in peace” .The majority of the mothers were worried and anxious for their infants’ health. The infants had been ill several times with fever, cough, measles, and dysentery. Several mothers reported that their infants have had pneumonia. The majority of the mothers expressed that their infants were very thin, had lost weight, and were less active, particularly after the breastfeeding stopped. One mother said, “I just look at how thin my baby is. I don't know what I am supposed to give her” .The women were well aware of the traditional customs around childbirth, but only a few mothers followed the custom of “giving birth in their father's house” to get support from her mother and female relatives. A majority of the women wanted to go to their parental home, but some of them preferred to give birth at their marital home, particularly if their biological mother was deceased. As reasons for not going to their parental homes, the women expressed that their husbands and in-laws did not allow them to go or because they did not want to leave for practical reasons, such as leaving the house empty, that the husbands had to work for an income and could not do all the household work himself or, as one woman said, he was “tired of cooking for himself” . Another mother said: “These rules, you know, we do not actually follow them anymore … but it is better to follow them, the baby stays healthier this way” . The mothers believed in the “evil eye” and that both they themselves and the baby could be jinxed. They said they were scared to go out in the evenings, fearing that something might happen to the infant.Traditional food restrictions were followed by a majority of the women but not all. One mother said: “They now say that you lose breast milk if you follow the diet, if I have fish and milk, then there will be plenty of breast milk” .The 24 years, 3-para).Those mothers who delivered their child at their parental house were satisfied with the support from their own families, particularly from their mothers and sisters. Even if they gave birth in their marital house, their own mothers and sisters seemed to be the greatest source of support, and also the mother-in-law and elder children helped. Husbands often did the heavier work and took care of the other children in the family. One mother said: “Everybody has to do their part” . These mothers felt helpless and bad for not having enough help, particularly when they had to start cooking for their family only 14–21 days after childbirth.A few mothers reported that they did not cook for 40 days, but most of them said that they started to do easy household work after 14 days, sometimes even after 7 days because there was no option. Some mothers said that their husbands did not help in the housework and one mother said: “My husband does not do women's work” , and if these mothers who wanted a boy instead had a girl, they admitted that they felt sad for having a girl. “Not disappointed. But I feel a little bad. Everybody wants a boy” . The mothers said that neighbours and relatives gossiped and criticized the mother if there were several girls in the family and they admitted that it hurt. “I feel a bit hurt when I hear their words” . The mothers did not feel criticized by their husbands, but in one family the husband talked about marrying again. This mother said: “If I had had a son this time, I wouldn't have any more sorrows” . However, if the mothers had sons earlier, they often wanted a girl because as one mother said, “you need both. A son alone cannot bring happiness, neither can a daughter” .Although the mothers often said that they did not have any preferences for the sex of the child, many of the mothers said that they wanted sons and one mother said: “A boy means peace in later life” (The mother's narratives included a lot of worries, anxiety and fear, mostly related to poverty and insecurity in their lives. Similar to Hanlon et al. , we founFischer, Tran, and Tran  did not Mothers in our study, who complained of physical and mental ill health after birth, also reported having negative experiences of pregnancy and child delivery. This finding was confirmed in a recently published quantitative study by Gausia et al. , who shoBeck  showed iIn a literature review, Fischer et al.  reportedBina  reportedDressler, Baliero, Ribeiro, and dos Santos  have devAs others (Fischer et al., Although we tried to control for error in the translation between Bangla and English, some misinterpretations might have taken place. All women had relatively low EPDS scores in our study, indicating low depressive symptoms. It may also be indicative that using an instrument developed in the Western world was not appropriate in identifying the most depressed women. However, EPDS has been validated in Bangladesh and we followed the cut off with the highest sensitivity and specificity (Gausia, Fisher, Algin, & Oosthuizen, Although the women in this study showed depressive symptoms as assessed by EPDS, they talked more about worries and anxiety than sadness and unhappiness. This may be explained by the women's insecure and vulnerable situation due to financial constraints, poor physical and mental health, and their experience of domestic violence. It indicates a need for protection by the community as they did not always trust their husbands or did not have their own parents for support. Our findings suggest that accessibility to trained midwives may alleviate insecurity and fear during the delivery. After childbirth, it is important to pay attention to anxiety and depressive symptoms among the new mothers. Those showing anxiety or depressive symptoms can be helped with counselling, as due to practical constraints, the cultural traditions do not necessarily alleviate depressive symptoms in the changing Bangladeshi society today.


People typically attribute more responsibility to those individuals who are infected with sexually transmitted diseases (STD) than other diseases. This study tested how different routes  of transmission have an impact on individuals’ general perception on stigma/shame and the attributions of responsibility, when controlling for symptoms/conditions of the hypothetical virus infection. Two hundreds and ninety eight college students were recruited for the study. As predicted, people who were attributed with control over contracting the virus  were likely to be assigned a greater level of personal responsibility and were more likely to receive blame from others than people who were attributed relatively less control over contracting the virus . The relationship between the attribution of responsibility and communication efficacy was also assessed. The results supported our prediction that there was a significant association between the attribution of responsibility and communication efficacy, in that the perceived controllability of the situation, perceived responsibility for the situation, and blame were all significantly correlated with communication efficacy in a negative direction. Practical applications by evaluating the effectiveness of the actual Merck’s Gardasil advertisement were discussed that the Gardasil advertisement appears to reduce the perceived shame and stigma associated with the sexually transmitted nature of the virus by not revealing the true nature of the virus upfront. STDs are problematic not only because they cause serious physical disabilities but also that they are closely associated with stigma . People The purpose of this study is twofold. First, we attempted to assess individuals’ general attitude about STDs. Specifically, this study examined how different routes of transmission has an impact on individuals’ general perceptions on stigma and its attributions of responsibility when controlling for symptoms/conditions of the disease. Second, this study tried to explain how attributions of responsibility predicted individual’s communication efficacy in terms of disclosing about the disease. Especially, the present study proposed a slight modification of Weiner’s decision-stage model  by testiStigma is a social construct that is shared by members of a society, which has an impact on personal and group interactions. It has been recognized by medical sociologists that various types of illnesses are associated with stigma. For instance, it has been frequently reported that individuals with HIV/AIDS have suffered from extreme stereotyping, associated with homosexuality or IV drug use . In termAccording to Stigma is intensified when the individuals who are infected are viewed as holding responsibility for the condition. When people make attributions of responsibility, they examine whether the disease carrier had control over the situation or not. When the public observe that infection of the disease was controllable by the individuals, in that, they knew about the potential outcomes of their own actions, then the public is more likely to hold the infected individuals responsible for their own illness , and in printed brochures for Gardasil, the only information regarding HPV tend to emphasize its 1) prevalence , and 2) involvement in the development of cervical cancer . The fact of the sexually transmitted nature of HPV is either not stated or is found in a small font on the back of the brochure. Perhaps it is a strategic move because concealing that HPV is a type of STD may have permitted people to talk freely about the disease without being afraid of becoming stigmatized by other people.Accordingly, the pharmaceutical company, Merck, hid the fact that HPV is a sexually transmitted virus in their ads for the HPV vaccine Gardasil, despite the American Cancer Society’s recommendation that health practitioners should educate people that HPV is a STD . For insThe current study proposed to examine if the phrase “sexually transmitted infection” has a significant effect on forming stigma. This study tested how different routes  of transmission has an impact on individuals’ general perception on stigma/shame and the attributions of responsibility , when controlling for symptoms/conditions of the hypothetical virus infection. Also, this study added one more condition, which is similar to Merck’s Gardasil advertisement. This condition contained the information that this hypothetical infection can develop into cancer, but the information regarding the route of transmission would not be revealed to participants. To this end, the first hypothesis stated:H1: Among the following three conditions , the sexually transmitted route will have the highest score for the perceived (1) controllability, (2) responsibility, (3) blame, (4) stigma, and (5) shame.In addition, this study examined the impact of the word “cancer” on individuals’ perceived health threat. According to Witte’s (1994) Extended Parallel Process Model (EPPM), people’s cognitive appraisal of health threat is an important factor to motivate people to do something about this health threat. When people are presented with a health risk , they initially consider two factors: susceptibility and severity of the threat. Susceptibility is defined as people’s subjective perception of the possibility that they will face this threat . Severity refers to subjective perceptions about the seriousness of the threat . Susceptibility combined with severity generally induces people’s perception of threat. It came to our attention that the most of HPV brochures appeared to emphasize its potential cause for the cervical cancer rather than its route of transmission. Frequently, cancer is referred to as the most feared of all illnesses; also cancer is so common that it actually accounts for one out of every four deaths in the United States. Considering Witte’s EPPM, it is somewhat plausible to heighten the fact about cancer in HPV brochure in order to create a substantial health threat for people. Thus, we proposed the following research question:RQ1: Among the following three conditions , will the participants in the “cancer” condition perceive higher health threat in terms of the perceived susceptibility and severity than the participants in the other two conditions?Once individuals realize that they are infected with STDs, they fear that they might be rejected by members of the community and more likely to isolate themselves from society. The anticipated shame or fear after being found out by the community lead the stigma-carrying individuals to engage in secrecy . AccordiSTD-infected women worried about telling their family members because of the stigma of a STD and its association with sexual promiscuity. The qualitative study conducted by Oftentimes, secrecy is closely related to communication efficacy. Stigma-carrying individuals might not want to reveal the information, but even though they want to reveal it to their close family members or friends, they simply cannot do it because they have low communication efficacy. Communication efficacy concerns individuals’ perceptions that they can successfully engage in the communication in order to gather information  or, in tConsidering the fact that high perceived stigma (such as STDs) are often associated with secrecy (H2: Among the following three conditions , the sexually transmitted route will have the lowest score for communication efficacy.RQ2: What are the reasons that prevent people from engaging in communication about the disease, and do these reasons vary in different conditions?SV-41) by sexual intercourse would be perceived to have had greater controllability of the situation, thus, be assigned more responsibility for the disease. This would lead to greater blame and, ultimately, to lower communication efficacy. The last hypothesis (H3) would test this sequence by proposing a path model.The current research was also designed to incorporate the impact of the attributions of responsibility with communication outcomes. Weiner’s (1995) decision-stage model holds that behavior is determined by a cognitive process: individuals make attributions about the cause and its controllability of a person’s illness, which lead to inferences about responsibility. These inferences lead to blame, which affects the likelihood of helping or punishing behaviors. In sum, the sequence of judgments is: causal controllability - responsibility - blame - behavioral response. The current study explicated this sequence by substituting behavior responses with a communication variable to examine how attributions of responsibility sequence have an impact on individuals’ communication efficacy in terms of disclosing the disease. Applying Weiner’s (1995) model in this study, we hypothesized that people who are attributed with control over contracting the disease are likely to be assigned greater levels of personal responsibility and would be more likely to receive blame from others. This process will have a significant impact on one’s communication efficacy. In other words, people who are infected with the hypothetical virus  individuals’ general attitudes on stigma and perceptions on attribution of responsibility  toward STDs and (2) the relationship between attribution of responsibility and individuals’ communication efficacy. The basic design for this study involved randomly presenting participants with one of three vignettes  regarding hypothetical virus infection and then asking them to respond to questions about the scenario.M = 23.79, SD = 5.60). More than half (65.8%) of all participants were Caucasians, 24.0% were African Americans, and 4.3% were Asians. Analyses revealed no significant differences across experimental groups on any of the pretest or demographic variables.Two hundred and ninety-eight students enrolled in an entry-level communication course at a Midwestern university earned course credits for participating in this online survey study. The participants were 82 males (27%) and 216 females (73%). Participants ranged in age from 18 years to 54 years  sexual intercourse or (2) food. The third scenario did not indicate the route of transmission, but it described a situation of being infected with (3) a virus that can develop into prostate cancer. This study used and modified a scenario which was originally created by To test the prediction that STDs are implied with more stigma, regardless of their symptoms/conditions, a scenario describing a hypothetical virus, the William is 22 years old, a typical college kid at a Midwestern university (where participants were attending to). He has lots of friends and everyone seems to like him. William is a pretty healthy individual who exercises regularly and tries not to eat much fast food. However, about a week ago, William began to feel a burning sensation when urinating. William also had intestinal symptoms, such as diarrhea and nausea. He decided to see his physician, Dr. Smith. After Dr. Smith ran some tests , William was told that he had tested positive for newly identified virus named “SV-41”. Dr. Smith told William that the SV-41 infection is known to be transmitted by sexual intercourse. Dr. Smith also mentioned that SV-41 is not a deadly virus, but there is no “cure” yet.SV-41 infection is known to be transmitted by eating food containing this virus.”) or omitted but stating it can be a potential cause of cancer . There were 95 participants in the “sexually transmitted route” condition, 95 participants in the “cancer” condition, and 108 participants in the “foodborne route” condition.The other scenarios had exactly the same information, but the route of transmission was either different  = .77, p = .44, and in the perceived severity, t (296) = .46, p = .65. Therefore, female participants as well as male participants perceived SV-41 to be equally susceptible and severe.Although the scenarios were using a male as a main character , no sex difference was found in the perceived susceptibility, In order to measure the attribution variables, the current study adopted a scale designed by The perceived stigma was measured by using Fortenberry et al.’s (2002) stigma scale. Their scale was originally developed to measure STD-related stigma, which reflected the participant’s expectation of isolation and adverse social outcome associated with STD, however, it was adapted to fit the purposes of the current study. This measure has six items using a 5-point Likert-type response format. The reported Cronbach’s alpha was .89.Items for perceived shame were developed for the current study. Participants responded on a 5-point Likert scale. It was originally a four item scale (α = .79), but one item was deleted in order to have a higher internal consistency (α = .92).Participants were asked four items, each concerning perceived susceptibility and severity on a 5-point Likert-type response format. The reported Cronbach’s alpha for the perceived susceptibility dimension was .80, and for the perceived severity was .85.SV-41 infection themselves. Participants were expected to answer whether they could communicate about their SV-41 infection with four different targets , in a yes/no format. As a filtered question, the reason was asked if they could not talk about SV-41 to a certain target person. If the participants currently did not have a partner or a roommate, the data was left as missing data. The score was added after data collection, and higher scores indicated more efficacy to talk about SV-41.Communication efficacy was measured by asking about their ability to tell other people if participants had the In order to assess the reason for not communicating about their hypothetical virus, the responses were content analyzed by the authors. Coders evaluated every response. Using Cohen’s kappa (κ) formula, the intercoder reliability was .92. After calculating the intercoder reliability, the few disagreements were resolved by follow-up discussion.SV-41 significantly affected the combined DVs, Wilks’ Λ .59, F  = 17.32, p < .001, partial 2η = .23.The first hypothesis predicted that participants would perceive a hypothetical person who was infected with virus in a sexually transmitted route as having the highest levels of the perceived (1) controllability, (2) responsibility, (3) blame, (4) stigma, and (5) shame. Due to the conceptually-related nature of the dependent variables, a one-way MANOVA was conducted to determine the effect of different transmission routes on participants’ general perceptions on stigma/shame and its attributions of responsibility. The MANOVA results indicated that the route of transmission of F  = 71.83, p < .001, partial 2η = .33. As expected, when controlling for the symptom/condition of the disease, the participants perceived a person who was infected through a sexually transmitted route as having significantly more control over the situation  than via foodborne  or no specification of the route but a possibility to develop into cancer . Interestingly, the mean difference between a foodborne and a possible cancer development condition was significant  that participants viewed that an infected person with a possible cancer development actually had more control over the situation.The data were further analyzed separately for the various dimensions of responsibility attributions. A univariate ANOVA was conducted as a follow-up test, and the results indicated that different transmission routes had a significant effect on controllability of the situation, F  = 69.13, p < .001, partial 2η = .32. The participants held significantly more responsibility to an infected person in the sexually transmitted route scenario  than in the foodborne route scenario  or cancer scenario . The mean difference between a foodborne and a cancer scenario was close to statistical significance, , but, again, participants held more responsibility for the infected person in a cancer development scenario than in a foodborne scenario.Regarding perceived responsibility, a similar pattern was found in that route of transmission had a significant effect, F  = 49.87, p < .001, partial 2η = .25. Participants who were in the sexually transmitted route scenario  blamed the infected person significantly more than participants either in the foodborne route scenario  or in the cancer development scenario . Again, the infected person in the cancer development scenario received significantly more blame than in a food borne scenario .As predicted, the significant main effect of transmission route was found in ratings for blame F  = 3.60, p < .05, partial 2η = .02, and as predicted, participants in the sexually transmitted route scenario perceived the infected person to have significantly higher stigma; however, a slightly different pattern was found in the perceived stigma in that no statistical difference was found between a sexually transmitted route  and a foodborne route . In addition, the difference between the foodborne route and cancer development  was not significant. The only statistical significance found was between a sexually transmitted route scenario and a possible cancer development scenario , which indicated that participants, indeed, associated significantly more stigma with the STD than with cancer.Statistical significance was found in the perceived stigma, F  = 23.22, p < .01, partial2η = .14. The mean pattern was in a predicted direction that participants perceived the highest shame in a sexually transmitted route scenario , followed by a cancer scenario , and a cancer development scenario , and the mean differences among these three conditions were all significant.Lastly, there was a statistical significance in terms of the perceived shame, F  = 5.68, p < .001, partial 2η = .04. A further univariate ANOVA result indicated that statistical significance was found in the perceived susceptibility, F  = 3.62, p < .05, partial 2η = .02, but it was mainly due to participants in a foodborne scenario who perceived themselves to be significantly more susceptible to the condition  than participants either in a cancer scenario  or in a sexually transmitted route scenario . In terms of the perceived severity, a univariate ANOVA revealed the statistical significance at p-level of .10, F  = 2.19, p = .06, partial 2η = .02; however, a somewhat different result was found in that participants perceived the sexually transmitted route  as having significantly higher severity than the foodborne route , but the difference between the sexually transmitted route scenario and the cancer development scenario  was not significant. This result indicated that the word “cancer” was not powerful enough to increase the perceived health threat.Research question 1 was proposed to assess the health threat, more specifically, whether the word “cancer” actually increased participants’ perceived susceptibility and severity of the disease. A one-way MANOVA result indicated the different condition had a significant impact on the perceived susceptibility and severity as a whole, Wilks’ Λ .93, F  = 4.65, p < .05, in that participants in a foodborne route condition indicated that they could communicate about SV-41 infection with significantly more number of people  than participants either in a cancer development condition  or in a sexually transmitted route ; however, the mean difference between the cancer development condition and the sexually transmitted condition was not statistically significant, which indicated that participants in both conditions had similar levels of communication efficacy.Hypothesis 2 predicted that the route of transmission would have a significant impact on participants’ communication efficacy. As predicted, hypothesis 2 received support, SV-41 infection.More specifically, 42% (40 of 95) of all participants in the sexually transmitted route scenario and 36% (34 of 95) of all participants in the cancer scenario felt that they could not (or did not want to) tell other people about their virus infection. Only 11% (12 of 108) of all participants in the foodborne scenario, however, felt that they could not engage in conversation about their As a follow-up question, research question 2 asked about the reasons that would prevent people from engaging in communication about the hypothetical virus infection and if these reasons varied in different conditions. In sexually transmission, 32.5% of the participants indicated that their lack of communication efficacy was rooted in fear of being stigmatized . Some of the participants described, “I think that they would think less of me. They would also feel that I let them down by being irresponsible” or “Because it is sexually transmitted, my family would look down upon me.” 20% of the participants indicated that it was too private to discuss with other people (including their family).In the cancer development scenario, among those of who decided not to tell other people about their virus infection, 23% of the participants stated that they were afraid of being stigmatized by others, and 32% of the participants stated that it was too private to discuss with other people. A few participants indicated that they were not close enough to talk about the infection with their family or roommates. Three participants (8%) indicated that they were not willing to engage in communication about the infection because they did not want others to be worried about them. A few participants wrote, “The reason I would not tell them is because I would not want them to be all worried about me” or “I wouldn’t want them to worry about a condition that has nothing to do with them. It’s one less thing for them to have going in their busy schedule.”Compared to the other two conditions, a quite different result was found in the foodborne scenario in that significantly less participants  worried about being stigmatized from the virus infection. 33% (4 of 12) of the participants would not communicate because they did not want others to worry about the infection. The underlying reason was slightly different from the cancer scenario, however, in that participants did not want others to worry about the infection being contagious.In order to further examine these data for a mediating relationship between attributions of responsibility sequence and communication efficacy, a path model was proposed (H3). In order to test the proposed model see , the ordParameter size was estimated for the path diagram by performing a simple regression of each endogenous variable onto its causal antecedent (See P (.69 ≤ ρ ≤ .79) = .95, indicating that controllability had a significant effect on responsibility. Responsibility, in turn, affected blame  = .95), such that the more responsibility an infected person is said to hold, the more blame they deserve to receive. Lastly, blame predicted communication efficacy  = .95), such that if individuals perceive more blame, their communication efficacy is decreased.From p < .05 when controlling for responsibility; the relationship between responsibility and communication efficacy (r = - .15) became r = - .06, n.s when controlling for blame.The discrepancies between predicted and obtained correlations for all unconstrained bivariate relationships in the model were also examined, and none differed substantially from what was expected from sampling error. In addition, using Baron and Kenny’s (1986) mediational analysis, the mediated relationships were tested. The results indicated that the relationship between controllability and blame (r = .74) dropped substantially to r = .28, 2 (3) = 5.72, p > .05. Given that the path coefficients were relatively large and that the model and parameter estimates accurately predicted the unconstrained correlations, the model and data were judged to be consistent with one another.The global test for goodness of fit indicated that the data were consistent with the model, χThe current study explored the mechanism of how individuals formed stigma associated diseases have different transmission routes and how the attributions of responsibility process had an impact on communication efficacy. As predicted, people attributed with greater control over contracting the virus  were likely to be assigned a greater level of personal responsibility and would be more likely to receive blame from others than people attributed with relatively less control over contracting the virus . This process of the attributions of responsibility had a significant impact on communication efficacy, in that the perceived controllability of the situation, perceived responsibility for the situation, and blame were all significantly correlated with communication efficacy in a negative direction.SV-41. Also, by using a hypothetical virus, we could control for the symptoms/conditions for the disease. Interestingly, although the symptoms/conditions were controlled across the experimental conditions, and only the route of transmission was manipulated, the perceptions of the virus infection, in terms of stigma, were significantly different. It was interesting to observe, that in spite of having vague information regarding how the target person was infected with SV-41, participants simply regarded being infected with a sexually transmitted virus as more stigmatizing and shameful than being infected with a foodborne virus. Participants seemed to assume that being infected via the foodborne route was a consequence of “passive” and “normal” behavior that the target person had no or relatively less control over the situation, while being infected via sexual intercourse was a consequence of “active” and “non-normative” behavior, and that the target person could have made a different decision to not be infected.In order to control for preexisting attitude or knowledge associated with actual diseases, this study created a hypothetical virus, r = - .05, n.s), a significant correlation coefficient was found between shame and communication efficacy . This finding has a practical implication in that Merck’s strategic plan for Gardasil appears to be successful in terms of reducing the perceived shame and stigma associated with the sexually transmitted nature of the virus. By not revealing the true nature of the virus upfront, they may prevent people from experiencing additional anxiety and distress from stigmatization  the effect of hiding a stigmatizing phrase, “sexually transmitted virus,” on shaping individuals’ perceived stigma and shame and (2) the effect of presenting the word “cancer” on shaping individuals’ perceived health threat. In other words, this study examined if drug company Merck’s HPV advertisement strategies were effective in terms of minimizing the stigma associated with the sexually transmitted nature of HPV and idealizing the level of health threat, which was measured by perceived severity and susceptibility. When participants did not know the transmission route of the hypothetical virus but knew that this virus infection was related to potential prostate cancer development, their perceived shame and stigma were significantly lower than when they knew it was a sexually transmitted virus. Out of curiosity, the correlations among the perceived shame, stigma, and communication efficacy were assessed. Although stigma was not significantly correlated with communication efficacy . It would be interesting to see if participants’ perceptions of susceptibility/severity differed if they were informed or not informed about how HPV is a virus that can develop cervical cancer. Moreover, it will be meaningful to study the relationship between participants’ perceived the health threat when they learn that HPV can cause cancer and their motivation to engage in appropriate actions. threat, is a cognitive appraisal that motivates action, efficacy. The threat part of the model is usually measured by the perceived susceptibility and severity. The EPPM indicates that, as people feel more threatened based on the perceived susceptibility and severity, they have greater motivation to engage in behaviors that can reduce the cause of the threat. We would like to add one more component to the threat part, the perceived stigma of the disease. If perceived susceptibility and severity are related to one’s physical threats, then it can be speculated that the perceived stigma can induce one’s psychological threat. It also resonates with Smith and her colleagues’ argument that fear of being stigmatized can also motivate people to act, but if their fear is greater than their ability to deal with the stigma, people are more likely to engage in behaviors that control their fear (In addition, our study suggests areas of future investigation by advancing a possible extension of Witte’s EPPM. The EPPM has two parts: threat and efficacy. The first part, eir fear . BecauseIf the perceived stigma has a negative influence on forming self-efficacy, it should be the next step to investigate the way to minimize the perceived stigma associated with various diseases. The current study did not assess the effect of prevalence and its “normalizing” function and left room for future studies to come in. The current study, as an exploratory step, introduced a practical implication for how to tailor health messages in order to maximize the awareness of the health threat among people but at the same time to mitigate the perceived stigma and negative emotional outcomes associated with a certain diseases. Stigma is known as the leading barrier to health promotion, treatment, and support . In addi


The simple, but quite unusual plan, promised much: two leading academics (Gary Francione and Robert Garner) prepared to make their respective cases with conviction and candour, followed by a lively debate between them, during which no stone need be left unturned. In prospect, then, was an opportunity for nuances to be clarified, misunderstandings dispelled and some common ground established. But while it proved to be an enthralling engagement, the apparent inability of one author to concede even an inch of ground to the other's case meant that the divide between the viewpoints was, regrettably, no narrower at the end than at the beginning.Francione, a law professor at Rutgers University in the USA, is a leading philosopher of animal rights theory. He has pioneered the abolitionist theory of animal rights, claiming that animal welfare regulation is both theoretically and practically unsound, and serves merely to prolong the status of animals as property by making the public feel comfortable about using ‘happy’ animals. Accordingly, abolishing animal use, e.g., by adopting strict veganism, is the only acceptable course of action and the only basis on which people ought to be encouraged to relate to animals.Garner, a politics professor at Leicester University, UK, is a political theorist who specialises in the field of animal protection. One of his major concerns (as summarised on his website) is ‘the difficulties of protecting the interests of animals from within the liberal tradition: focusing on the costs, for liberal societies, of adopting animal rights; the impact of liberal neutrality as regards the good society; and the protection of human autonomy’. While acknowledging the importance of campaigning for veganism, and indeed practising it personally, he considers it can realistically only form one part of an overall program to encourage more ethical treatment of animals.The contents of the book fall into three, roughly equal, parts, viz. Francione's essay, ‘The abolition of animal exploitation’, Garner's essay, ‘A defence of a broad animal protectionism’, and the discussion between the two. In essence, both the essays and the discussion epitomise the marked differences that prevail between a lawyer's categorical, legalistic, approach and the much more pragmatic, politically-informed, approach of a political scientist. In the following, reference to specific points is made by quoting in parentheses the pages on which they are made.Francione's position is based on several strong assertions. For example, he claims that: ‘ethical veganism is a recognition of the moral personhood of animals’, for which the only cognitive characteristic required is that they be sentient (p. 15), a condition which is itself inconsistent with the property status of animals, and with any animal use, however ‘humane’ (p. 4). While conceding that there are ‘relevant differences between the minds of humans and non-humans’, these are not logically relevant to whether they are used in experiments or killed for other purposes (p. 19), because ‘to say that a sentient being is not harmed by death denies that the sentient being has the very interest that sentience serves to perpetuate’ . These rights arguments are supported by several consequentialist claims, e.g., that animal welfare regulations do not work, and that there is ‘absolutely no evidence whatsoever’ that animal welfare reform will reduce animal use in future (p. 26); that ‘most human disease is due to consumption of animal products’ (p. 29), which are also a disaster for the environment (p. 28); and that welfarism has not decreased animal use (p. 47)—in fact, animal advocacy groups have aided the meat industry (p. 46).Unsurprisingly, the categorical nature of such assertions encounters some difficult issues. The thorny question of how to cope with the needs of billions of non-humans on a shrinking planet is answered by arguing that we should stop bringing animals into existence (p. 79), an objective which is facilitated by the belief that ‘sterilisation is consistent with abolitionist programs’ (p. 80). For ‘however well we treat non-human companions, they are completely dependent on humans for every aspect of their existence’ (p. 79). And in response to the alleged inconsistency that vegans appear unconcerned by the harms accidentally inflicted on wildlife in cultivating crops or in building roads, Francione argues that although it is impossible to avoid such secondary effects, they are ‘different morally from intentionally killing an individual animal’ (p. 72).In conclusion, Francione argues that bringing about a paradigm shift in our relationship with animals would be best achieved by a program of ‘clear, unequivocal, non-violent education targeted at abolishing all animal use’ (p. 85). For, if instead of the dominant welfarist approach, an abolitionist agenda had been pursued in the past, ‘there likely would be many hundreds of thousands more vegans than there are today’ (p. 65).etc.—experiences of a qualitatively different nature from those experienced by animals (p. 116).Garner's approach is quite different in style and in the assumptions made about how improvements in the condition of non-humans might best be achieved. For him: ‘it is important to distinguish between what is prescribed by ethics and what is achievable politically or strategically, because any viable moral discourse must take into account more than rationalistic ethical principles’ (p. 105). Like Francione, he stresses that sentience is a crucial factor in ascribing ethical standing to animals, but this does not equate with the notion that animals have ‘personhood’ (p. 113) For example, loss of life causes harms to humans that, inter alia, entail loss of beliefs, desires, goals, projects In answer to Francione's claim that animal welfare measures introduced have been counter-productive because people feel more comfortable about eating meat from ‘happier animals’, Garner argues that the improvements are in themselves desirable, and that claims about the likely effectiveness of vegan campaigns are highly speculative (p. 122): indeed, it is possible that matters might be worse if all efforts had been directed to an abolitionist program. The political reality is that no country in the world has prohibited use of animals in medical research or as a source of food (p. 125). Garner agrees that much of what is currently permitted under the aegis of animal welfare ought to be banned (p. 119), but suggests that ‘no measure that does not at the same time promote benefit to humans is likely to gain a hearing’ (p. 126).i.e., the need to check rational principles with moral intuitions. The upshot is that, for him, the advantage of concentrating on eliminating unnecessary suffering is that it maximises public support, and is progressive in that what is deemed ‘unnecessary’ has expanded over recent decades, reflecting greater public awareness, changes in cultural norms and technological developments (p. 142).Fundamentally, he argues that abolitionist aims are unrealistic because the underlying principle—that animals have a moral status close, if not identical, to humans—is not accepted by the vast majority of society (p. 143). The political reality for Garner is that ‘the battle of ideas in a liberal democratic society is conducted in a pluralistic universe where the rationale is not for one set of ideas to prevail but for a plurality of ideas to coexist’ (p. 148), conditions which, e.g., have been the guiding force behind post-war legislation on homosexuality in some western societies. In this context, he cites the late John Rawls, who stressed the importance, in seeking sound political decisions, of ‘reflective equilibrium’, Although the discussion is presented as a verbatim dialogue, it would be interesting to know precisely how it was conducted. For example, were the discussants present in the same room or conversing by telephone? Did the discussion occupy more than one session? Since the published version is word perfect, one suspects it was edited—and if so it presumably lost some spontaneity, and hence authenticity. Even so, the discussion is a revealing part of the book, although perhaps not entirely in ways the protagonists might have anticipated.Without attempting a blow-by-blow summary of the exchange, I doubt that I am the only reader to be left with an impression of a discussion characterised by Francione's somewhat strident approach, to which Garner responded with remarkable amiability. And while Garner was prepared to acknowledge several areas of agreement, Francione's only reciprocal response was the single word ‘agreed’, in the book's final sentence, to the proposition that currently animals endure unacceptable levels of suffering. Not even the revelation that Garner was a dietary vegan, in reply to Francione's ‘personal’ question, elicited any recorded response (p. 257). A discussion where one participant seems unprepared to concede any merit in the opposing perspective, a condition which is perhaps intrinsic to an absolutist, abolitionist stance, hardly provides fertile ground for intellectual enquiry. Yet it might have been anticipated that the fact that both participants reputedly sought to achieve desired changes incrementally would have provided a sound basis for fruitful discussion.Readers of this review will doubtless detect a bias in views expressed here, but there are some matters  which it is virtually impossible for a thoughtful person to approach with a completely open mind. Acknowledging that caveat, Francione seems to me to be guilty of making several assertions that are either speculative in the extreme or based on a very limited consideration, or understanding, of objective evidence.One example that must suffice to make a point of more general validity is his claim that ‘Animal agriculture is a disaster for the environment because it involves a very inefficient use of natural resources …’ (p. 28). While the statement is accurate in the case of many intensive animal production systems, it is certainly not universally true. Thus, the claim ignores those, admittedly rarely-practised, forms of animal husbandry (but how can vegans dismiss claims merely because they are made by other minorities?), which operate within a permaculture livestock economy, and that achieve efficient food productivity in socially and ecologically integrated systems, in which ‘the by-product of one component is easily available to provide the feedstock of another’. The quotation is from Simon Fairlie's book , which mFairlie's point assumes enormous significance in terms of the environmental crisis that humanity faces in consequence of the combined effects of climate change and diminishing fossil fuel reserves; developments that imply the urgent need to adopt sustainable practices entailing ‘energy descent’. In achieving the latter, energy will necessarily be largely derived from biomass, renewable resources such as wind, water and solar, and increased use of muscle power; and farm animals could play an effective role in different elements of this process.The Farncione/Garner book certainly provides clear expositions of contrasting attitudes, but the territory explored often seems rather abstract, omitting consideration of several critical issues. So in conclusion it is perhaps appropriate to identify some of these. For example, the ethical implications of the following surely merit attention.(i)The resources allocated to concern for animals as opposed to those employed to address human survival, suffering or wellbeing—which may entail substantial opportunity costs for vegans. For example, the energy and time expended in ensuring dietary integrity, and promoting the vegan cause, is necessarily denied to efforts to ease the suffering of humans, of whom about one billion suffer from malnutrition in less-economically developed countries, while many, world-wide, are victims of abuse and exploitation.(ii)The rights and interests of humans at the level of personal health and wellbeing, in societies whose economies, cultures and, in some cases survival, depend on a symbiotic relationship with animals. The discussion in the book seems dominated by attitudes and conditions in western ‘developed’ countries.(iii)The fate of prey, and more generally of adverse effects on ecological sustainability in the wild , of permitting predators, and wild species in general, to satisfy their biological needs. If sentience is the sole relevant characteristic in granting animals rights, what could be the ethical basis of showing partiality to domesticated rather than wild animals?(iv)The adverse effects on wild animals  of practices employed in arable farming, on which most vegan diets are necessarily dependent. For example, pest control, not only of insects but also of indisputably sentient mammals like rabbits and mice, is crucial for efficient arable farming. Is it really valid to argue that since the adverse effects on wild animals are ‘accidental’ they are beyond vegans' ethical concern?(v)The basis of the distinction assigned to the meaning of ‘property’ in the cases of farmed animals  and ‘rescued’ companion animals. Indeed, it is pertinent that there is a real sense in which human children are, when young, their parents' ‘property’—without this being considered remotely problematical from an ethical perspective.The rigour with which vegans attempt to lead lives according to the strict observance of ethical principles is often regarded as exemplary, and vegan philosophy certainly represents a significant challenge to long-established norms of behaviour. But if the aim of ethics is to choose the right, or best, course of action in specific circumstances ‘all things considered’, it is arguable that adherence to such an absolutist agenda is simplistic and open to serious self-contradictions. Or, as Farlie puts it, with characteristic panache: ‘to conclude that veganism is the ‘only ethical response’ is to take a big leap into a very muddy pond’ (p. 2).


Research on screen-viewing in preschool children has predominantly focused on television viewing. The rapid development of mobile devices  and the increase in their use by preschool children means there is a need to understand how and why these devices are used by this age group. The aim of this study was to explore mothers’ views of their preschool children’s screen viewing behaviour (including mobile devices) and investigate how preschool children use different screen-viewing devices.One-to-one, semi-structured interviews with mothers of preschool children (aged between 2 and 4 years old). Mothers were recruited through preschools, nurseries, and mother and toddler groups located within four areas of varying socio-economic status within Bristol, UK. Data were analysed thematically using a framework approach.Twenty-six mothers were interviewed. Mobile devices were regularly used as a form of screen-viewing for most children but were used on an ad hoc basis rather than being a habitual activity. The reasons and influences of mobile device use described by mothers were similar to that of television viewing. However, the portability of mobile devices meant that they were often used outside of the home as a distraction tool. Their multi-functionality meant that they could be used as a portable television, or for purposeful learning through educational games and applications. Some mothers showed concerns over mobile device use by their child, whilst others felt it was an important and useful educational tool. Although the majority of mothers felt they needed to set rules and restrictions for mobile device use, many mothers felt that they are also a necessary and unavoidable part of life.Mothers in this study suggested that mobile device use by preschool children is common. More research is needed to determine the impact of mobile device use in preschool children, how much time preschool children spend using mobile devices and which activities their use may be replacing. For preschool children, screen-viewing mainly consists of television viewing but also includes computer use and, increasingly, the use of touchscreen mobile devices . The curIn the UK, there are no specific government guidelines of daily screen-viewing time for young children, only that screen-viewing should be minimised . The AusMobile devices, such as smart phones and tablets, are easily and intuitively used by very young children and provide an instant interactive element that appeals to both children and parents . There aParents greatly influence the screen-viewing behaviours of young children and act as ‘gatekeepers’ to the amount of screen-time and the type of devices children have access to . This inParents’ perspectives of their preschool child’s screen-viewing have been explored in qualitative studies , 33–36. There is a paucity of research available about parents’ perspectives of newer technologies such as catch-up television , internet television , and mobile devices. A recent study by Carson et al.  looked aConsidering the rise in accessibility to mobile devices and the continual advances in this type of technology, a more comprehensive understanding of how they are used by preschool children is needed. Furthermore, there is a need to break away from solely examining television viewing and begin to explore parents’ attitudes to these newer devices and investigate the factors that influence their use. This study aimed to explore mothers’ views of their preschool children’s screen viewing behaviour (including mobile devices) and investigate how different screen-viewing devices are used by preschool children.In-depth, semi-structured interviews were held with mothers of preschool children in order to explore their views of their children’s screen viewing behaviours. The study was approved by the University of Bristol, Faculty of Medicine and Dentistry ethics committee. GFB, a female PhD student who has experience and training in qualitative research, carried out the recruitment and data collection.http://data.gov.uk/dataset/index-of-multiple-deprivation] which is an area based measure of deprivation associated with the residential postcode.To ensure socioeconomic and urban diversity in the sample, mothers were recruited within low, medium, and high-socio-economic status (SES) areas, within the City of Bristol, and one rural community (mid SES) located 13 km outside the city centre. SES was defined by thirds of the 2010 index of multiple deprivation (IMD) . They can’t pick it up without our permission.”Interviewer: “And how long would you let him use it for?”Mother: “I guess not really much more than two hours”P55, Rural, Boy, age 4“He does love it and he would ask for it and once he’s playing it’s difficult to encourage him not to. It would be difficult to get him off that onto another activity, difficult to upgrade from his favourite game.” P31, High SES, Boy, age 4A child’s preference for screen-viewing appeared to influence the amount of screen-time allowed. Many mothers described the strong desire from their child to use mobile devices, and often parents felt they needed rules and restrictions in place to manage children’s demands for their use. These included hiding devices, only being able to use devices in their fathers’ presence and with his permission, pass-coding devices, and time limiting use. However, it appeared that some of these children may still spend long periods using mobile devices and what mothers felt was ‘too much’ screen-viewing varied. For instance, although one mother described restricting her child’s use of the family tablet, she also allowed the child to use the device for up to two hours in one session. Some mothers mentioned that their child would have tears and tantrums when a screen-viewing device was taken away, which mothers described as difficult to manage.“In fact he’s not used the iPad for a few months now. He’s not needed it, he’s been quite happy playing by himself with his toys. I’ve not thought about it and he’s not asked for it.” P41, Mid SES Rural, Boy, age 3Contrary to this, some mothers felt that their child did not need restrictions on screen-viewing in order to prevent extended periods of viewing. For instance, some mothers explained that their child did not have the attention span for extended periods of television viewing and could only watch 15 to 30 min of television before they moved onto something else. In addition, some mothers who allowed their child to have free access to mobile devices found that after an initial enthusiasm for the device (e.g. a couple of months) their interest in it wore off and they would naturally choose other activities to do, such as playing with toys over screen-viewing.“The big thing which again he’s probably quite young to be doing is Minecraft. Which is a horrible build game. So he’ll do that, but again that’s his older brother influencing him.” P55, Mid SES Rural, Boy, age 4Family members also influenced the preschool child’s screen-viewing behaviours. Some preschool children were described as taking an interest in what their older sibling was doing on a computer, watching or participating with their sibling. Some mothers said that their older child would teach their preschool child how to use the computer and play games with them. It also seemed that preschool children with older siblings were exposed to television programmes and computer games aimed at older children.“It’s a bone of contention because he can’t see the problem with it… he’s opinion is its just fun and it’s good and it does give you skills.” P34, High SES, Girl, age 3Some mothers described their child’s father encouraging screen-viewing as a way of interacting with their child. A few mothers described this with some contention, as this behaviour went against their desire to restrict screen-viewing. These mothers said that their child’s father had different views towards screen-viewing  than themselves, where they felt fathers believed that there was no need for restriction because screen-viewing was harmless, fun, and important for skill development.“Oh we’ve always got the TV on, it’s pretty much always on because when I grew up the TV was always on, and it’s not a novelty at all… he won’t really sit down and watch it, it’s just always on.” P39, Low SES, Boy, age 3Mothers’ own childhood experiences appeared to influence how they felt about screen-viewing. For example, one mother grew up with very little technology and wanted her child to enjoy an equally active lifestyle. Whereas another mother grew up with the televsion on all the time and felt that this was a positive experience because it stopped it being a novelty and she carried this through with her son.Television viewing was the main form of screen-viewing discussed by mothers in this study and appears to be the main form of screen-viewing for their preschool child. Analysis of the data, however, shows that preschool children frequently have access to mobile devices. How the preschool children use this form of screen-viewing often overlaps with how they use television viewing and computers. There also appeared to be some differences in their use. For instance, unlike computers, mobile devices allow for independent play which means mothers are able to use them in a similar way to the television . Mothers feel that mobile devices have a purposeful and interactive educational value and are often viewed positively. Mobile devices seemed to be used at ad hoc times when its use was required, rather than regular periods of the day, which was the case with television viewing, indicating its use may not be habitual at this age.Qualitative studies have reported mothers’ reasons for their preschool children’s television viewing. For instance, as a way for children to rest –36, to uA unique difference between mobile devices and other screen devices is their portable nature, which means that screen-viewing can take place outside of the home and can provide a means to distract the child in situations that require them to be patient . Radesky et al.,  observedSome mothers in this study, used mobile devices  with caution and felt their allure to children difficult to manage. They also showed concerns about their accessibility, the child’s behaviour that mothers feel result from use of mobile devices, and the perceived possibility that screen-viewing might have a negative effect on their child. However, many of these mothers felt that mobile devices were now a necessary and unavoidable part of life and allowed their child to use them regularly with some reluctance. Similarly, Carson et al. , reporteIt is clear that mobile devices provide an intuitive, responsive and interactive component that other screen viewing devices cannot provide. Research has not yet ascertained as to whether mobile device use can be defined in the same way as television viewing, and if perhaps, its use should be evaluated as a separate behaviour. However, it is important to note that, although these screen-viewing devices vary in the way they are used, they all may still be considered a sedentary activity. As sedentary behaviour in young children is associated with negative health outcomes, it is important that their use is still minimised. This study shows that mothers regularly provide mobile devices for their preschool children and highlights the need for further research to determine the impact of its use in young children. It is not known how much time preschool children spend with these devices and further research is need to establish whether mobile device use is replacing an alternative sedentary activity (such as television viewing or reading books) or other  activities. In addition, this study indicates differences between mothers and fathers views on screen-viewing, and that fathers influence their preschool child’s screen-viewing behaviour. Therefore, further research should be carried out to explore fathers’ views and influences of screen-viewing in preschool children.The results of this study indicate that health policy and interventions aimed at reducing sedentary behaviour in young children need to be sensitive to the needs and priorities of parents and take into the account the reliance that parents have on screen-viewing devices. A qualitative study by Evans et al., reported that parents felt reducing television viewing in their 6 to 7 year old children would cause conflict in the home and require resources  that they were unsure they could provide,. This hiThe interviews were held with a diverse sample of mothers, i.e. individuals from different SES areas, which included both urban and rural areas, working and non-working mothers, and lone-parents. However, the extent to which the findings can be generalised will be limited by the fact that the majority of the interviewees were white British. As mothers were aware of the nature of the research  they may have been inclined to give socially desirable responses. As we do not have information on the age of the mothers in this sample, we are unable to comment on the generation from which the mothers belong or the extent to which their views are affected by the nature of their own screen-viewing as a child. Another limitation is that this study is based on interviews rather than observations, and so reports mothers’ perceptions of their child’s behaviour, rather than directly recording it.Mobile devices use is common in preschool children, although it does not appear to be a habitual behaviour. Their multi-functionality means that they may be used for independent play in the same way as television viewing , or more purposefully for learning through games and through computer skill development. A unique characteristic of mobile devices is its portability, meaning that screen-viewing can take place outside of the home. Although mothers expressed concerns over mobile devices use, they were generally viewed it more favourably than television viewing. The majority of parents had rules and restrictions to limit their child’s use of mobile devices. However, the strong allure of mobile devices to preschool children makes restricting their use problematic.AAP, American Academy of Paediatrics; App, mobile devices application; IMD, index of multiple deprivation; PC, personal computer; SES, socioeconomic status, UK, United Kingdom


Especially in schizophrenia research, the idea of endophenotypes has gathered a wide following. Meehl’s definition of schizotaxia typy and schizophrenia qualitatively share various similarities, albeit in a quantitatively different fashion.Although there are a number of ongoing debates regarding the nature of schizotypy, its distribution throughout the population and its relation with schizophrenia, a few elements may be considered “agreed upon”: (1) schizotypy is a latent trait (partly) harboring individual risk for schizophrenia . (2) Schphrenia . The stThere are, however, a number of findings that need further discussion before a final conclusion may be drawn. (1) A number of genetic factors associated with schizotypy are no longer considered relevant in schizophrenia genetics. (2) A number of genetic factors associated with schizophrenia are not (or even inversely) associated with schizotypy.not all highly schizotypic individuals are schizophrenic; both parts of this expectation hold true . This ve detail , 4 that hizotypy  has the health or resilience. High schizotypy is in and of itself, thus, not equal to schizophrenia; when coinciding with low health/resilience, however, schizophrenia is the outcome. Schizophrenia may therefore be viewed upon as resulting from low resilience to the high , thin general a suitable endophenotype of schizophrenia. This might be jumping the gun, however, as, upon closer examination, there are a number of discrepancies between schizotypy and schizophrenia; especially related to genetics and the distinction between positive and negative/disorganized traits. I would, therefore, suggest , while (high) negative schizotypy may be viewed upon as an endophenotype of schizophrenia-in-psychosis . The latter is important, as (high) negative schizotypy is not exclusive to psychotic disorders, but also found to share considerable variance with another personality trait linked to other  disorders; i.e., Neuroticism  high positive and negative schizotypy. This interaction between different aspects of personality (and inherent cognitive patterns) regarding the development of schizophrenia has been clearly shown by Gaweda and Prochwicz , whereas this is not the case in schizotypy. In other words, accepting discrete facets of schizotypy per se as suitable endophenotypes of psychosis-in-schizophrenia vs. schizophrenia-in-psychosis may not only help researching the  basis of psychosis in eneral , but also help us examine why certain (highly schizotypic) individuals develop schizophrenia while others benefit from their perceived “oddness.” Schizotypy research is, in my opinion, better suited for both aforementioned aspects of schizophrenia research than simple case–control designs both due to the possibility of differentiation between individual schizotypic facets and due to schizotypy’s naturally dimensional nature compared to the  dichotomy in the comparison between schizophrenic patients and “healthy” controls.This makes schizotypy no less useful in schizophrenia research, however. I would state that it actually strengthens the case made by schizotypy researchers when saying that it is a useful and “search” [; p. S363The author declares that this research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.