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China has a shortage of health workers in rural areas, but little research exists on policies that attract qualified medical and nursing students to rural locations.

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Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. BMC Med Educ. Published online Mar 5. Meiling Bao 1, 2 and Cunrui Huang 1, 3. Author information Article notes Copyright and License information Disclaimer. Cunrui Huang, Email: nc. Corresponding author. Received Nov 15; Accepted Feb The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material.

If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. Associated Data Supplementary Materials Additional file 1. Additional file 2. Abstract Background China has a shortage of health workers in rural areas, but little research exists on policies that attract qualified medical and nursing students to rural locations.

Methods Attributes of potential jobs were developed through the literature review, semi—structured interviews, and a pilot survey. Results The final sample comprised medical and nursing students. Conclusions Strategies for patient—doctor relationships, Bianzhi and salary should be considered to attract final—year medical and nursing students to work in rural China. Supplementary Information The online version contains supplementary material available at Keywords: Discrete choice experiment, Job preferences, Health workers, Medical and nursing students, Recruitment policy.

Introduction The uneven distribution of health workers reduces access to essential health services and contributes to inequalities in health outcomes [ 1 ]. Methods Study setting and sampling This research was conducted in Guizhou Province for three reasons.

Identification and selection of attributes and levels instrument development DCE is an evaluation method founded on the random utility theory. Table 1 Posting attributes and levels used in discrete choice experiment. Open in a separate window. Experimental design and choice set construction As described in Table 1 , there were two attributes with four levels, two attributes with three levels and four attributes with two levels. Survey administration The self—administered questionnaire was emailed to the class tutor who uploaded it to Class QQ Population instant messaging software, widely used in China.

Pilot-testing Prior to the start of data collection, we conducted a pilot study with 33 medical students. Table 4 Willingness to pay a for medical and nursing students. Table 5 Predicted impact of different policy interventions on uptake of rural postings.

Discussion In the absence of well—designed studies using revealed preference data, we conducted a DCE among final—year health students to understand their preferences in job attributes. Supplementary Information Additional file 1. Acknowledgments We thank all medical and nursing students who participated in the study.

Funding Not applicable. Competing interests The authors declare that they have no competing interests. References 1. Preferences for working in rural clinics among trainee health professionals in Uganda: a discrete choice experiment. Fritzen SA. Strategic management of the health workforce in developing countries: what have we learned?

Hum Resour Health. Dussault G, Franceschini MC. Not enough there, too many here: understanding geographical imbalances in the distribution of the health workforce. Early implementation of WHO recommendations for the retention of health workers in remote and rural areas.

Bull World Health Organ. China’s human resources for health: quantity, quality, and distribution. Transformation of the education of health professionals in China: progress and challenges. Doctors in China: improving quality through modernisation of residency education.

Job preferences of undergraduate nursing students in eastern China: a discrete choice experiment. Attracting and retaining health workers in rural areas: investigating nurses’ views on rural posts and policy interventions. World Health Organization. Geneva: World Health Organization; Understanding health Workers’ job preferences to improve rural retention in Timor-Leste: findings from a discrete choice experiment.

PLoS One. Motivation and incentive preferences of community health officers in Ghana: an economic behavioral experiment approach. Mangham LJ, Hanson K. Employment preferences of public sector nurses in Malawi: results from a discrete choice experiment.

Tropical Med Int Health. Should I stay or should I go? Exploring the job preferences of allied health professionals working with people with disability in rural Australia. Human Resour Health. Stated preferences of doctors for choosing a job in rural areas of Peru: a discrete choice experiment. Nurse employment contracts in Chinese hospitals: impact of inequitable benefit structures on nurse and patient satisfaction. Appeal from Chinese doctors to end violence.

Huan Z, et al. Health Policy Plan. Statistical Report on health development in China in Assessed 10 May Lancsar E, Louviere J. Conducting discrete choice experiments to inform healthcare decision making: a user’s guide. Which incentive package will retain regionalized health personnel in Burkina Faso: a discrete choice experiment. The impact of pecuniary and non-pecuniary incentives for attracting young doctors to rural general practice. Soc Sci Med. Kuhfeld WF. Marketing research methods in SAS.

The use of discrete choice experiments to inform health workforce policy: a systematic review. Labeled versus unlabeled discrete choice experiments in health economics: an application to colorectal cancer screening. Value Health. Rural practice preferences among medical students in Ghana: a discrete choice experiment.

Keeping community health workers in Uganda motivated: key challenges, facilitators, and preferred program inputs. Glob Health Sci Pract. How to attract health students to remote areas in Indonesia: a discrete choice experiment. Int J Health Plann Manag.

Preference for practice: a Danish study on young doctors’ choice of general practice using a discrete choice experiment. Eur J Health Econ. Addressing health workforce distribution concerns: a discrete choice experiment to develop rural retention strategies in Cameroon. Int J Health Policy Manag. Policy interventions that attract nurses to rural areas: a multicountry discrete choice experiment.

Physician shortages in rural Vietnam: using a labor market approach to inform policy. For more than money: willingness of health professionals to stay in remote Senegal. Kolstad JR. How to make rural jobs more attractive to health workers. Findings from a discrete choice experiment in Tanzania. Health Econ. Job preferences among clinical officers in public sector facilities in rural Kenya: a discrete choice experiment.

Factors that influence midwifery students in Ghana when deciding where;to practice: a discrete choice experiment. BMC Medical Education.

Motivation and retention of health workers in developing countries: a systematic review. Junior doctors’ preferences for specialty choice. J Health Econ. Policy interventions to improve rural retention among neurosurgeons in Iran: A discrete choice experiment. What sort of work can 14 and year-olds do? Dog walker. Grocery bagger. Old Navy does not accept 15 year olds with a work permit. They hire starting at age Yes they hire you with a work permit.

How old must an associate be to work in a claire’s or icing store? To apply for hourly positions at Target stores and our Distribution Centers: You must be at least 16 years old to apply for a Target store job. You must be at least 18 years old to apply for a Target Distribution Center job. In primates, subordinate individuals have a different neuro-immune-endocrine fingerprint: they are relatively hypercortisolemic, have an increased NPY release, an enhanced appetite, leptin resistance [ 58 – 60 ], and central fat deposition [ 61 , 62 ].

Similar patterns are observed in modern human societies: in a large prospective study of British civil servants, the Whitehall study, a dose-response relationship was found between exposure to work stressors, high cortisol levels, central adiposity and risk of metabolic syndrome [ 63 – 65 ]. Information on the social structure of our ancestors prior to the Holocene, approximately 10 years ago, is sparse and can be inferred studying fossils and paintings.

Foraging populations led a semi-nomadic life dictated by climate, danger, and resource availability. Egalitarism in ancestral societies was achieved through sharing of resources [ 66 ]. Differences in social status nevertheless existed and influenced reproductive success and survival [ 48 , 49 , 55 ].

The stress responses have been advantageous during the hominin evolution [ 67 , 68 ]. Disputes may have initiated avoidance and resignation as coping strategies in subordinate subjects rather than active responses, as the latter were likely to generate harsher penalties [ 48 , 70 , 71 ]. In a state of positive energy balance and low physical demands, an increased cortisol secretion may have been the predominant stress responses in emotionally stressed subordinate subjects Fig.

System in positive energy balance and influence of the stress responses hypothalamus-pituitary-adrenal HPA axis and symphatoadrenal system SAS on the system entire figure. The increase in energy intake produces a rise in the internal energy inner circle which is primarily stored and, to some extent, dissipated as heat to restore the equilibrium of the organism triangle. The HPA interacts with the genome to modulate energy fluxes but exerts also a stimulating effect solid line on energy intake and fat deposition and an inhibiting effect dotted line on heat generation via a modulation of the immune system.

The SAS has the opposite effects as induce a decrease in appetite and increase in heat generation and fat mobilization. The size of the arrows and wheels is proportional to the effect and the direction of the arrows indicates the movement of the energy fluxes.

Wheels are non-energetic, regulatory interactions between the three components genome, physical activity, energy intake and the mechanisms controlling the internal energy.

The two main components of the stress system, the hypothalamic-pituitary-adrenal and the sympathetic system have integrated metabolic effects which are complex and depend significantly on insulin secretion and insulin sensitivity [ 72 ]. Changes in energy balance modulate the interaction between these systems to control fuel partitioning, disposal, accretion and distribution. Studies in rats and humans have demonstrated the tissue specific actions of the three systems after manipulation of energy intake [ 73 – 76 ].

One of the main findings was the observation of a threshold effect of corticosteroid levels on insulin action and energy metabolism [ 77 ]. At low levels, corticosteroids amplify the effects of insulin on the liver and increase gluconeogenesis and lipogenesis. At this level of activation of the stress system muscle metabolism seems relatively unaffected. In the adipose tissue, insulin and corticosteroids promote adipocyte differentiation and lipid deposition by increasing lipoprotein lipase activity in a depot-specific manner [ 78 ], that is, visceral fat is more responsive to the action of corticosteroids due to a higher number of corticosteroid receptors [ 79 ].

If the stressor becomes more severe and sustained resulting in higher levels of corticosteroids, the scenario becomes more complex. Stress-induced increased sympathetic activity favours fat mobilization lipolysis , glucose production gluconeogenesis , and mobilization glycogenolysis.

These mechanisms are highly conserved across species and the different modus operandi of the metabolic pathways becomes more elaborate as we ascend the phylogenetic scale and metabolic control starts to be more closely intertwined with cognition.

In summary, modern lifestyle stress occurs in a sleep-deprived, sedentary, energy abundant environment, which induces cortisol release and enhances visceral fat accumulation, a risk factor for metabolic syndrome and type 2 diabetes. Prior to the emergence of agriculture, hunting, scavenging and gathering maintained physical demands [ 16 , 17 ].

The activities were performed in open spaces and, most likely, done in small groups of individuals. It is likely that the neuro-endocrine response was primarily directed at improving muscular efficiency to capitalize gathering, hunting and scavenging and raise the level of attention, readiness and awareness [ 16 , 25 , 26 , 80 , 81 ].

Thus, the involvement of the sympato-adrenal system may have been more pronounced than the HPA axis, as catecholamines adrenalin, noradrenalin enhance awareness and alertness vision, hearing, attention , readiness increased blood pressure and redistribution of blood to brain and muscles from gastrointestinal system, increased respiratory rate and metabolic support increased lipolysis, glycogenolysis, gluconeogenesis, while lessening internal cues decreased hunger and pain [ 23 , 82 , 83 ].

Table 1 outlines the anthropometric and energetic characteristics of our progenitors [ 84 ]. Indirect estimate of body size through fossils has been possible in few of the species that have populated the Earth in the last millions years [ 85 , 86 ].

Hunting, scavenging and gathering were the principal feeding practices of early hominins in the Lower and Middle Palaeolithic eras years ago, approx. Hominin became able to produce rudimentary hand shaped tools [ 53 , 85 ]. The morphometric evolution of hominins proceeded with a progressive increase in height, weight, and brain volume Table 1. Increased body size was the expression of a better nutritional status [ 87 – 90 ]. The encephalization allowed greater structural, cognitive, and problem-solving ability in the setting of an improved diet essential fatty acids [ 87 , 89 – 91 ].

BSA is calculated using the formula of DuBois el al. All hominids were assumed to have an age of 25 years. Table modified from McHenry et al. The increased energy requirements of the brain of early hominids were compensated by a decrease in gut dimensions related to a more digestible and assimilable diet [ 92 , 93 ].

The progressive encephalization allowed an evolving, species-typical computational and neural architecture of the human mind. More effective neural circuitries allowed solving the ecological problems facedby hunter-gatherers [ 68 , 87 , 94 ].

The Upper Palaeolithic era years ago, approx. Human language developed in this period with fundamental implications for brain development.

Agriculture, farming and animal domestication changed food availability, as food was stocked for longer periods. In agricultural societies a dominant role was associated with control of food supplies and easier access to food. This power was particularly evident during famines, which affected mainly individuals lacking control over their food supply. Genetic adaptations may have occurred in the post-agricultural age through assortative mating [ 95 ] and periodic exposure to food insecurity, famine, migrations, colonization and slavery, which were likely to select genes conferring an advantage on survival in different environments [ 31 , 96 ].

With the appearance of the first civilisations, progress became an increasingly localized phenomenon, with Western populations changing more rapidly [ 97 ]. The Industrial Revolution dramatically modified the genome-environment interaction.

Mechanization, food storage, transport and mobility, social and urbanistic structure, working demand, changing social relationships, scientific discoveries and increased life expectancy are all dynamics still evolving in modern societies and altogether are imposing a burden on the relatively unchanged human genome [ 19 , 98 – ].

The most recent changes in food processing and eating habits have converted the seasonal experience into a state of incessant, positive energy balance.

The human genome responds by running the energy-sparing programs coded by the thrifty genes. The causative factors leading to weight gain are numerous and all contribute, to a different extent, to the global burden of obesity in developing and developed countries [ , ].

Emotions and cognitive functions depend on brain development and encephalization [ 67 , 79 , ]. Compared to modern humans, early hominins presumably had simpler mental circuits and a stressful or joyful situation may have evoked simpler reactions [ 90 , , ]. Encephalization, the development of tools and the use of language with the consequent effects of communication on human relations probably coincided with the rapid growth of brain volume and expansion of cortical areas and neurocircuitry [ 68 , ].

Animals perceive food shortage as stressful, which increases vigilance, post-pones sleep, and enhances food-seeking behavior [ ]. Similarly, humans facing unpredictability in food availability were presumably stressed during periods of negative energy balance and increased food seeking behaviors and physical exertion while curtailing sleep. The stress system response would have been an activation of the catecholaminergic system over the HPA system to enhance fuel availability, level of awareness and physical performance and the activation of lipolysis, glycogenolysis and gluconeogenesis.

Insulin orchestrated the energy fluxes towards fat deposition in states of chronic stress [ 73 ]. The environment has dramatically changed in the last century and especially in the last 20 years. The advent of the computer has further reduced physical activity and intensified mental efforts [ ]. The modern, computer-dependent, sleep-deprived, physically-inactive humans live chronically stressed in a society of food abundance. Desk jobs, computers, and high-energy food are commonly associated.

The sprawling urban environment is not conducive to walking and physical activity and may be playing a major role that only now is starting to emerge.

Families are smaller and co-dependent relationships, characteristic of more primitive societies, are declining. Global mobility has changed and migratory fluxes from developing countries to industrialized nations are larger, creating more prominent social disparities and inter-ethnic tensions [ 64 , – ]. Over the same period of time energy expenditure due to physical activity has not declined [ ] and caloric intake has not increased. Thus, the search for other obesogenic factors.

In a seminal review article [ ], it has been hypothesized that a reduction in variability in ambient temperature, along with other factors, may be one of the contributory reasons to the obesity epidemic. In the last 25 years, both house heating during the winter and air conditioning in the summer have indeed become much more prevalent.

As during cold exposure the metabolic rate increases and in a hot environment the propensity to feeding is diminished, these two factors may theoretically have contributed via different mechanisms to increasing body weight.

The Thrifty Gene hypothesis attempts to explain the high prevalence of obesity in Pimas mostly in terms of adaptation to an environment with limited and unpredictable food resources. Little attention has however been paid so far to the fact that essential adaptive abilities in an ambient such as the desert would also include the ability to endure hot days as well as cold nights, and the capability to limit water losses in a hot environment.

As high body mass per se has been indicated as a key factor both in the adaptation to a cold or a hot environment, high BMI may have indeed protected the Pima Indians towards extreme daily excursion [ ]. No functional studies of adaptation to cold have been conducted in Pima Indians therefore this testable hypothesis has not been directly verified yet, however genetic data may provide circumstantial evidence that Pima Indians under selective pressure may have evolved mechanisms to better cope with cold.

This more abundant form correlated positively with resting metabolic rate and lipid oxidation during an insulin clamp. The brown adipose tissue BAT is the only tissue whose main function is heat production; this tissue is largely represented in rodents and in hibernating animals like bears [ ].

In recent evolutionary history such as during the Ice Age humans had to cope with major changes in environmental temperature. Higher on in the phylogenetic scale the role of this tissue has greatly diminished, and BAT until recently was deemed to be mostly reductional in Homo sapiens. Recently, the widespread notion that BAT disappears in humans after the first few years of life has been challenged by empirical evidence. It is not clear however whether the BAT detected by nuclear imaging methods is metabolically active.

More recently, in a large convenience clinical series BAT was correlated by imaging with improved insulin sensitivity, although it is not clear how much of the BAT tissue, as revealed by imaging, may be functionally active.

Finally, BAT has been shown to derive from a common precursor that may later differentiate into either a skeletal myocite or a BAT cell, challenging the doctrine that all adypocites derive from a common precursor [ ]. This mutation has been associated with inability to lose weight and insulin resistance [ ].

The effects of psychosocial stress on metabolism and neuroendocrine systems could be investigated by conducting studies in countries still subjected to seasonality.

Epidemiological investigations in rural populations living in Sub-Saharan African countries such as Gambia or Senegal would be informative of the changes in the gene-environment interaction in fieri. In experimental settings, the relationship between stress response, adiposity, and appetite control could be investigated by the exposure to stressors including sleep deprivation and cold exposure, while assessing the ability to metabolize a standardized high fat meal.

In conclusion, we have revisited from an anthropological angle the thrifty genotype hypothesis and have expanded it to include the effects of emotional stress and sleep deprivation. Horm Metab Res. Author manuscript; available in PMC Jun Siervo , 1 J. Wells , 2 and G. Cizza 3. Author information Copyright and License information Disclaimer. Correspondence, G. Copyright notice. The publisher’s final edited version of this article is available at Horm Metab Res.

This article has been corrected. See the correction in volume 41 on page Abstract The Thrifty Gene hypothesis theorizes that during evolution a set of genes has been selected to ensure survival in environments with limited food supply and marked seasonality.

Keywords: adiposity, neuro-endocrine stress response, thrifty genotype, energy sensing, energy balance. Introduction A secular trend is the long-term, continuous change of a variable over years or decades [ 1 ]. Evolution of Weight Gain and Gene-environment Interaction Effects of seasonality The human genome has been shaped into its configuration via erratic food availability and physical requirements for food procurement and reproduction [ 24 – 26 ].

Thrifty genes and evolutionary pressures The genes involved in the regulation of energy balance have most likely been exposed to substantial selective pressure. Open in a separate window. Evolution and Energy Sensing Mechanisms Storage sensing mechanisms Energy sensing mechanisms are continuously operating. Is ATP the genergostat? Evolution and Energy Balance Different thermodynamic scenarios Low physical activity level, high-energy intake and possibly sleep deprivation, a factor previously overlooked, may have a critical role in the obesity epidemic, as they have changed the genome-environment interaction.

Evolution of Weight Gain and Psychosocial Stress Food availability and social structure Baboons and chimpanzees live in relatively small and stable groups characterized by dominant-subordinate relationships, which influence the stress system, social behavior, feeding, reproduction and health status [ 48 , 49 ]. Hormonal fingerprints and group dynamics The relative contribution of the specific neuroendocrine profiles to obesity based on social rank has started to be characterized only recently.

Evolution of the stress response: Interplay between the hypothalamic-pituitary-adrenal axis and the sympathoadrenal system; metabolic consequences The stress responses have been advantageous during the hominin evolution [ 67 , 68 ].

The preagriculture era Prior to the emergence of agriculture, hunting, scavenging and gathering maintained physical demands [ 16 , 17 ]. Evolution and encephalization Table 1 outlines the anthropometric and energetic characteristics of our progenitors [ 84 ].

The agriculture era and the industrial revolution Genetic adaptations may have occurred in the post-agricultural age through assortative mating [ 95 ] and periodic exposure to food insecurity, famine, migrations, colonization and slavery, which were likely to select genes conferring an advantage on survival in different environments [ 31 , 96 ].

The Energetic System of Modern Man and his Stressful Surroundings The most recent changes in food processing and eating habits have converted the seasonal experience into a state of incessant, positive energy balance. Stress and evolution Emotions and cognitive functions depend on brain development and encephalization [ 67 , 79 , ].

The modern thermodynamic scenario in industrialized countries The environment has dramatically changed in the last century and especially in the last 20 years. Conclusions and Future Directions The effects of psychosocial stress on metabolism and neuroendocrine systems could be investigated by conducting studies in countries still subjected to seasonality.

References 1. Last J. A Dictionary of Epidemiology. Oxford University Press; Oxford: Kac G. Secular height trend: a literature review. Cad Saude Publica. Secular trend of earlier onset of menarche with increasing obesity in black and white girls: the Bogalusa Heart Study. Ethn Dis.

Secular trends in anthropometric characteristics, physical fitness, physical activity, and biological maturation in Flemish adolescents between and Am J Hum Biol.

Overweight and obesity in the United States: prevalence and trends, Prevalence and year secular trend of obesity in Oman. Saudi Med J. Recent trend in overweight and obesity in male adolescents in Austria: a population-based study.

Eur J Pediatr. A five-year trend of increasing obesity among elementary schoolchildren in multiethnic, low-income, inner-city neighborhoods in Montreal, Canada. Rona R. Genetic and environmental factors in the control of growth in childhood. Br Med Bull. Silventoinen K. Determinants of variation in adult body height. J Biol Sci. Tanner J.

Growth as a measure of the nutritional and hygienic status of a population. Horm Res. Neel JV. Am J Hum Genet. Prentice A, Jebb S.

Obesity in Britain: gluttony or sloth? Prentice AM. Obesity – the inevitable penalty of civilisation? Twenge JM. The age of anxiety? Birth cohort change in anxiety and neuroticism,


H&m official website usa jobscan – h&m official website usa jobscan.H & H Amps in the 80’s – love?


Supporting Membership. Forums New posts Trending Search forums. What’s new New posts New media New media comments Latest activity. Media New media New comments Search media. Merch Shop. Members Current visitors. Log in Register. Search only containers. Search titles only. Search Advanced search…. New posts. Search forums. Log in. Install the app. Change style.

Contact us. Close Menu. JavaScript is disabled. For a better experience, please enable JavaScript in your browser before proceeding. You are using an out of date browser. It may not display this or other websites correctly. You should upgrade or use an alternative browser. Thread starter paulvcarter Start date May 24, Messages 2, I really liked mine but it had no clean head room Fun times.

Messages Orren Member. Messages 1, If I’m thinking of the right amp, didn’t T-Rex use one? Wilco Johnson used one IC combo in the early Dr. Feelgood days, ish. My son gave me one, it was given to him as payment for some work he had done, it works but has a few faults. I was going to repair it, but I see now that most parts are no longer available. It has a ported cab and 2×12 heavy magnet speakers, they had seen better days but still sounded good, until some daft jerk me dropped one of them, bending the frame badly.

I’ve put in 2×12 celestion cs, but I hardly ever fire it up these days, far too loud for my use. I should find a new home for it, if my son doesn’t want it back, that is. Anje Silver Supporting Member. I’ve never played a full amp head or combo though, I’m curious how they sound; are those solid state amps?

Do they sound similar to Roland JC in any way? Well, I would say, big clean and punchy. It has reverb and a sustain switch, which seems to be some form of overdrive or induced clipping, not that good from what I remember. Steve Hackett Messages 3, Did Marc Bolan of T-Rex use one? He was probably the most famous endorser. Interesting, thanks for the headsup. Messages 7, Didn’t EVH use their power amps at one point in his rig? Yes indeed V , as a lot of others! Messages 37, I used the combo on different occasions.

I liked them a lot. They had a ‘valve sound’ switch that introduced some controlled grit. No lack of volume. I think the speaker brand and model varied as they didn’t all sound quite the same or the circuit changed, some features varied, etc.

They were pricey around here and I never owned one. I gigged an MA for years through a late 70s Marshall 4x Mosfet based, so driven it sounded like Zvex Super Duper. You must log in or register to reply here. Trending Topics. Boss DS-1W Finally! Started by pinkfuzz65 Today at AM Replies: The Sound Hound Lounge. Best Sounding Amp for you of All Time? Started by beckstriad Saturday at AM Replies: Amps and Cabs. Where does tone come from in a guitar amplifier? Started by nl Monday at PM Replies: Top Bottom.

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