Accidents in the home among children under 5: ethnic differences or social disadvantage?

Accidents in the home to children under 5 in a multiracial population with a high level of social disadvantage were studied by interviewing at home the parents of 402 children attending the accident department of a west London hospital during one year. The parents'' country of birth, whether they were employed, and their housing conditions were recorded using the definitions of the 1981 census. Four ethnic groups (British (183 children), Asian (127), Caribbean (61), and other (31)) were identified. Though attendance rates based on the populations of electoral wards at the census and standardised for distance from the hospital showed no significant differences among the ethnic groups, there was a strong gradient by social class and strong associations with unemployment of the mother (although not of the father), overcrowding, and tenure of housing.Social disadvantage seems to be more important than ethnicity as a determinant of accidents to children in the home.     

Using behavioural and state variables to identify proximate causes of population change in a seabird

Changes in animal population size are driven by the interactions between intrinsic processes and extrinsic forces, and identifying the proximate mechanisms behind population change remains a fundamental question in ecology. Here we report on how measuring behavioural and state proxies of food availability among populations experiencing different growth rates can be used to rapidly identify proximate drivers of population trends. In recent decades, the Cape gannet Morus capensis has shown a major distributional shift with historically large colonies in Namibia decreasing rapidly, whilst numbers at South African colonies have increased, suggesting contrasting environmental conditions in the two regions. We compared per capita growth rates of five of the six extant colonies with foraging range (using miniaturised Global Positioning System loggers), foraging work rate, food delivery rates and body condition of breeding adults. We found significant associations between the rate of population change, individual behaviour, energetic gain and body condition that indicate that recent population changes are associated with extrinsic effects. This study shows that behavioural and state data can be used to identify important drivers of population change, and their cost-effectiveness ensures that they are an appealing option for measuring the health of animal populations in numerous situations.     

Animal Housing and Welfare: Effects of Housing Conditions on Body Weight and Cortisol in a Medium-Sized Rodent (Cavia aperea)

Rodents are the most abundant experimental nonhuman animals and are commonly studied under standard laboratory housing conditions. As housing conditions affect animals' physiology and behavior, this study investigated the effects of indoor and outdoor housing conditions on body weight and cortisol level of wild cavies, Cavia aperea. The changing housing condition strongly influenced both parameters, which are commonly used as indicators for animal welfare. The transfer from outdoor to indoor enclosures resulted in a body-weight loss of about 8%. In contrast, animals kept indoors showed a substantial weight gain of about 12% when they were transferred outdoors. These effects were reversible. To substantiate a connection between body-weight changes and the health states of the animals, blood basal cortisol concentrations were measured. Animals kept outdoors had significantly lower cortisol levels than did animals kept indoors. These results imply that indoor conditions have a direct effect on the animals' states. The physiological and metabolic consequences as well as potential welfare aspects should be taken into account when planning experimental work, especially on nondomestic animals.     

Home Foreclosure,Health, and Mental Health: A Systematic Review of Individual,Aggregate, and Contextual Associations

Background

The U.S. foreclosure crisis intensified markedly during the Great Recession of 2007-09, and currently an estimated five percent of U.S. residential properties are more than 90 days past due or in the process of foreclosure. Yet there has been no systematic assessment of the effects of foreclosure on health and mental health.

Methods and Findings

I applied systematic search terms to PubMed and PsycINFO to identify quantitative or qualitative studies about the relationship between home foreclosure and health or mental health. After screening the titles and abstracts of 930 publications and reviewing the full text of 76 articles, dissertations, and other reports, I identified 42 publications representing 35 unique studies about foreclosure, health, and mental health. The majority of studies (32 [91%]) concluded that foreclosure had adverse effects on health or mental health, while three studies yielded null or mixed findings. Only two studies examined the extent to which foreclosure may have disproportionate impacts on ethnic or racial minority populations.

Conclusions

Home foreclosure adversely affects health and mental health through channels operating at multiple levels: at the individual level, the stress of personally experiencing foreclosure was associated with worsened mental health and adverse health behaviors, which were in turn linked to poorer health status; at the community level, increasing degradation of the neighborhood environment had indirect, cross-level adverse effects on health and mental health. Early intervention may be able to prevent acute economic shocks from eventually developing into the chronic stress of foreclosure, with all of the attendant benefits this implies for health and mental health status. Programs designed to encourage early return of foreclosed properties back into productive use may have similar health and mental health benefits.     

Inequalities in women's health: looking at mortality differentials using an alternative approach

Data obtained from follow up of the 1971 census sample in the Office of Population Censuses and Surveys longitudinal study of England and Wales were used to look at women''s mortality differentials at ages 15-59. Women were grouped by combining information on marital state, own occupation, husband''s occupation (if married), economic activity, and indicators of household wealth (housing tenure and access to a car). Large groups were found with considerable differences in mortality. High mortality was associated with working in manual occupations and living in rented housing with no car in the household. In contrast, low mortality was associated with non-manual occupations and living in owner occupied housing with a car. Among married housewives and single women these extreme groups contributed 44% of expected deaths, the disadvantaged group experiencing death rates two and a half times that of the advantaged group. Smaller differences were found among married women with an occupational class.These findings are further evidence of the “health divide” in England and Wales and show that accurately to reflect the relation between a woman''s life circumstances and mortality it is necessary to utilise other measures than those based solely on occupation.     

Changes in the association of low birth weight with socioeconomic status in Hawaii: 1970-1990

This study examines rates of low birth weight (LBW) in the state of Hawaii and changes in the association of LBW with socioeconomic status from 1970 to 1990. The analysis is based on aggregate data for census tracts. Rates of low birth weight were calculated for each census tract. Relative socioeconomic scores were calculated from average household income and years of education. The results show that (1) there was a decrease in the rate of low birth weight infants in Hawaii; and (2) that the correlation between socioeconomic status and low birth weight was substantially reduced, though a significant correlation remains. The paper suggests likely ceiling effects, but that the progressive public health policies and expansion of access to primary health care in Hawaii during this period played a major role in reducing the rate of low birth weight infants and in decreasing socioeconomic inequality on this important health indicator.     

Changes in the association of low birth weight with socioeconomic status in Hawaii: 1970–1990

Abstract

This study examines rates of low birth weight (LBW) in the state of Hawaii and changes in the association of LBW with socioeconomic status from 1970 to 1990. The analysis is based on aggregate data for census tracts. Rates of low birth weight were calculated for each census tract. Relative socioeconomic scores were calculated from average household income and years of education. The results show that (1) there was a decrease in the rate of low birth weight infants in Hawaii; and (2) that the correlation between socioeconomic status and low birth weight was substantially reduced, though a significant correlation remains. The paper suggests likely ceiling effects, but that the progressive public health policies and expansion of access to primary health care in Hawaii during this period played a major role in reducing the rate of low birth weight infants and in decreasing socioeconomic inequality on this important health indicator.     

Unemployment and mortality among Finnish men, 1981-5.

OBJECTIVE--To ascertain whether, after controlling for several relevant background variables simultaneously, unemployment is related to mortality and to assess whether this relation is causal or whether unhealthy people are more likely to become unemployed. DESIGN--Prospective study of mortality in Finland during 1981-5 based on 1980 census data on 30-54 year old wage earner men and with particular attention to unemployment in the year before the census. SETTING--Research project at the University of Helsinki. SUBJECTS--All wage earner men in Finland aged 30-54 at the 1980 census. MAIN OUTCOME MEASURES--Causes of death during 1981-5 and duration of unemployment in the year before the census. Background variables controlled for were age, socioeconomic state, marital state, and health. The data were analysed by log linear regression models. RESULTS--During the study period 1981-5, which covered almost 2.7 million person years, there were 9810 deaths. After controlling for all background variables relative total mortality among unemployed versus employed men was 1.93 (95% confidence interval 1.82 to 2.05). The excess mortality was highest in accidental and violent causes of death (relative mortality 2.51; 95% confidence interval 2.28 to 2.76). For circulatory diseases the relative death rate was 1.54 (95% confidence interval 1.40 to 1.70), but among neoplasms only lung cancer was associated with excess mortality. Selection for unemployment based on age, socioeconomic state, and marital state was evident but no such selection was detected based on health. Effects of unemployment on mortality were more pronounced with increasing duration of unemployment. CONCLUSIONS--The relative excess mortality of unemployed men in Finland cannot fully be explained by demographic, social, and health variables preceding unemployment. Unemployment therefore seems to have an independent causal effect on male mortality. Further studies are needed to elucidate the mechanisms between unemployment and mortality.     

Effects of directional environmental change on extinction dynamics in experimental microbial communities are predicted by a simple model

Global temperatures are expected to rise between 1.1 and 6.4°C over the next 100 years, although the exact rate will depend on future greenhouse emissions, and will vary spatially. Temperature can alter an individual's metabolic rate, and consequently birth and death rates. In declining populations, these alterations may manifest as changes in the rate of that population's decline, and subsequently the timing of extinction events. Predicting such events could therefore be of considerable use. We use a small‐scale experimental system to investigate how the rate of temperature change can alter a population's time to extinction, and whether it is possible to predict this event using a simple phenomenological model that incorporates information about population dynamics at a constant temperature, published scaling of metabolic rates, and temperature. In addition, we examine 1) the relative importance of the direct effects of temperature on metabolic rate, and the indirect effects (via temperature driven changes in body size), on predictive accuracy (defined as the proximity of the predicted date of extinction to the mean observed date of extinction), 2) the combinations of model parameters that maximise accuracy of predictions, and 3) whether substituting temperature change through time with mean temperature produces accurate predictions. We find that extinction occurs earlier in environments that warm faster, and this can be accurately predicted (R² > 0.84). Increasing the number of parameters that were temperature‐dependent increased the model's accuracy, as did scaling these temperature‐dependent parameters with either the direct effects of temperature alone, or with the direct and indirect effects. Using mean temperature through time instead of actual temperature produces less accurate predictions of extinction. These results suggest that simple phenomenological models, incorporating metabolic theory, may be useful in understanding how environmental change can alter a population's rate of extinction. Synthesis Understanding how populations will respond to future climatic change is a key goal in ecology, however the exact rate of future warming will vary both spatially and temporally. Consequently, mathematical models must be used to understand the potential range of future population dynamics under various warming scenarios. We use a combination of experimentation and modelling to show that the effects of varying rates of environmental change on population dynamics can be predicted by a simple model. However, the accuracy of these predictions depends upon, amongst other things, a detailed knowledge of how temperature will change over time, rather than approximating this change to mean temperature.     

Unemployment and mortality in Denmark, 1970-80.

Relative mortality in the period 1970-80 was studied among Danish men and women who were unemployed and employed on the day of the 1970 census. The study population consisted of the total labour force in the age range 20-64 on 9 November 1970--that is, about 2 million employed and 22,000 unemployed people. Relative mortality was analysed by a multiplicative hazard regression model (as a natural extension of the standardised mortality ratio) and a multiplicative regression model with extra-Poisson variation. A significantly increased death rate (40-50%) was found among the unemployed after adjusting for occupation, housing category, geographical region, and marital state. Analysis of five main causes of death showed increased mortality from all causes, but especially from suicide or accidents. In areas where the local unemployment rate was comparatively high the relative mortality among the unemployed was lower. The increased mortality among the unemployed was interpreted as a consequence of health related selection as well as increased susceptibility associated with the psychosocial stress of unemployment.     

Environmental variation and population responses to global change

Species' responses to environmental changes such as global warming are affected not only by trends in mean conditions, but also by natural and human‐induced environmental fluctuations. Methods are needed to predict how such environmental variation affects ecological and evolutionary processes, in order to design effective strategies to conserve biodiversity under global change. Here, we review recent theoretical and empirical studies to assess: (1) how populations respond to changes in environmental variance, and (2) how environmental variance affects population responses to changes in mean conditions. Contrary to frequent claims, empirical studies show that increases in environmental variance can increase as well as decrease long‐term population growth rates. Moreover, environmental variance can alter and even reverse the effects of changes in the mean environment, such that even if environmental variance remains constant, omitting it from population models compromises their ability to predict species' responses to changes in mean conditions. Drawing on theory relating these effects of environmental variance to the curvatures of population growth responses to the environment, we outline how species' traits such as phylogenetic history and body mass could be used to predict their responses to global change under future environmental variability.     

Care Giver Perception of Children's Obesity‐Related Health Risk: A Study of African American Families

Objective: To examine care giver perception of children's weight‐related health risk in African American families. Research Methods and Procedures: One‐hundred and eleven families (representing 48 boys and 63 girls) screened for participation in a diabetes prevention study participated. Care givers completed a health awareness questionnaire that assessed their perception of the child's weight, eating habits, appearance, exercise habits, and health risk. The care givers also reported each subject's family history of obesity, diabetes, and other chronic diseases. After a physical examination, height and weight were used to compute an age‐ and sex‐adjusted body mass index for each child. Results: Despite the fact that a substantial number of children were obese (57%) and super‐obese (12%), only 44% of the care givers perceived the child's weight to be a potential health problem. Regression analysis showed that 21% of the variance in parental perception of obesity‐related health risk could be predicted by child age, body mass index, perception of frame size, and perception of exercise habits. Discussion: A number of reasons for the apparent minimization of child health risk are discussed, including cultural differences in the acceptance of a large body habitus, lack of knowledge about the connection between childhood obesity and future health risk, and an optimistic bias in the perception of personal health risk.     

Part-time grouping of rabbit does in enriched housing: effects on performances,injury occurrence and enrichment use

Collective housing is perceived as a possible way to improve rabbit welfare, especially among adult females, which are normally individually housed. Part-time group housing seems to allow a better balance between welfare and health than continuous group housing, but practical implementation and consequences for reproductive performance have not been extensively studied. The aim of this work was to compare weight, feed intake, litter size, injury occurrence, body integrity, and spatial location of female rabbits housed part-time in group housing (PGH group, n = 32) or housed individually (IH group, n = 8). Females were grouped by opening connecting hatches between four individual enriched cages (platform, wood stick and gnawing block). Collective housing started 12 days after artificial insemination and was interrupted at the 10th day (instead of the 15th day later as originally planned) due to high injury rates and severe injuries caused by fighting. The proportion of injured females increased from 25% on the first day of grouping to 63% on the 10th day. Female weight gain during the experiment was similar in the two groups. Litter size at weaning was 9% lower in the PGH group than in the IH group (9.2 vs 10.0, P < 0.01). Platform use was recorded in 32% of the observations and was the highest during the 2 weeks before weaning (46% and 47% of total observations, P < 0.05). During the grouping period, there were at least two females in the same housing unit in 59.4% of the cases, at least two females were located on the same level in 31.3% of the cases. In conclusion, connecting individual cages is an ergonomic solution for part-time group housing, but does not prevent fights for the establishment of a social hierarchy. This is detrimental to the health and body integrity of female rabbits.     

Regional Inequalities in Lung Cancer Mortality in Belgium at the Beginning of the 21st Century: The Contribution of Individual and Area-Level Socioeconomic Status and Industrial Exposure

Being a highly industrialized country with one of the highest male lung cancer mortality rates in Europe, Belgium is an interesting study area for lung cancer research. This study investigates geographical patterns in lung cancer mortality in Belgium. More specifically it probes into the contribution of individual as well as area-level characteristics to (sub-district patterns in) lung cancer mortality. Data from the 2001 census linked to register data from 2001–2011 are used, selecting all Belgian inhabitants aged 65+ at time of the census. Individual characteristics include education, housing status and home ownership. Urbanicity, unemployment rate, the percentage employed in mining and the percentage employed in other high-risk industries are included as sub-district characteristics. Regional variation in lung cancer mortality at sub-district level is estimated using directly age-standardized mortality rates. The association between lung cancer mortality and individual and area characteristics, and their impact on the variation of sub-district level is estimated using multilevel Poisson models. Significant sub-district variations in lung cancer mortality are observed. Individual characteristics explain a small share of this variation, while a large share is explained by sub-district characteristics. Individuals with a low socioeconomic status experience a higher lung cancer mortality risk. Among women, an association with lung cancer mortality is found for the sub-district characteristics urbanicity and unemployment rate, while for men lung cancer mortality was associated with the percentage employed in mining. Not just individual characteristics, but also area characteristics are thus important determinants of (regional differences in) lung cancer mortality.     

Modeling the Pre-Industrial Roots of Modern Super-Exponential Population Growth

To Malthus, rapid human population growth—so evident in 18th Century Europe—was obviously unsustainable. In his Essay on the Principle of Population, Malthus cogently argued that environmental and socioeconomic constraints on population rise were inevitable. Yet, he penned his essay on the eve of the global census size reaching one billion, as nearly two centuries of super-exponential increase were taking off. Introducing a novel extension of J. E. Cohen''s hallmark coupled difference equation model of human population dynamics and carrying capacity, this article examines just how elastic population growth limits may be in response to demographic change. The revised model involves a simple formalization of how consumption costs influence carrying capacity elasticity over time. Recognizing that complex social resource-extraction networks support ongoing consumption-based investment in family formation and intergenerational resource transfers, it is important to consider how consumption has impacted the human environment and demography—especially as global population has become very large. Sensitivity analysis of the consumption-cost model''s fit to historical population estimates, modern census data, and 21^st Century demographic projections supports a critical conclusion. The recent population explosion was systemically determined by long-term, distinctly pre-industrial cultural evolution. It is suggested that modern globalizing transitions in technology, susceptibility to infectious disease, information flows and accumulation, and economic complexity were endogenous products of much earlier biocultural evolution of family formation''s embeddedness in larger, hierarchically self-organizing cultural systems, which could potentially support high population elasticity of carrying capacity. Modern super-exponential population growth cannot be considered separately from long-term change in the multi-scalar political economy that connects family formation and intergenerational resource transfers to wider institutions and social networks.     

The impact of unemployment on health: a review of the evidence.

OBJECTIVE: To review the scientific evidence supporting an association between unemployment and adverse health outcomes and to assess the evidence on the basis of the epidemiologic criteria for causation. DATA SOURCES: MEDLINE was searched for all relevant articles with the use of the MeSH terms "unemployment," "employment," "job loss," "economy" and a range of mortality and morbidity outcomes. A secondary search was conducted for references from the primary search articles, review articles or published commentaries. Data and definitions of unemployment were drawn from Statistics Canada publications. STUDY SELECTION: Selection focused on articles published in the 1980s and 1990s. English-language reports of aggregate-level research (involving an entire population), such as time-series analyses, and studies of individual subjects, such as cross-sectional, case-control or cohort studies, were reviewed. In total, the authors reviewed 46 articles that described original studies. DATA EXTRACTION: Information was sought on the association (if any) between unemployment and health outcomes such as mortality rates, specific causes of death, incidence of physical and mental disorders and the use of health care services. Information was extracted on the nature of the association (positive or negative), measures of association (relative risk, odds ratio or standardized mortality ratio), and the direction of causation (whether unemployment caused ill health or vice versa). DATA SYNTHESIS: Most aggregate-level studies reported a positive association between national unemployment rates and rates of overall mortality and mortality due to cardiovascular disease and suicide. However, the relation between unemployment rates and motor-vehicle fatality rates may be inverse. Large, census-based cohort studies showed higher rates of overall mortality, death due to cardiovascular disease and suicide among unemployed men and women than among either employed people or the general population. Workers laid off because of factory closure have reported more symptoms and illnesses than employed people; some of these reports have been validated objectively. Unemployed people may be more likely than employed people to visit physicians, take medications or be admitted to general hospitals. A possible association between unemployment and rates of admission to psychiatric hospitals is complicated by other institutional and environmental factors. CONCLUSIONS: Evaluated on an epidemiologic basis, the evidence suggests a strong, positive association between unemployment and many adverse health outcomes. Whether unemployment causes these adverse outcomes is less straightforward, however, because there are likely many mediating and confounding factors, which may be social, economic or clinical. Many authors have suggested mechanisms of causation, but further research is needed to test these hypotheses.     

A Census Tract–Level Examination of Social Determinants of Health among Black/African American Men with Diagnosed HIV Infection, 2005–2009—17 US Areas

Background

HIV disproportionately affects black men in the United States: most diagnoses are for black gay, bisexual, and other men who have sex with men (collectively referred to as MSM). A better understanding of the social conditions in which black men live and work may better explain why HIV incidence and diagnosis rates are higher than expected in this population.

Methods

Using data from the National HIV Surveillance System and the US Census Bureau''s American Community Survey, we examined the relationships of HIV diagnosis rates and 5 census tract–level social determinants of health variables for 21,948 black MSM and non-MSM aged ≥15 years residing in 17 areas in the United States. We examined federal poverty status, marital status, education level, employment status, and vacancy status and computed rate ratios (RRs) and prevalence odds ratios (PORs), using logistic regression with zero-inflated negative binomial modeling.

Results

Among black MSM, HIV diagnosis rates decreased as poverty increased (RR: 0.54). At the time of HIV diagnosis, black MSM were less likely than black non-MSM to live in census tracts with a higher proportion below the poverty level (POR: 0.81) and with a higher proportion of vacant houses (POR: 0.86). In comparison, housing vacancy was positively associated with HIV diagnosis rates among black non-MSM (RR: 1.65). HIV diagnosis rates were higher for black MSM (RR: 2.75) and non-MSM (RR: 4.90) whose educational level was low. Rates were significantly lower for black MSM (RR: 0.06) and non-MSM (RR: 0.26) as the proportion unemployed and the proportion married increased.

Conclusions

This exploratory study found differences in the patterns of HIV diagnosis rates for black MSM and non-MSM and provides insight into the transmission of HIV infection in areas that reflect substantial disadvantage in education, housing, employment, and income.     

What are health authorities doing about the health problems caused by unemployment?

Unemployment is over three million in Britain, and unemployment is known to be associated with poor health. It has been suggested that health authorities should produce a comprehensive response to the health problems caused by unemployment, and a survey was undertaken to find how many had done so. All the regional and district health authorities in England, the health boards of Wales, Scotland, and Northern Ireland, and the family practitioner committees of England and Wales were asked by letter what they were doing to respond to the health problems of unemployment. A list of suggestions of what they might be doing was enclosed. The overall response rate was 77% (255/331), and 50% (127/255) of the respondents were doing something--33.3% (3/9) of the regional health authorities, 64% (101/158) of the district health authorities and health boards, and 26% (23/88) of the family practitioner committees. The paper describes what they were doing. A relation was sought between the level of unemployment in an area and the extent of the response, and a significant association was found. Half of Britain''s health authorities are now responding in some way to the health problems associated with unemployment.     

Population responses to perturbations: the importance of trait-based analysis illustrated through a microcosm experiment

Environmental change continually perturbs populations from a stable state, leading to transient dynamics that can last multiple generations. Several long-term studies have reported changes in trait distributions along with demographic response to environmental change. Here we conducted an experimental study on soil mites and investigated the interaction between demography and an individual trait over a period of nonstationary dynamics. By following individual fates and body sizes at each life-history stage, we investigated how body size and population density influenced demographic rates. By comparing the ability of two alternative approaches, a matrix projection model and an integral projection model, we investigated whether consideration of trait-based demography enhances our ability to predict transient dynamics. By utilizing a prospective perturbation analysis, we addressed which stage-specific demographic or trait-transition rate had the greatest influence on population dynamics. Both body size and population density had important effects on most rates; however, these effects differed substantially among life-history stages. Considering the observed trait-demography relationships resulted in better predictions of a population's response to perturbations, which highlights the role of phenotypic plasticity in transient dynamics. Although the perturbation analyses provided comparable predictions of stage-specific elasticities between the matrix and integral projection models, the order of importance of the life-history stages differed between the two analyses. In conclusion, we demonstrate how a trait-based demographic approach provides further insight into transient population dynamics.     

The environment of ageing.

The issue of housing and the wider environment for an ageing population is one where there are many unanswered questions. In this paper a number of key issues are discussed and for each of these the focus is on three aspects. These are the current situation, its reasonableness and what research is needed in order to make decisions about policy and practice. The first three issues relate to the profile of older people themselves and the importance of home to them. The changing profile of older people is not just about an ageing population but also about the growing prominence of those with dementia, women, people from black and ethnic minority groups and one person households, yet little is known about the type of housing which should be provided. Of equal concern is the widening gap between those with a high standard of living (including housing) and those with a low standard of living. The importance of home to older people means that research must focus on how people can be enabled to remain there, and also on the costs, financial and otherwise, to carers and to society. The next three issues relate to the type of housing older people live in and moves in later life. The startling change in the tenure pattern with a growth of owner occupation brings problems as does the decline in social housing. The advantages and disadvantages of the different types of housing--mainstream and specialized--for older people are relatively well known. However the balance between the two needs more research as does that on retirement communities. While it is well known that there are peaks of migration in old age and that moves are often made in haste, little is known about the process of decision making. The final two topics concern links between housing and other aspects of older people''s lives. On health more research is needed on temperature, mortality and morbidity, homelessness and accidents and especially on links between services. These topics have implications for planning and design. The emphasis should be on a multidisciplinary approach using a variety of quantitative and qualitative techniques with an emphasis on dissemination.