Scotland has a persistently high mortality rate that is not solely due to the effects of socio-economic deprivation. This “excess” mortality is observed across the entire country, but is greatest in and around the post-industrial conurbation of West Central Scotland. Despite systematic investigation, the causes of the excess mortality remain the subject of ongoing debate.Attachment processes are a fundamental part of human development, and have a profound influence on adult personality and behaviour, especially in response to stressors. Many studies have also shown that childhood adversity is correlated with adult morbidity and mortality.The interplay between childhood adversity and attachment is complex and not fully elucidated, but will include socio-economic, intergenerational and psychological factors. Importantly, some adverse health outcomes for parents (such as problem substance use or suicide) will simultaneously act as risk factors for their children.Data show that some forms of “household dysfunction” relating to childhood adversity are more prevalent in Scotland: such problems include parental problem substance use, rates of imprisonment, rates of suicide and rates of children being taken into care. However other measures of childhood or family wellbeing have not been found to be substantially different in Scotland compared to England.We suggest in this paper that the role of childhood adversity and attachment experience merits further investigation as a plausible mechanism influencing health in Scotland. A model is proposed which sets out some of the interactions between the factors of interest, and we propose parameters for the types of study which would be required to evaluate the validity of the model. Since about 1950, improvements in health in Scotland have not kept pace with those in other countries . Since aThese higher mortality rates relative to the rest of the UK persist even after adjustment for differences in area deprivation and individual social class, and so have been termed “excess” mortality .In the mid to late 2000s mortality at all ages was about 15 % higher in Glasgow compared to Liverpool and Manchester, similar cities in England. But premature deaths (in people less than 65 years old) were 30 % higher, and the causes of those deaths were different. Well over half of the excess premature mortality was attributable to deaths from alcohol, drugs-related poisonings, suicide and “external causes”, which includes violence . CurrentWhy does West Central Scotland have high rates of problem substance use, suicide and violence, even after deprivation and other conventional aetiological factors have been controlled for? Epidemiological studies have not been able to fully explain the causes of this excess mortality. Researchers have systematically examined a range of potential explanatory factors  and not found convincing effects –8. Some Harmful early years and childhood experiences have also been proposed as a possible explanation for the excess of poor health and mortality seen in Scotland , 11. ThiWe have long known that childhood experiences can affect health in adulthood. There are five main concepts that currently shape our understanding of those influences.The landmark Adverse Childhood Experiences (“ACE”) studies by Felitti et al. used a retrospective epidemiological approach to ask research participants about exposure to a range of harmful or distressing experiences before the age of 18 years. Those experiences included domestic violence, physical or sexual abuse, emotional neglect, parental separation, alcohol and drugs misuse; and mental illness, suicide or imprisonment affecting a member of the household in which the child grew up. These experiences may be categorised and counted using a 10-item questionnaire .Two thirds of the initial ACE study population  reported an score of one or more, and 12.5 % a score of four or more .Felitti et al’s study and similar work conducted more recently in the UK –16, showFigure Exposure to such childhood adversity is common: for example, 9·6 % of children in a European community survey reported sexual abuse, 22·9 % physical abuse and 29·1 % mental abuse .In UK studies, increasing exposure to childhood adversity has also been strongly related to adverse behavioural, mental and physical outcomes. There were no significant relationships between socio-economic (SE) deprivation and having between one and three ACEs, yet having four or more ACEs was strongly associated with higher SE deprivation .Studies consistently show strong, graded associations between childhood adversity and the risk of adult problem drug  and alcoExposure to childhood adversity is associated with lack of empathy, impulsivity and anger, and the emergence of behavioural problems , includiEach child will respond individually to their situation, and a minority of children may develop positively despite severe adversity . ProtectComplex trauma  is a term that describes psychological harm arising from repeated or prolonged trauma, including abuse or neglect during childhood. First described by Herman in the early 1990s , the conStressors leading to complex trauma are repetitive or prolonged, involve direct harm or neglect by caregivers, occur at developmentally vulnerable times, and compromise child development and adult functioning. This leads to patterns of thinking, feeling and behaving across a person’s life course which are characterised by impulsiveness, emotional lability, difficulty functioning in relationships and symptoms of Post-Traumatic Stress Disorder.These difficulties mean that people with complex trauma backgrounds are more likely to be involved in health harming behaviours and be exposed to ongoing risky relationships, violence and re-victimisation . ComplexStandard interview schedules used to measure complex trauma include items ranging from “having someone close die unexpectedly”, to “saw atrocities/carnage” , and theCriteria have been proposed for a diagnosis of complex trauma , but thiAttachment theory was developed by the psychoanalyst John Bowlby on the basis of observations of young children’s behaviour when separated from their parents. In order to survive, infants have to be able to form a bond with their caregiver , and to elicit a care-giving response from her. This “affectional bond” with a “differentiated and preferred individual”  gives thAs children interact with caregivers during infancy and childhood, they develop an “internal working model” of themselves in relation to others . This moBowlby’s ideas about child development have been endorsed and extended by decades of empirical evidence .When carers are sensitive and responsive to a child’s needs, a secure attachment style develops. Children who are securely attached tend to have a positive self-image, a capacity to manage distress, and the ability both to function independently and also to interact with others . This isBy contrast, insecurely-attached individuals tend to respond to stress with anxious features, including exaggerated emotional responses; or with avoidant characteristics, including suppressing negative feelings and withdrawal from help-seeking contact .These attachment patterns have a profound impact, not only on childhood development but also on adolescent and adult personality and relationships, including romantic relationships and choice of partner –49. AttaSecurely-attached parents tend to raise securely attached children; similarly, parents with a fearful, avoidant or disorganised attachment experience tend to raise children with a similar attachment style . The mecThe problems associated with dysfunctional attachment experiences are most evident when security is threatened . This isHuman stress responses are mediated by hormones which are essential for adaptation, metabolic stability, and survival. But longer-term exposure to fluctuating or heightened stress incurs a physiological cost, which has been termed “allostatic load”. It has been demonstrated that this load can accelerate disease processes , and mayThe concept of “toxic stress” seeks to synthesise the evidence from work on allostatic load, adverse childhood experiences and attachment theory. It arises from the strong, frequent, or prolonged activation of the body’s stress response systems in the absence of the buffering protection of a supportive, adult relationship . Unlike Toxic stress compromises children’s ability to cope , and incIt is hypothesised that the extent to which stress might be “tolerable” or “positive” rather than “toxic” will depend on genetic predispositions and the availability of supportive relationships, including secure attachment experiences .exposure to potentially harmful experiences the response to those experiences as influenced by attachment style and psychological development: securely-attached children (and parents) are likely to respond adaptively to stress, whereas insecure or disorganised attachment styles often predispose to further stress.the consequences of those experiences, in terms of allostatic load, toxic stress, psychological development and adult attachment styleSome of the issues described in the previous section overlap; Table These concepts are distinct but overlap, and have a dynamic interaction over the lifecourse. The relationship between the experience of adversity and attachment style is particularly important, since each may influence the other.For example, children living in poverty are more likely not only to experience more adversity , 71, butPoor outcomes in relation to childhood adversity are strongly linked to less stable family structures . FurtherFigure There are three main elements to the model. Negative socio-economic and “structural” factors predispose to childhood adversity and toxic stress (1). This causes increased allostatic load and toxic stress into adulthood, which in turn leads to premature mortality mediated by metabolic, immune, behavioural and environmental pathways.Some forms of premature morbidity and mortality in parents will also act as adverse childhood experiences for their children (2), thereby creating the potential for inter-generational transmission of adversity.Finally, attachment-related experiences and behaviours may act to mitigate the effects of adverse and stressful experiences (3).In this model, differing socio-economic contexts can be the cause of adverse experiences, or act to exacerbate or mitigate the consequences of such experiences.is consistent with concepts of “critical periods” for childhood development, and of a cumulative burden of allostatic load through the lifespan .is consistent with structural and social models of health, but emphasises important non-socio-economic influences .links some adult outcomes to childhood risk factors, creating a potential feedback loop which could persist even if the initiating external socio-economic circumstances were to remit.argues that harm caused by exposure to ACEs and toxic stress can potentially be prevented or modified by secure attachment experiences.This model:The interaction between individuals, groups and their socio-economic environment is not entirely predictable, and since each will affect the other, a “complex adaptive system” emerges . The timThe extent to which individuals should be held responsible for their own health and behaviours is the subject of controversy and political debate. It is important to emphasise that this paper does not seek to add to the “long and undistinguished pedigree” of stereotypes about disadvantaged people in society .Welshman summarises at least nine political “reconstructions” of social problems: the “social residuum” (1880s); the “unemployable” (1900s); the “social problem group” (1930s); the “problem family” (1950s); a “culture of poverty” (1960s); the “cycle of deprivation” (1970s); the “underclass” (1980s); “social exclusion” (1990s) and the idea of “troubled families” in Britain (from 2010) .The model described within this paper would be inconsistent with any attempt to “blame the victim” for social and health problems, for the following three reasons.First, every person has an experience of attachment, not only those living in poverty ; second,Figure Since violence, suicide and addictions are strongly correlated with adverse childhood experiences, what does current evidence tell us about that experience in Scotland compared to England, or in Glasgow compared to the similar cities of Liverpool or Manchester?Increased rates of “household dysfunction” in Scotland  in households with childrenA higher prevalence of parenting indicators associated with insecure attachment If premature mortality in Scotland and especially the West of Scotland were associated with differences in attachment experience or ACEs compared to England, then we would expect to see:A comparison of “poverty, parenting and poor health” between Scotland and England, and the Glasgow & Clyde Valley, Merseyside and Greater Manchester. This study used a range of data sources but principally relied upon the four British Cohort Studies collating longitudinal data between 1946 and 2000 .This study found that the social and material circumstances experienced by people living in Scotland and Glasgow and the Clyde Valley (GCV) were broadly similar to those in England, Merseyside and Greater Manchester.However several measures of household dysfunction were higher in Scotland and Glasgow and the Clyde Valley compared to comparator areas in England.Problem opiate drug use was twice as common in Scotland compared to England.Rates of children being taken into care may act as a proxy measure of childhood adversity, and have been about twice as high in Scotland compared to England for the last three decades . HoweverReports of actual and threatened domestic violence were high in the Glasgow and Clyde area compared to the English regions. Rates of imprisonment were also higher in the Glasgow and Clyde area compared with the English regions.A between-country comparison of suicide rates in the UK showed that in the early to mid-2000s, Scotland’s national suicide rate was 79 % higher than in England, and twice as high for people aged 15 to 44 years . In thisFurther analyses of data in the 1958 National Child Development Study  (one of The data show that children born in Scotland in 1958 may have been slightly more likely to experience two or more adversities in childhood compared to children born in England – 9.8 % (95 % CI 8.4–11.2 %) in Scotland compared to 7.9 % (95 % CI 7.4–8.4 %) in England. However, using the same measures, there were no meaningful differences between children born in Glasgow and the Clyde Valley (8.0 % (95 % CI 6.0–10.0 %), Merseyside (9.0 % (95 % CI 6.2–11.8 %) and Greater Manchester (12.3 % (95 % CI 9.1–15.5 %)).In other words, the data suggest that there may be slightly more exposure to childhood adversity in Scotland compared to England, but not necessarily among people born in Glasgow and the Clyde Valley in 1958 when compared with Scotland as a whole, and also to Merseyside and Greater Manchester.This is a counter-intuitive finding, since if exposure to childhood adversity were higher in Scotland than England, one would expect the difference to be most marked in the area of highest socio-economic deprivation with the highest subsequent mortality, i.e. Glasgow and the Clyde Valley.An examination of the 1958 National Child Development Study and the 1970 British Cohort Study comparing childhood experiences in Scotland and England, and in Glasgow and the Clyde Valley compared to Merseyside or Greater Manchester .This study used different data from the 1958 National Child Development Study and the 1970 British Cohort Study to examine the relationship between childhood experiences and behavioural, respiratory and reading/vocabulary problems in children aged 5 and 7 years. The measures used in this study are summarised in A cross-sectional survey of the populations of Glasgow, Liverpool and Manchester carried out in 2011 examined adult psychological function and self-reported childhood happiness and childhood relationships with parents . This stContemporary analyses of Scottish longitudinal data showed that the current social, emotional and behavioural development of preschool children in Glasgow  is not worse than children elsewhere in Scotland .Five data sources allow us to assess these predictions against data comparing the geographical areas of interest.In summary, some data sources suggest that there are differences in childhood exposure to adversity when comparing areas in Scotland to English comparators. Those differences are most evident in routinely collected data, including rates of imprisonment, domestic violence, problem substance use and numbers of children taken into care. By contrast, data sources suggesting little or no differences tend to rely on informant reports of feelings or behaviours (e.g. from surveys), which are more subject to recall and cultural biases.Currently available data do not allow us to study possible links between relevant exposures (childhood adversity and complex trauma), responses (attachment) and adult health outcomes.Be able to collect accurate measures of childhood adversity, complex trauma and attachmentBe able to consider those measures in the context of structural and material factorsBe clear about the period of risk exposure and the latency between exposure and outcome in order to identify appropriate age cohorts for comparisonBe sensitive to potential selection and responder biases, given the propensity for ACE scores and attachment style to influence recruitment, and the sensitive nature of the questionsBe able to adjust for a range of potential confounding variablesInvestigate these effects with appropriate geographical comparisons.In order to examine the hypothesis that excess mortality in Scotland and especially the West of Scotland relates to childhood experience of attachment and adversity, future studies would require to:Each of these considerations brings challenges to designing a research study.Scotland has a persistently high mortality rate that is not solely due to the effects of socio-economic deprivation. This “excess” mortality is observed across the whole country, but is greatest in and around the post-industrial conurbation of West Central Scotland. Its causes remain the subject of discussion and debate, despite systematic investigation.Nonetheless, there is now strong evidence to show that childhood experience of both adversity and attachment exert a significant influence on adult morbidity and mortality. Each of these factors is therefore a plausible influence on the excess mortality observed in Scotland.We describe in this paper a possible model through which socio-economic factors might influence childhood experiences in a way that not only leads to harm in adulthood, but simultaneously exposes the next generation to similar risks. In this model, childhood adversity leads to damaging metabolic, immune, behavioural and developmental changes, which can be offset or mitigated to some extent by secure attachment experiences.Inter-generational effects suggested by the model may serve to perpetuate and entrench poorer health in some population groups, especially when those groups are exposed to ongoing adversity.Thinking about Scotland’s health problems from this perspective links social, environmental and political factors to the health of individuals and groups. Since income, wealth, power, environment and access to services all have the potential to affect childhood adversity and attachment processes, this approach is consistent with a “structural” perspective on health inequalities, which holds that differences in the socioeconomic circumstances, at all stages of the life-course, cause differences in health outcomes” .We present data from a number of sources with which to examine this model. The critical aspect of the hypothesis is that there might be “something different” about childhood experiences in Scotland, and especially West Central Scotland, compared to other areas. Unfortunately, existing data are conflicting. In general, routinely-collected data that signal higher exposure to adversity - such as domestic violence, problem substance use, rates of imprisonment and rates of children being taken into care - indicate an excess of childhood adversity in Scotland. However measures requiring self-report about current or historic aspects of social and family functioning (eg parents reading to the child) tend not to show significant differences.Existing datasets were not designed to answer these questions, and are subject to a number of difficulties: the samples may not be optimal, the questions asked of participants may not be appropriate, and comparisons across countries and over decades are subject to recall and cultural biases.The model presented here emphasises the methodological complexities of conducting a study capable of exploring this hypothesis. We hope that this developmental perspective on those challenges will support future work in this important area.ACEs, adverse childhood experiences; DSM-5, diagnostic and statistical manual of mental disorders


According to the recently recognized functions of the insula, and the results of nuclear brain imaging and electrical stimulation, the ecstatic symptoms in these patients seem to localize to a functional network centered around the anterior insular cortex, where we thus propose to locate this rare ictal phenomenon. Here we summarize the role of the multiple sensory, autonomic, affective, and cognitive functions of the insular cortex, which are integrated into the creation of self-awareness, and we suggest how this system may become dysfunctional on several levels during ecstatic aura.Ecstatic epileptic seizures are a rare but compelling epileptic entity. During the first seconds of these seizures, ecstatic auras provoke feelings of well-being, intense serenity, bliss, and “enhanced self-awareness.” They are associated with the impression of time dilation, and can be described as a mystic experience by some patients. The functional neuroanatomy of ecstatic seizures is still debated. During recent years several patients presenting with ecstatic auras have been reported by others and us (in total  Ecstatic epileptic seizures are described as an overwhelmingly positive experience. Patients have trouble finding appropriate words  intense positive emotion (bliss), (2) enhanced physical well-being, (3) heightened self-awareness or heightened perception of the external world (clarity). BOX  intense Box 11. Intense serenity and bliss.This led to a feeling of complete serenity, total peace, no worries; it felt beautiful, everything was great.”– “The immense joy that fills me is above physical sensations.”– “It is a feeling of total presence, an absolute integration of myself, a feeling of unbelievable harmony of my whole body and myself with life, with the world, with the ‘All’.”– “2. Enhanced physical well-being.It was something that I have never felt before. It felt as though my body was filling up with a sensation which was quite surreal. The feeling was almost out of this world.”– ““[…] a halo, something pleasant which fills my inner body, wrapping me, with a rapid crescendo. It is a well-being inside, a sensation of velvet, as if I were sheltered from anything negative. I feel light inside, but far from being empty. I feel really present. Something has taken possession of my body, to feel really good…”– –3. Heightened self-awareness and/or perception of external world.During the seizure it is as if I were very, very conscious, more aware, and the sensations, everything, seems bigger, overwhelming me.”– “I feel rooted to the spot with a more developed consciousness. I feel a stronger consciousness of the body and the mind, but I do not forget what is around me.”– “It affects both the cerebral thought, which is very intense and concentrated on itself, and the physique.”– “Being very conscious of myself, I feel discharged from anything else, although I do not lose consciousness.”– “I feel very, very, very present at that time; the consciousness of myself is very increased, rather on a psychic point of view. I am one hundred percent concentrated on myself.”– “4. Feeling of dilated time.I escape into the time space of my body. It is a moment of fullness in the loophole of time, a return to myself.”– “Entirely wrapped up in the bliss, I am in a radiant sphere without any notion of time or space. My relatives tell me that it lasts two to three minutes, but for me these moments are without beginning and without end.”– “5. Feeling of overload.It is a physical state, an overload. The feeling is intense, with a sensation of fullness.”– “The sensation is certainly more intense than could be achieved with any drug.”– “This feeling became stronger and stronger, until it became so strong that it was unbearable and led to a loss of consciousness.”– “6. Mystic/religious experience.Maybe the closest sensation that I know would be an orgasm, but what I felt was not at all sexual. I have no religious feeling, but it was almost religious.”– “These experiences brought me confidence. They confirm that there is something that surpasses us.”– “It is a big happening in your life to have these seizures. Thanks to these experiences, I do not fear death anymore. I see the world differently.”– “7. Anxiety.…soon after the very first seizures, an anxiety intermingled very rapidly with the bliss sensation”– “A patient described anxiety because of the anticipated fear of how he would appear to other people during his complex focal seizures. However, as the bliss increased, it overcame the associated anxiety.– Recently, it has been proposed that ecstatic epileptic symptoms may localize the beginning of the seizure  in the anterior-dorsal insular cortex . Also, the Geschwind syndrome  and discharge propagation, or the directly connected target areas within the network, determine the clinical presentation (“symptomatogenic zone”), but also the temporal relationship of the dynamic interplay between them during the ictal event , facilitate rapid seizure propagation, from and to, insular and connected areas of the epileptic network. Depending on the exact distribution of the ictal discharge, this propagation is likely the cause for individual manifestations of ecstatic auras associated with different symptoms like olfactory, gustatory, or bodily sensations  of several regions in the network of the anterior-dorsal insula . The coverage of the anterior insula activated by the usual electrical stimulations could be too limited to induce such complex cognitive/emotional symptoms. In addition, although being the most direct approach to brain neurophysiology, electrical brain stimulation has some important limitations. It is difficult to estimate the extent of the brain volume that is activated by stimulation, but it is around several mmIn the following section we discuss the semiology of ecstatic auras in the context of the multiple functions of the insular cortex. The insular cortex is a rather old structure, and during hominoid evolution, the anterior part has particularly undergone an important volume increase and differentiation  receives fibers from entorhinal cortex. It projects to the anterior cingulate cortex (ACC), temporal pole, limbic structures, medial ventral striatum, and lateral hypothalamus  receives fibers from the primary somatosensory area and the superior temporal sulcus. It projects to the ventral prefrontal and orbitofrontal cortices, frontal operculum, pre-supplementary motor area, secondary somatosensory cortex, superior temporal sulcus, amygdaloid regions, entorhinal and perirhinal cortices, and the central and lateral ventral striatum  receives fibers from the primary somatosensory cortex, retroinsular area, superior temporal sulcus, basolateral amygdaloid body, entorhinal cortex and dorsolateral striatum. It projects to the supplementary motor area, ventral prefrontal cortex, secondary somatosensory area, temporal pole, retroinsular area, and dorsal thalamus .von Economo neurons (VENs), which are atypically large and spindle-shaped pyramidal neurons , and depression (20%), while ictal joy is only rarely reported  at the utmost positive valence: all patients underline the extraordinary blissful moment. As to the degree of arousal during ecstatic auras, however, there is a certain paradoxical situation: many patients report simultaneously both high arousal emotions like power or joy, and low arousal emotions like peacefulness or transcendence. Despite the peacefulness, patients describe that they feel extraordinarily alert and highly aware of the “here and now” during the episodes. We suggest therefore that (b) the semiology of ecstatic seizures is not obviously correlated with the degree of arousal, according to the categories proposed in this model. The reason for this ambivalence in arousal appraisal can possibly be found in the unusual emotional nature of the ecstatic state itself, “never felt in everyday life.”Different neuroimaging studies have shown that insula and amygdala responses predominantly reflect stimulus valence interacting with intensity and arousal effects  in the “salience network” , giving rise to a feeling of heightened perception of the (body) self and of the neighborhood . This paradox of the heightened self-awareness in combination with a feeling of union with the world, could be related to an intensification of the “sentient self” and a functional extinction of the “narrative,” autobiographical self, which is prominent during mind wandering and related to the activity of the default mode network  using emotional tasks  or more oriented toward the external world . Could this, as well as differences in valence, possibly be related to differences in predominating activity in the left or the right insula? Or could there be differences according to the insular subregions involved, as shown for the anterior cingulate cortex where a rostral subregion was activated by reward and a caudal subregion was activated by negative aspects of reward processing  and experimental paradigms using aversive learning .This remarkable paradox explains the general fascination for the ecstatic auras. Similar experiences might have influenced religious beliefs over time, and therewith have had an impact on the history of human culture.MG was supported by the Swiss National Science Foundation No. 33CM30-124115. FP by the Swiss National Foundation No. 320030-127608.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. The Associate Editor VM declares that, despite of being affiliated with the same institution as the author MG, the review process was handled objectively.


Perceptual science has frequently benefited from studying illusions created outside of academia. Here, we describe a striking, but little-known, example of inattentional blindness from the British comedy series “Monty Python's Flying Circus.” Viewers fail to attend to several highly incongruous characters in the sketch, despite these characters being clearly visible onscreen. The sketch has the potential to be a valuable research and teaching resource, as well as providing a vivid illustration of how people often fail to see something completely different. Researchers have long had an interest in inattentional blindness, with, for example, Despite widespread interest in inattentional blindness, most researchers are unaware that a striking example of the phenomenon appears in the British comedy series “Monty Python's Flying Circus.” Episode 12 of the second series of Monty Python's Flying Circus aired in December 1970 contained a short sketch entitled “Ypres 1914—Abandoned.” This sketch takes place during the First World War, and begins with a close-up image of a harmonica being played by a British soldier (Eric Idle). The camera then slowly zooms out to reveal four soldiers  sitting in an army encampment. Standing behind them are several actors dressed in a series of highly incongruous costumes, including that of a nun wearing a large white hat (Graham Chapman), a sheikh, and a Greek Orthodox priest. The film then cuts to a shot of the soldiers from another angle, and additional incongruous characters can be seen behind them, including a Viking and a topless man wearing a vibrant blue “Hawaiian” skirt. The incongruous characters are visible during the scene, with the nun being especially prominent see . Two of N = 54) to discover the percentage of people that fail to perceive the incongruous characters, despite them being in full view throughout. The sketch was shown via a projector (image approximately 2 m wide) and participants watched en masse in a classroom setting. Immediately after viewing the film, participants were presented with a two-item questionnaire. First, participants were asked “Did you notice any of the unusual characters  before they walked out of the scene?” . 70.4% of participants failed to notice the incongruous characters prior to them leaving the scene. Second, those participants who had failed to notice the incongruous characters were asked “Are you surprised that you didn't notice any of the unusual characters before they walked out of the scene?” . 78.9% of participants expressed surprise that they hadn't spotted the characters. In short, as expected, the sketch produces a strong inattentional blindness effect.We showed the sketch to a group of undergraduates (N = 74). The sketch was shown under the same conditions as before  and participants were presented with the same questionnaire immediately afterward. 62.1% of participants still failed to see the incongruous characters prior to them leaving the scene, and there was no significant difference in detection rates with and without the initial close-up shot  = 0.33), suggesting that the inattentional blindness effect produced by the sketch does not rely on the initial focusing. Additional work could examine other potential factors, including, for example, the sense of narrative and the soldiers chatting.The Python team may have intentionally created the sketch as a funny and clever perceptual illusion, a metaphor for how those involved in the First World War were often blind to the larger context of the conflict, or simply a piece of surreal humor. Either way, just as research into other illusions created outside of academia have proved beneficial to perceptual scientists (see, e.g., the “cafe wall illusion”  and conjIn short, it's hoped that Monty-Python's “Ypres 1914—Abandoned” sketch will now act as a useful teaching and research resource, and illustrate how we can all sometimes fail to see something completely different.


Cardiovascular diseases are the leading causes of death around the world. The coronary artery disease (CAD) is one of the most common diseases in this category, which can be the trigger to various psychosocial complications. We believe that inadequate attention has been paid to this issue.The purpose of the present study was to explore the psychosocial complications of CAD from the Iranian patients’ perspective.A qualitative design based on the content analysis approach was used to collect the data and analyze the perspective of 18 Iranian patients suffered from CAD, chosen by a purposeful sampling strategy. Semi-structured interviews were held in order to collect the data. Sampling was continued until the data saturation. The data were analyzed using qualitative content analysis approach by MAXQUDA 2010 software.This study revealed the theme of the patients’ challenges with CAD. This theme consisted of: "primary challenges," including doubting early diagnosis and treatment, and feeling being different from others; "psychological issues," including preoccupation, fear of death and surgical intervention, recurrence stress , anxiety and depression; "problems of life," including financial problems, work-related problems, and family-related problems; and "sociocultural issues," including change in perspective of people towards the patient, and cultural issues.Although the management of physical problems in patients with CAD is important, psychosocial effects of this disease is more important. Thus, health care personnel should pay ample attention to identify and resolve psychosocial problems of these patients. Results of this study can be used to empower these patients. Today, because of mechanistic lifestyle, technological progress, overpopulation in urban areas, changes in lifestyle and tendency toward bad habits, cardiovascular diseases (CVD) are increasing worldwide . StudiesCoronary artery disease (CAD) is one of the most important causes of death in the United States (USA). Based on estimates, 1250000 cases of myocardial infarction (MI) happen in the USA every year, which 50000 of them ended in death. The annual global death rate caused by MI is around four million . Rate ofCoronary artery disease causes various problems for the patient and his/her family. Absence from work, high cost of treatment, and morbidity impose pressure to the community resources. However, CAD prevention can reduce these losses significantly .Patients with the history of MI or coronary artery bypass graft (CABG) surgery experience radical changes in their health status. They should adjust to these changes; otherwise, they will be unable to cope with the health-care plan . AlthougIn training the medical personnel to deal with MI, the treatment and pathological processes are emphasized more than the psychosocial consequences of the disease. However, long-term quality of life significantly depends on psychosocial outcomes and their management during the medical care . IncreasThis qualitative study aimed to explore CAD psychological complications from the perspective of these patients in Iran to provide the required knowledge for both caregivers and sufferers to prepare an appropriate empowerment process.We used a qualitative research method with a content analysis approach. Qualitative research is an appropriate tool to get in-depth information from the patient's perspective . The resThe participants should express their experiences willingly and coherently. In a qualitative research, the sample size is variable and researchers must continue the sampling process to a point at which a new idea is obtained , 11. ThuAt first, we explained the aim of the research to the participants. They were informed that participation in the study was voluntary, and they could withdraw from the study at any time. The participants were reassured that their identity would not be revealed in the research report. Then, the participants signed a written form of consent agreeing the recording of the interview.This research was approved by the Ethics Committee of the Mashhad University of Medical Sciences (No: 900569).Semi-structured interviewing was used for data collection; it is an appropriate method for qualitative researches because of its flexibility and comprehensiveness . The priQualitative content analysis was used for subjective interpretation of the text data. In this method, codes and themes are identified via systematic categorization. Content analysis does more than merely extract objective data; it also helps to reveal hidden themes and patterns within the data . To this end, the analysis was carried out based on Graneheim and Lundman approach . The visLincoln and Guba (1985) proposed the criteria to enhance the rigor of a qualitative research, which comprised credibility, transferability, dependability and conformability . In thisThe principal investigator collected and analyzed the data while the others checked and verified the results. The participants were selected by considering the maximum variety in their gender, age, family history, treatment, duration of disease, educational and job background, to ensure the transferability of the study.Our study categorized the theme of patients’ challenges with CAD. This theme consisted of: "primary challenges," including doubting primary diagnosis and treatment, and feeling being different from others; "psychological issues," including preoccupation, fear of death and surgical intervention, stress due to recurrence of disease, anxiety and depression; "problems related to life," including financial problems, work-related problems and family-related problems; and "sociocultural issues," including change in perspective of people towards the patient, and cultural issues. This theme and its subthemes characterize the psychosocial consequences of coronary artery disease in Iranian patients .At the early stages of the disease, participants doubted the primary diagnosis and treatment. Thus, they kept searching for more reliable diagnoses and treatments. They were referred to equipped centers and more-experienced physicians and specialists for consultation. One participant (No. 8) commented: “Patients should consult with expert physicians not just anyone. A doctor, who suggests doing something and going somewhere specific, should be an expert in that field.” Participants felt overprotected by their family and relatives. One participant (No.16) said: “My brothers, children, bride, and groom tell me ‘don’t work’, ‘be careful’, ‘don’t put pressure on yourself’.”Patients’ thoughts were preoccupied by their disease and its outcome: “What will happen to me? Is it necessary to have a surgical operation? and what are the consequences?” They related almost everything to their disease even if it did not have the slightest relevance to their disease. One participant (No. 2) stated: “I didn’t think about the disease in the past but now if I want to do any work, I feel that this heart disease is with me. It comes to my mind. If I want to do anything this disease is with me.”Most of the people suppose that heart disease equals death and because of this, they are terrified even by a chest pain, thinking that they may die from it. One participant (No. 12) said: “From the day I was told that my heart had a problem, I felt anxiety. This is because, I had a peer who was told the same; he paid no heed and died”.More invasive treatments such as angioplasty, stent placement, and CABG are horrifying for them. One participant (No. 5) commented: “I was terrified when they told me that I must have a heart operation. I told them no, I wouldn’t allow that. They told me that you must have an emergency operation. I was very terrified”.Recurrence of the disease manifests itself as a persistent worry. One participant (No. 11) pointed out: “Stress doesn’t vanish. This is one problem. Stress isn’t just a word to use and then finished! In fact, it is with me everywhere. It's really disturbing because I can't even go about my daily decision-making without feeling stressed”.One participant (No. 10) about anxiety commented: “If the meal was harmful, I thought it was related to this disease, and my heart would hurt. I was worry. My mobile was with me everywhere, and I felt anxiety every day”. Another participant (No. 4) about depression stated: “When someone comes to visit me, they love to see me in the same state as I was before. They expect me to be as I was in the past. Neighbors and relatives got upset, and they tell me that I am depressed because I don’t speak as much as I did”.The cost of diagnosis and treatment is very high, especially if the patients need operations such as, angiography, angioplasty, stent placement, or CABG. The problem got worse, if they did not have any kind of complementary health insurance. One of them (No. 18) commented: “It would have been better if I hadn’t had any pressure in my life. It will be a real problem for me if I want to borrow money for hospitalization. This stress affects my disease”.These patients mostly cannot do their job, especially hard work such as agriculture. Moreover, they also try to be cautious. One patient (No. 9) mentioned: “I can't work in the farm. I can't do any of the things I used to do before my heart attack and surgery. I can't do anything.” After CAD, not only the patients but also their families got worried. However, the family forbids them and tries to do those duties instead. Moreover, going to hospitals and visiting doctors can affect the everyday duties or routine of the patients and their families; therefore, their lives do not follow a natural course either. Another example of this subtheme includes limitations of the patients and their families’ social life. They are unable to go on vacations and journeys or simply visit other people. One participant (No. 6) commented: “Warm weather is harmful for those who have heart disease. They are depriving of facilities. They can’t travel”. Another participant (No. 7) stated: “My family is sensitive about me. They tell me ‘don’t work’, ‘don’t run’, ‘don’t pressure yourself’, ‘don’t go riding’, ‘don’t do any kind of heavy work’ ”.People show a change in their views through certain conduct and actions, and this makes the patients lose confidence in themselves and start to isolate from the community. One participant (No. 13) commented: “Others see us vulnerable. They feel that we are not able to do work as we used to. They think we have a disease and should be helped”.Iranian patients try to show that they are humble. For example, they eat the same food as the others in parties and family gatherings. Sweet and fatty foods are usually served in these events which are not healthy for CAD patients. One participant (No. 7) said: “Everyone is used to serve a special, culture-based food at home. We used sweet and fat in our meals in the past. This is our culture. In a party, we usually eat fat, sweet, and the best fruits like the others”.Findings of this study can assist to understand better the psychosocial complications of CAD in the Iranian community. The subtheme “doubting initial diagnosis and treatment” is consistent with a research done by Afraciabi Far et al.  . They bMoeini et al. mentioned that ischemic heart disease has multidimensional effects on patient’s life; there are frequent courses of pain that affect patient’s thoughts and feelings . This fiIndratula et al. defined “fear of death and surgical interventions” like our study, and reported that these patients had lost confidence in life and started exhibiting fear of death and disability. Patients were also anxious about the risk of death and inability both before and after their surgery .Arnold et al. highlighted stress of recurrence of the disease and reported medium to high levels of stress after MI even after long term adaptation . The exiShah et al. like our study, found the frequent presence of financial problems in the patients suffering from CAD that was a risk-factor worsening the outcome of MI . LikewisSimilar to our findings, Svedlund et al. , Nasiri With reference to cultural issues, Astin et al. concluded that there may be cultural and ethnical differences in patients and families, which could adversely affect recovery; therefore, health care personnel should bear this in mind when giving service and think up appropriate solutions based on a cultural approach to overcome any problem arising from these differences .Since the heart is one of the most important organs of the body, any heart disorder can be a direct threat to the patient’s identity; thus, the psychosocial complications can be more important than the physical ones. As patients worry about correct diagnosis and treatment of CAD, it is vital that health care personnel pay ample attention to this matter. Sufficient attention must be paid to the psychological and spiritual problems of the patients and giving consultation to alleviate them is strongly suggested.Furthermore, it is also essential for the mass media to educate the public on how to treat patients with CAD. Adequate focus on financial, work, and family problems is of great importance, too. Last but not the least, physicians and health care personnel must consider patient’s cultural background and traditions in order to overcome any cultural obstacles hindering the process of recovery.Since the present research studied a limited number of patients, its generalization to other conditions and situations must be performed with caution. We recommend that similar researches conducted on more patients and in other countries.


Immigrant women may be regarded as a vulnerable population with respect to access and navigation of maternity care services. They may encounter difficulties when accessing culturally safe and appropriate maternity care, which may be further exacerbated by language difficulties and discriminatory practices or attitudes. The project aimed to understand ethnocultural food and health practices and how these intersect in a particular social context of cultural adaptation and adjustment in order to improve the care-giving capacities of health practitioners working in multicultural perinatal clinics.This four-phase study employed a case study design allowing for multiple means of data collection and different units of analysis. Phase one consists of a scoping review of the literature. Phases two and three incorporate pictorial representations of food choices with semi-structured photo-elicited interviews. This study was undertaken at a Prenatal and Obstetric Clinic, in an urban Canadian city. In phase four, the research team will inform the development of culturally appropriate visual tools for health promotion.Five themes were identified: (a) Perceptions of Health, (b) Social Support (c) Antenatal Foods (d) Postnatal Foods and (e) Role of Health Education. These themes provide practitioners with an understanding of the cultural differences that affect women’s dietary choices during pregnancy. The project identified building collaborations between practitioners and families of pregnant immigrant women to be of utmost importance in supporting healthy pregnancies, along with facilitating social support for pregnant and breastfeeding mothers.In a multicultural society that contemporary Canada is, it is challenging for health practitioners to understand various ethnocultural dietary norms and practices. Practitioners need to be aware of customary practices of the ethnocultural groups that they work with, while simultaneously recognizing the variation within—not everyone follows customary practices, individuals may pick and choose which customary guidelines they follow. What women choose to eat is also influenced by their own experiences, access to particular foods, socioeconomic status, family context, and so on.The pilot study demonstrated the efficacy of the employed research strategies and we subsequently acquired funding for a national study. Immigrant women may be regarded as vulnerable populations since challenges exist with respect to access and navigation of health services and more specifically maternity care services . DifficuGlobal migration contributes to increasing diversity within nation states resulting in diverse populations. Immigrant populations in Canada are more diverse than the Canadian-born population in terms of ethnic origin, first language, culture, traditions and socio-economic status . As evidWithout culturally appropriate health care delivery, a negative trajectory of events may occur ranging from simple miscommunication to life-threatening incidents ,9. Poor Epidemiological research from Canada and elsewhere has reported equal or more favorable birth outcomes for migrants -13 suppoAlthough there is no consensus that poor birth outcomes are associated with immigrant women, the potential negative health outcomes include significantly higher rates of gestational diabetes (predisposing the mothers to preeclampsia and type 2 diabetes and their offspring to obesity and type 2 diabetes) , low matThe purpose of this project was to understand ethnocultural food and health practices and how these intersect in a particular social context of cultural adaptation and adjustment in order to improve the care-giving capacities of health practitioners (i.e. maternity nurses) working in a multicultural perinatal clinic located within a hospital. The funding stream awarded for this study has, as its ultimate aim, a goal of enhancing services in the hospital. As a secondary goal, this study aimed to assess the feasibility of the study design, and in turn expand the research with specific immigrant communities residing in different places.We employed a case study design that incorporated a participatory approach . The casPhase One - A scoping review of the literature; Phase Two - Pictorial representations of food choices (photovoice/photo-elicitation); Phase Three – Semi-structured photo-assisted narrative interviews of 10 immigrant women; Phase Four - Production of a culturally appropriate visual tool for immigrant women. The description of the methodological approaches of the all four phases is published, as are the findings from phase one , some of them believed that mother weight gain will reflect the baby’s’ weight Like being healthy in pregnancy eating well, sleeping, sleeping well…you can feel your baby moving, you go to the hospital, they check you and say baby’s okay… But for pregnant women I think we have to take all the veggies, yeah, and the banku and then the fish. Fish and meat is also very good for us. .Healthy foods are not just types of foods, such as “veggies,” “proteins” or “milk”, but also reflect the quality of foods, as illustrated by one participant’s description of the importance of “fresh” foods: “in Chinese culture, people think the black food, red food, are good for our body. Yeah, especially for the blood” [27:2].The following image Figure  was takeConsiderations of how food choices and behavioral practices can affect the health of one’s developing child also affected the health and dietary practices of mothers, and these understandings of how (un)healthy bodies were maintained or developed are partly informed by customary cultural knowledge and practices.Yeah. After delivering baby at least two or three week, traditionally the family support everything. I don’t need to care about the housework; I don’t wash dishes, laundry, anything. Just stay relaxed, take care of your baby” [4:2]. Other women described the intangible emotional encouragement that contributes to the support they receive from others, “When if it’s – let’s say if it’s your first pregnancy everybody like, won’t let you get down from the bed. … they will be very careful for you” [15:1]. There was a wide variety of experiences within this theme, influenced by each woman’s cultural background, socioeconomic status, and access to support networks. Many had relatives living nearby, so there was at least one adult the women could rely on, as one woman noted, “And if my mom is not here, maybe husband prepare everything. … even if he can’t do all but he will have to help something and then leave while these things were okay” [4:2].The role of family, partners, friends, and community members in supporting and enforcing healthy eating and healthy behaviors were highlighted by almost all immigrant women. There were a variety of kinds of support described by participants, including those related to pragmatic everyday activities , as explained by one woman, “No, she tell me every day, “Take care of you, don’t work too much, don’t do something you don’t like it (?).” I say, “Okay, mom.” I said, “Okay, mom.” She’s scared because I’m here just with myself. My husband is not at home sometimes and I have another two boys and this is not easy” [14:1]. Based on the importance of the social support networks described by the women, it suggests that for those without family or friends in Canada or who were unable to speak English, social support may be low or absent altogether. The absence of social support for antenatal or postnatal women can be a significant factor in their antenatal and postnatal choices, behaviors and overall health status.Some women’s support networks were stretched across space. This is exemplified by women receiving advice from relatives over the telephone or internet. For example, one woman from western Africa spoke with her mom regularly via phone and Skype, noting that: “During pregnancy, they said that during pregnancy you should drink as much as you can, so like it makes your uterus like really strong and it makes it like, let’s say slippery so the baby can just slip down, slip down easily” [15:1]. This South Asian woman, pregnant for the second time, heeded the advice of family, despite having lived in Canada for ten years. Thus, not only biomedical health care providers, but also family, are important sources of dietary knowledge.This relates to the foods consumed and avoided before and/or during pregnancy. These choices correlated with cultural beliefs on what a healthy pregnancy entailed, advice given by friends and family, and past pregnancy experiences, as exemplified by: “We were all eating the same thing, the pita, and chapatti during pregnancy” [20:2]. However, in most cases, pregnant women ate more frequently, consumed specific foods thought to improve birth outcomes, and/or ate greater quantities. For example, one South Asian participant [22:2] noted that pregnant women were encouraged to have butter in every meal. “Butter, butter, butter; every meal butter. Even during pregnancy, like after seventh or eighth month, they said if you eat more butter it will soothe all your birth canal so the delivery will be easier.” This echoes the South Asian woman’s comment on the importance of drinking liquids above, so as to improve ease of delivery. Clearly, these ideas are linked to women’s culturally informed concepts of the body, and how bodies work.In some cases, pregnant women continued eating similar foods to what family members consumed, as one participant explained, “And I was not allowed to drink water out of the tap because it was cold, so they always give you warm water to drink, you know, for fear of catching a cold. That’s one thing. But of course, you know, I cannot have water without ice so I’m so used to the cold water” [20:2].Some cultural ideas of food and bodies are based on the concept of balance, originating in various humoral medical systems. For instance, pregnancy in many humoral medical systems is viewed as a ‘hot’ condition, thus ‘hot’ foods must be avoided. This is reversed after birth, where ‘hot’ foods are consumed. This notion of balance is alluded to by this woman, “white’ or have a lighter skin color, and lighter baby signified a healthy baby: the baby will be whiter, the baby. Because the skin color will be lighter, your baby will be healthy. But the milk especially, they - every people, apples and milk” [22:2].Other cultural ideas on the body also impact food practices. For example, a participant described how pregnant women were advised to drink a lot of milk (and apples too) so that the baby would be fair-skinned. This was important not only for aesthetic preferences, but also for the health and wellness of the child: “‘People say caffeine is not good during pregnancy…. I know it’s not good but I just couldn’t, you know, give it up. So I just have to” [20:2]. This participant also noted the common experience of craving familiar foods of home:“Usually, you know, in India when women are pregnant people do go ahead and make special pickles at home because they have the craving. You know sometimes you just want to go and have pickles. Pickles in the sense that yeah, even here, you know, in North America people do want to eat pickles, the bottled ones, you know, the dill or whatever you call them, you know. …they crave for this pickle because it’s a little sour and spicy”.Food cravings were another common experience shaping pregnant women’s food choices. Food cravings may pose a dilemma for pregnant women, in terms of whether to succumb or resist the craving, especially if the food they were craving was viewed as unsafe or unhealthy during pregnancy. For example, one South Asian woman admitted that while “So craving is something. [laughter] But the diabetes was a very big issue. Like my readings go very high during pregnancy, my hormones changes so much. For some people, my doctor was saying, for some people it’s not that bad, but for some people they just mess up all the hormones and mine was one of those.”Food cravings cam become a complex matter for women with an underlying health condition such as gestational diabetes, as one participant [22:2] described; “noting: Yeah, but in our context when we say - let’s say somebody is going to eat banku and pepper, it means you add pepper with tomatoes, with onions, or with ginger and garlic or whatever. But ginger and garlic are optional, so we take pepper, onions and tomatoes, add a little salt to it. You grind them together and then take it with banku, yeah, just to kill the nausea.” [8:2]“Food aversions are also mediated through culturally informed practices. One participant illustrated this through the following image Figure ,Figure 2The ethno-cultural socialization and experiences of women highly influenced their antenatal behaviors, especially in terms of food consumption patterns. For some women, religious beliefs or health challenges limited their food choices, although most seemed aware of possible dietary deficiencies and had alternatives in place. Socioeconomic status was variable among the sample and was not explicitly stated to be an issue affecting the ability to make healthy choices; however, it is worth considering that lower socioeconomic status affects one’s ability to purchase nutritionally dense foods. Geographical location was mentioned by some participants as a factor in their ability to purchase certain seasonal foods, or foods not readily available in Canada as they are in their home countries.In addition, at least one participant mentioned the urban/rural location distinction affecting dietary choices. In terms of availability, the existence of specialty ethnic food stores or aisles in supermarkets allowed most women to find cultural and religiously sanctioned foods, however, some foods were simply not available or too expensive in Canada. Lastly, all of the women in the sample were experiencing high-risk pregnancies, and so they were dealing with previous or developed medical conditions  that affected their choices and behaviors.you eat some sweets, the sweets will give you milk for the baby, and nuts. And we drink like hot tea with cinnamon, cinnamon with ginger for cleaning the blood after delivering the baby” [7:1]. Following such beliefs often depended on having the social support, typically of a female kin, who would prepare these foods, teach which foods ought to be consumed in the forty days post-birth, and who could ensure the new mother rested and followed these post-birth food traditions . Women that had previous children referred back to those experiences when making choices regarding food practices, and her educational status was an important factor in how post-birth food traditions were adhered to.Immigrant women were very concerned about the foods that are consumed or avoided directly after and in the forty days following birth. These choices correlate with cultural beliefs surrounding health and healing, production of breast milk, and advice from social networks. For instance, “So the palm fufu, if it’s in the afternoon your mommy will bring fufu and soup and then you take for you to replenish your energy that you spend during bearing [child], and then the soup itself, you will drink it, for you to get enough milk, yeah, to come” [8:2] , the doctor prescribed the meals for the first few days. However, for a normal vaginal delivery in a hospital, regular light, semi-liquid, energy rich foods were provided. But many women also described the foods their female kin would prepare: “Because they said if you eat more of those starchy foods they will make you more gassy and the baby will be more uncomfortable, so try to avoid starchy food - rice, more pitas. Try to fill your stomach with more proteins, even though nuts or whatever you can” [22:2]. Another participant provided images . One woman noted, “mom taught me like that and, yeah, she’s teaching me like that. Also, I am going to do [i.e. teach] my daughter, yeah” [4:2]. Women’s relatives are frequently the first source of advice and ministrations, but many women also rely on their experiential knowledge, as illustrated in the following exchange:P: I would say all of them, because that was the food I was eating.I: Why do you feel that those foods are healthy while you’re pregnant?P: Because I’ve been eating [these foods] since I was born so I don’t see anything [wrong]. [10:2]Another woman shared, “The foods this woman had consumed for her entire life could not possibly be unhealthy, for in this woman’s opinion, she would have previously suffered illness if that was the case. This is an important consideration for health care professionals, to navigate cultural norms and individual experiences when advising on healthy dietary practices.Because all participants were experiencing high-risk pregnancies and dealing with a variety of health issues, many referenced these experiences when explaining their food choices.Through the process of immigration, some of the women exhibited acculturation in the food choices and in the acceptance of Western biomedical understandings of pregnancy. Furthermore, some women decided not to adhere to “traditional” guidelines. However, the women in this sample largely favored advice given by family members, continuing to follow customary food practices of their foremothers.The scoping literature review emphasizes the limited amount of data on this topic. More studies are required to elicit deeper understanding of ethnocultural food choices and practices, in order to fully inform processes to improve cultural competency of maternity care. Therefore our pilot study using photovoice and photo-assisted interviews had provided deeper understandings of ethnocultural food choices and practices. Our findings from the photo-assisted interviews validates the finding of the scoping review that there is a complex interplay of cultural, social, and economic factors exists to affect the food choices, intake and nutritional adequacy for pregnant immigrant women .Family and social support during pregnancy was important for participants, especially when they are not with their extended family post-migration, as has previously been reported ,43. ImmiThe role of health practitioners, especially medical doctors were identified as an important source of information in our study. One possible reason we found health personnel as important sources of dietary information is the location and context of the study. The clinic is recognized for providing language interpretative services for diverse cultural groups. Conversely a few studies have reported that immigrant women experience difficulty in following healthy diet advice during pregnancy that is provided by health care personnel. Some studies indicate this is most challenging when they are from low-income groups ,45,50, aOur study provides a snapshot of relatively recent immigrant women’s experiences, which had little prior exposure to the Canadian health care system and reproductive health  practices. The thematic analysis emphasizes the importance of local social milieus of immigrant women in providing the context for healthy practices and behaviors. Sources of nutritional knowledge include female family members, but also health practitioners. This is an opportunity to incorporate cross-cultural normative practices when advising immigrant women on health dietary practices during pregnancy. We suggest that honoring and respecting traditional knowledge will potentially make it easier to explain biomedical dietary norms and recommendations.Based on our findings, we recommended that clinicians working within our hospital partners’ setting: (a) look for intersections in cultural food practices during pregnancy with biomedical recommendations and build upon these when providing dietary advice; (b) infrastructure and policy activities of the hospital should continue building collaborations with various ethnocultural communities beyond language translation services to support health pregnancies, recognizing the particular constraints and opportunities in various immigrant communities ; and, (c) Health care policies of the hospital need to provide support for practitioners, particularly with respect to cultural knowledge they may need to improve their effectiveness, perhaps during some of the regular training sessions.Recruitment from the diverse ethnocultural group was the key challenges in this research project. To recruit women for the study, we relied on our hospital partners. Although the study was initially conceived to include Aboriginal pregnant women, this was not done because the Aboriginal hospital coordinator left the position and the team decided that without an Aboriginal coordinator/liaison it was not appropriate to proceed. Although our hospital partners working with immigrant women were enthusiastic, recruitment proved to be time-consuming, and recruitment involved additional time constraints on our partners’ schedules. To assist with recruitment, a brief information sheet with permission to contact  was developed. It also seemed that women were often in the latter part of their pregnancies when recruited, and in a few cases this meant that they were no longer pregnant by the time they were contacted. Furthermore, the hospital setting arguably had stressful connotations for potential participants which may have influenced their willingness to participate. Consequently, of the twenty-one women who indicated that they would be willing to be contacted, only ten agreed to participate in the pilot study. Clearly potential and actual participants had many stresses to grapple with and participation in this research study, even for those who were interested, was not always possible. A high-risk pregnancy is stressful for anyone, but particularly so for those who may have cultural and/or linguistic barriers and limited social support networks.Our study sample consisted of women mostly from South Asia (six out of ten). Among our participants, shared dietary experiences when pregnant post-migration centered on the importance of support networks for pragmatic and emotional support while pregnant, and as knowledge sources for appropriate dietary practices . Although this seemed salient for all our participants, it ought to be kept in mind that immigrants from other places, particularly Latin America which was not represented in our sample, may have other factors shaping food beliefs and practices in pregnancy and in the immediate post-natal period. Furthermore, all the participants were experiencing high-risk pregnancies, and this may have influenced our results. Nevertheless, findings of this pilot study did enable us to progress to a large national study, in which we are currently examining immigrant pregnant women’s food beliefs and practices from select ethnocultural groups, to better understand variations in beliefs and practices between and within specific immigrant communities .In a multicultural society that contemporary Canada is, it is challenging for health practitioners to understand various ethnocultural dietary norms and practices. Practitioners need to be aware of customary practices of the ethnocultural groups that they work with, while simultaneously recognizing the variation within—not everyone follows customary practices, or individuals may pick and choose which customary guidelines they follow. It is critical that health care providers recognize the complexity in cultural food and health beliefs and practices, and how socioeconomic status, age, ethnicity and family structure and support may differentially shape these beliefs and practices. Findings of this project are valuable for health practitioners to recognize that not all women accept customary dietary rules. What women choose to eat is also influenced by their own experiences, their access to particular foods, their socioeconomic status, family context, and so on. Thus, it is important to not assume that all people of a particular cultural group share the same dietary notions and food practices. The project team suggest that building collaborations between practitioners and communities to support healthy pregnancies and social support for pregnant and breastfeeding mothers is of prime importance. Working with community organizations will also be important in continuing to develop culturally appropriate dietary recommendations that incorporate biomedical knowledge and customary practices. The pilot study enabled us to establish the feasibility of our approach in terms of methodology and recruitment strategies for a larger study; in particular, we realized that recruiting at the perinatal clinic was not the best approach, so for the larger study we partnered with community groups for recruitment of immigrant women with normal pregnancies. For our hospital partner, we recommended that policies and practices ought to consider cultural food practices, building on traditional strengths while addressing customs that may not be ideal for the health of the mother or child. It cannot, though, be forgotten that additional approaches such as social and financial assistance programs addressing the array of health determinants are also required. These findings may be useful in other clinical settings providing care for immigrant women.


Retrieving relevant biomedical literature has become increasingly difficult due to the large volume and rapid growth of biomedical publication. A query to a biomedical retrieval system often retrieves hundreds of results. Since the searcher will not likely consider all of these documents, ranking the documents is important. Ranking by recency, as PubMed does, takes into account only one factor indicating potential relevance. This study explores the use of the searcher’s relevance feedback judgments to support relevance ranking based on features more general than recency.It was found that the researcher’s relevance judgments could be used to accurately predict the relevance of additional documents: both using tenfold cross-validation and by training on publications from 2008–2010 and testing on documents from 2011.This case study has shown the promise for relevance feedback to improve biomedical document retrieval. A researcher’s judgments as to which initially retrieved documents are relevant, or not, can be leveraged to predict additional relevant documents. When a person judges a document to be relevant to a particular query, or information need, such a judgment is called a relevance judgment. Relevance judgments have been used to evaluate document retrieval systems since the 1950s . RelevanThe 1990s was a time of innovation in the development of large-scale information retrieval systems in the medical, legal, and aerospace domains and on the Web. Until that time academic research on information retrieval had little connection with commercial online information retrieval systems. The commercial systems all used Boolean exact match retrieval, while academic researchers studied vector space or probabilistic retrieval models, which ranked documents according to relevance in response to a user’s query. In 1992, West Publishing Company, the legal publisher, introduced a ranked retrieval search mode for its Westlaw retrieval system. Westlaw’s probabilistic retrieval algorithm is based on Bayesian belief networks .Lexis-Nexis, the other major legal retrieval system, and DIALOG, a widely-used retrieval service, also developed ranked retrieval search modes within a year. These three were the first large-scale commercial retrieval systems providing relevance ranking. Any document retrieval system that displays lists of retrieved documents in response to a query needs to rank documents. Before the 1990s, however, commercial systems did not rank based on relevance, but rather ranked based on some objective feature of the document, e.g., its recency of publication. Biomedical searchers are often interested in finding the most recent papers, but recency is only one factor that might be used to predict relevance. Searchers using each of these three retrieval systems, however, had the option of using the traditional Boolean search mode as well, rather than the new ranked retrieval mode, and the vast majority of users continued to use Boolean search. At the National Aeronautics and Space Administration (NASA) and at the European Institute of Cognitive Sciences and Engineering (EURISCO) research projects during this same period focused on developing machine learning algorithms to model the information needs of individual searchers who searched through technical documentation on a daily basis –14.While informatics researchers in the biomedical domain eventually explored many techniques for information retrieval and extraction, as well as automated curation, retrieval systems, such as PubMed , the NatDuring this same time the World Wide Web was introduced, and there were soon Web search engines. Early Web search engines used the same ranked retrieval approaches developed in academia and implemented in legal and other search services. These approaches did not work well on the Web and were soon replaced by new algorithms, such as Hubs and Authorities , or PageOntologies and taxonomies, such as UMLS or the KeyNumber system are costly to develop and maintain. Furthermore, a searcher may not view her, or his, research area in the same way as the creators of ontologies or taxonomies. In a rapidly developing field such as the human microbiome, terminology may evolve quickly. The attraction of ranked retrieval algorithms is that they can make use of the full text of documents to rank documents for searchers. The example of early Web search engines shows that having the full text may not be enough. A Web search would typically return, say, 5,000,000 results with a very poor ranking of the documents. A similar point was shown in the 1970s for the legal domain, when full text retrieval systems first became available . Attornen ranked documents are relevant and then proceeding as though a user had judged each of these n documents to be relevant. From 2008 to 2010 the TREC conference held a relevance feedback track [Laboratory experiments in academia have often shown dramatic gains from using relevance feedback . Once rack track . DespiteBy the user or questioner—person who posed own question made the judgment as well;By a user surrogate(s)—such as a specialist  who perform judgments on the topic of a given question in their specialty;By an information professional  who is professionally entrusted or involved with some aspect of the process, who performs judgments on the topic of a given question that is not necessarily in their specialty, but is familiar with what is going on; andBy “bystanders” signifying none of the above—for example, by students asked to do a given task of judgment, including possible prescreening.The objective of relevance judgments in IR tests is to get as close as possible to real-life situations so that test results would have real-life validity. This is very, very difficult to achieve. Thus, simulation methods have been developed. Basically, there are four methods by which relevance judgments have been obtained that are regarded as gold standards:The first method involves “real users” and the others “laboratory-type users”.An issue with most relevance feedback studies, as well as with evaluations of retrieval systems more generally, is that relevance judgments are not provided by real users with real information needs. Rather, as with the evaluations done for the Text REtrieval Conference, or, TREC , one or Very few evaluations of document retrieval systems have used relevance judgments as described in method one. For example, the TREC conference primarily uses method two and, to some extent, methods three and four. For previous evaluations using method one, Saracevic mentions only Lancaster’s evaluation of the National Library of Medicine’s Medical Literature Analsyis and Retrieval System (MEDLARS)  and SaraThe information retrieval problem is to find the right document, or documents, that will help satisfy a searcher’s information need. While there are many types of information need, e.g., to find a known item, more generally, a more complex information need can be regarded as a mental state representing a gap in the searcher’s knowledge. Information found in one or more documents, which may satisfy this information need, is an expression of knowledge represented in the mind of the author of the document. An information retrieval system, such as PubMed, of course, has access to neither the searcher’s information need, nor the knowledge in the mind of the author. Instead, the retrieval system has the searcher’s query and some representation of the document, say an abstract and descriptors, or possibly the full text of the document.Relevance is one of the fundamental concepts of information retrieval. Many definitions have been proposed –33. ManyIn the past most searching, particularly in the biomedical and legal domains, was done by professional searchers. Often these searchers were trained reference librarians who engaged in a reference interview with the researcher who needed the information so that the searcher could express the researcher’s information need correctly, usually as a Boolean logic expression with search terms connected with logical operators such as AND, OR, or NOT . For exaToday manual curation in the medical and legal fields, i.e., the assignment of metadata to documents by domain experts, as described above, continues, though generally a researcher does her or his own searching. Traditional retrieval systems were bibliographic retrieval systems. The record for each document only included metadata. If any of the textual content of the document were included, it was only the abstract. In today’s retrieval systems, the full-text of the document is usually available to search. This is true of Web search engines as well as legal information retrieval systems and medical retrieval systems such as PubMed Central . While WThe study of the human microbiome is a cross-disciplinary, rapidly evolving field. As such it can be difficult for a clinical researcher to find relevant papers from the literature. Medical literature search can be cumbersome, incomplete, and produce “islands” of references that are not integrated or miss large amounts of relevant data. Arguably, relevance feedback can help alleviate this problem. Once a researcher has identified, through the provision of relevance judgments, a seed collection of relevant, and non-relevant documents for her or his research, these documents can be used as a model of that researcher’s information need, which is potentially a much more powerful representation of the researcher’s information need than the PubMed queries which were used to retrieve the documents for review. These queries retrieve documents that match the specification of the query, but which may, or may not, be relevant. Once a researcher has indicated which documents are in fact relevant, the relevant, and non-relevant documents can be used as positive and negative examples for machine learning algorithms to predict the relevance of additional documents. By reading each relevant and non-relevant document a person with domain knowledge could gain a good understanding of what constituted a relevant document for this researcher.Our research seeks to establish whether an automated approach could simulate this understanding, i.e., of what distinguishes a relevant from a non-relevant document for this researcher, in order to predict which as yet unseen documents the researcher would judge relevant. The goal of this study is to show that the words, and their within document and overall frequencies within the collection of reviewed documents, taken from documents judged to be relevant and non-relevant to her information need by a human microbiome researcher, can be used to predict the relevance and non-relevance of additional documents to her information need. This technique is called relevance feedback. While we have not implemented relevance feedback in an operational document retrieval system, we have provided a case study of the effectiveness of a relevance feedback component of an operational system.Our initial hypothesis was that we could use our searcher’s relevance judgments on the approximately three quarters of the documents published during 2008–2010 to predict her judgments for the quarter of the documents published in 2011. Since the field of human microbiome research is evolving very rapidly, we thought that the language of the 2008–2010 documents might not predict which documents from 2011 were relevant, as well as might be the case if the field were not so rapidly evolving. Accordingly, we also did another set of experiments in which we pooled all of the documents and used ten-fold cross-validation.Figure For this study we retrieved 658 documents, using six PubMed queries, for one of the authors, a neonatal human microbiome researcher. She judged each one of these documents as relevant, possibly relevant, or not relevant. Two of the queries, “gut AND microbiome” and “intestine AND microbiome”, retrieved largely overlapping sets of documents, so documents returned by the latter query were not judged. In addition on a second examination of the documents, for the documents judged relevant, she further categorized the documents as relevant for: a) the methodology, b) relation to her specific research question, or c) for her bibliography. Also on this second examination she reviewed documents in greater detail for which she felt less certain of her initial relevance judgments. Some of these original judgments were changed. Of the 401 documents that were judged only 201 were used for the experiments. Some of these documents were duplicates, i.e., retrieved by more than one query, while others were not used because electronic full text versions of the papers were not readily accessible.html version of documents available through the linkout functionality of PubMed. After stripping the html files of markup, stopwords were removed using a standard stopword list. Once stopwords were removed a representation was created for each document. This representation was a vector with a component for each word in the collection. For each component of the vector the corresponding count of the word in that document was entered. This representation was then converted into the ARRF format used by WEKA (see below) to represent feature vectors for machine learning. All experiments were binary categorizations. The documents judged by the researcher to be possibly relevant were alternatively considered relevant, or non-relevant, i.e., we merged the possibly relevant, or “maybe”, documents alternately with either the relevant, or non-relevant, documents as shown in Tables To assemble a collection of documents for training and testing the machine learning algorithms, scripts were written which pulled the Most research on relevance feedback has represented documents using a bag-of-words representation, i.e., wherein a document is represented by the frequencies of words appearing in the document. Using the bag-of-words representation, after common stop words, such as “and” and “the” are removed, a document is represented by the frequencies of the unique words that it contains. These “words” are usually not true words, but rather word stems, such as “comput”, which represents “computer” as well as “computed” or other variations. It is possible to represent a document using a much richer representations using methods from natural language understanding. Such representations might predict relevant documents more accurately, but would also be more expensive computationally to implement. In the future we plan to experiment with richer representations of document content, e.g., based on the concepts contained in the documents as represented in ontologies.Table n = 19, for the testing on 2011 documents. Our results show the importance of having the researcher express her relevance judgments as “yes”, “maybe”, or “no”. Predicting which documents she will judge relevant, whether based on tenfold cross-validation, or on predicting relevance for 2011 documents based on training on pre-2011 documents, is noticeably more accurate when “maybe” judgments are folded in with “no” judgments than when “maybe” judgments are folded in with “yes” judgments.Table In our study we show that relevance feedback from a human microbiome researcher can be used to predict the relevance, for that same researcher, of unseen additional documents. We have not deployed this relevance feedback capability in an information retrieval system, but our task can be seen as a surrogate for the relevance feedback functionality of such a system. In an operational information retrieval system it may not seem practical to ask a searcher to provide relevance judgments for every retrieved document, as we have done in this study. On the other hand, much use has been made of implicit relevance judgments, particularly by Web search engines . SystemsOur results are positive when judgments of maybe relevant are converted to not relevant, i.e., as shown in Tables To obtain substantially better results, though, we believe that richer representations will be needed. The bag-of-words approach can be effective for topic categorization, e.g., that a document is about the microbiome, or is not about the microbiome. For example, in the legal domain one of the authors was able to categorize case law documents as being on the topic, or not, of bankruptcy with a 0.8193 recall rate and a 0.6898 precision rate, though other categories, such as government benefits, were harder with only a 0.2586 recall rate and a 0.3652 precision rate being achieved . Recall Our case study has shown that the relevance feedback judgments of a human microbiome researcher can be used to effectively predict the relevance of additional documents. If these results can be replicated with studies of the relevance feedback judgments provided by additional biomedical researchers, then a proof of concept will be given for the utility of a relevance feedback capability as a component of a biomedical information retrieval system. As mentioned above, such systems are already being used, e.g., RefMed .