Publications by authors named "Anne Kristine Aarestrup"

11 Publications

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Maternal-fetal bonding among pregnant women at psychosocial risk: The roles of adult attachment style, prenatal parental reflective functioning, and depressive symptoms.

PLoS One 2020 17;15(9):e0239208. Epub 2020 Sep 17.

Center for Clinical Research and Prevention, Frederiksberg Hospital, Capital Region of Denmark, Copenhagen, Denmark.

Pregnancy offers a unique period for initiating preventive parenting interventions. Disturbances in maternal-fetal bonding may indicate suboptimal parenting and a need for intervention. However, more knowledge is needed on the development of maternal-fetal bonding among at-risk groups. The study aim was to examine psychosocial correlates of maternal-fetal bonding among pregnant women identified to be at risk socially and regarding their mental health. The sample consisted of 78 at-risk pregnant women participating in a perinatal intervention study: Godt på Vej Sammen [A Good Start to Life-an Early Cross-sectorial Intervention]. This study was cross-sectional reporting on the baseline characteristics of the participants. In the beginning of the second trimester, participants completed questionnaires assessing maternal-fetal bonding (the Maternal Antenatal Attachment Scale [MAAS]), prenatal parental reflective functioning, adult attachment style, and depressive symptoms. We compared the distribution of MAAS styles with norms from a recent Dutch community sample. In addition, we tested associations between psychosocial variables and the quality and intensity of MAAS scores in regression models and performed Chi-square analyses to assess the association of MAAS styles with psychosocial variables. First, compared to women from a community sample, approximately half of the women in our sample presented lower and suboptimal MAAS scores. Second, insecure avoidant adult attachment style was negatively associated with MAAS intensity, and depressive symptoms were negatively associated with MAAS quality. Third, prenatal parental reflective functioning positively correlated with both quality and intensity of MAAS. Fourth, we found no association between insecure anxious adult attachment style and MAAS scores. Fifth, women with a negative disinterested MAAS style demonstrated the highest avoidant attachment scores, while women with a positively preoccupied MAAS style demonstrated the highest prenatal parental reflective functioning scores. The results suggest that there is a need to differentiate among at-risk pregnant woman and that prenatal screening using the MAAS may help identify those who need preventive parenting interventions and what those interventions should focus on. A main limitation of the study is the lack of a representative group of at-risk pregnant women which limits the generalizability of the study results to all risk groups.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0239208PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7498041PMC
November 2020

An early intervention to promote maternal sensitivity in the perinatal period for women with psychosocial vulnerabilities: study protocol of a randomized controlled trial.

BMC Psychol 2020 Apr 28;8(1):41. Epub 2020 Apr 28.

Center for Clinical Research and Prevention, Frederiksberg Hospital, Nordre Fasanvej 57, Vej 8, Indgang 1, 1.sal, 2000, Frederiksberg, Denmark.

Background: Maternal mental well-being and social circumstances during pregnancy and early childhood impact the child's well-being and development. Supportive and sensitive parenting is one of the strongest predictors of positive emotional, social and behavioral outcomes for the child. Knowledge is needed about how to detect and support vulnerable families already during pregnancy and in the postnatal period. The aim of this study is to assemble and evaluate an interdisciplinary cross-sectoral intervention to promote maternal sensitivity among women with psychological or social vulnerabilities.

Methods/design: This randomized controlled trial tests the efficacy of an intervention program in the perinatal period compared to care as usual in enhancing maternal sensitivity in a group of psychologically or socially vulnerable women in the Capital Region of Denmark. The intervention consists of four components: 1) detecting symptoms of mental illness in vulnerable pregnant women and initiating treatment if indicated, 2) strengthening parenting skills using the Circle of Security Parenting program, 3) supporting breastfeeding, and 4) sharing knowledge and organizing treatment pathways for families across sectors. Seventy-six families will be randomly assigned to the intervention or care-as-usual. Data will be obtained at study inclusion at 3-5 months of pregnancy, eight weeks after childbirth, and nine months after childbirth. The primary outcome is maternal sensitivity. Secondary outcomes include infant's socio-emotional development, parents' mentalization, parental stress, depressive symptoms, and parental wellbeing. Qualitative data will provide insight into the implementation process.

Discussion: This paper presents the rational and background for developing the intervention. Furthermore, the design and protocol of the randomized controlled trial. It is hypothesized that the intervention will be associated with positive changes in primary and secondary outcomes. If effective, the intervention will provide insights into prenatal risk profiles among an identified group of psychosocial vulnerable women important for early screening and point to effective preventive interventions that can support women in the perinatal period, increase maternal sensitivity and promote positive child development -starting before the child is born.

Trial Registration: ClinicalTrials.gov: ID: NCT03190707. Registered June 16, 2017.
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http://dx.doi.org/10.1186/s40359-020-00407-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7189589PMC
April 2020

Curricular activities and change in determinants of fruit and vegetable intake among adolescents: Results from the Boost intervention.

Prev Med Rep 2017 Mar 14;5:48-56. Epub 2016 Nov 14.

Centre for Intervention Research in Health Promotion and Disease Prevention, National Institute of Public Health, University of Southern Denmark, Øster Farimagsgade 5A, 2nd floor, 1353 Copenhagen K, Denmark.

Knowledge of the association between implementation of different intervention components and the determinants they are tailored to change may contribute to evaluating the effects and working mechanisms of multi-component interventions. This study examined 1) the effect of a Danish multi-component school-based intervention (2010 - 2011) on key determinants of adolescents' fruit and vegetable intake and 2) if dose of curricular activities was positively associated with change in these determinants. Using multi-level linear and logistic regression analyses stratified by gender and socioeconomic position, we analyzed survey data from the cluster-randomized Boost study targeting Danish 13-year-olds' fruit and vegetable intake. We examined 1) differences in knowledge of recommendations, taste preferences and situational norms between students from 20 intervention (  991) and 20 control (  915) schools at follow-up; and 2) associations between curriculum dose received and delivered (student and teacher data aggregated to school- and class-level) and these determinants among students at intervention schools only. At follow-up, more students from intervention than control schools knew the recommendation for vegetable intake (OR 1.56, CI:1.18, 2.06) and number of fruits liked (taste preferences) increased by 0.22 (CI:0.04, 0.41). At class-level, curriculum dose received was positively associated with proportion of students knowing the recommendation for vegetable intake (OR 1.06, CI:1.002, 1.13). In stratified analyses, this association was only significant among students from high social class (OR 1.17, CI:1.04, 1.31). The Boost intervention succeeded in improving students' taste preferences for fruit and knowledge of recommendation for vegetable intake, but only the latter determinant was positively associated with curriculum dose. ISRCTN11666034.
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http://dx.doi.org/10.1016/j.pmedr.2016.11.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5123064PMC
March 2017

Parental involvement and association with adolescents' fruit and vegetable intake at follow-up: Process evaluation results from the multi-component school-based Boost intervention.

Int J Behav Nutr Phys Act 2016 10 26;13(1):112. Epub 2016 Oct 26.

National Institute of Public Health, University of Southern Denmark, Øster Farimagsgade 5A, 2., 1353, Copenhagen K, Denmark.

Background: Based on the assumption of parental influence on adolescent behavior, multicomponent school-based dietary interventions often include a parental component. The effect of this intervention component is seldom reported and the evidence is inconsistent. We conducted a systematic process evaluation of the parental component and examined whether the leveal of parental involvement in a large multi-component intervention: the Boost study was associated with adolescents' fruit and vegetable (FV) intake at follow-up.

Methods: The Boost study was targeting FV intake among 1,175 Danish 7 graders (≈13- year-olds) in the school year 2010/11. The study included a school component: free FV in class and curricular activities; a local community component: fact sheets for sports- and youth clubs; and a parental component: presentation of Boost at a parent-school meeting, 6 newsletters to parents, 3 guided student-parent curricular activities, and a student-parent Boost event.

Study Population: Students whose parent replied to the follow-up survey (n = 347).

Data: Questionnaire data from students, parents and teachers at 20 intervention schools. Process evaluation measures: dose delivered, dose received, appreciation and level of parental involvement. Parental involvement was trichotomized into: low/no (0-2 points), medium (3 points) and high (4-6 points). The association between level of parental involvement and self-reported FV intake (24-h recall), was analyzed using multilevel regression analyses.

Results: The Boost study was presented at a parent-school meeting at all intervention schools. The dose delivered was low to moderate for the three other parental elements. Most parents appreciated the intervention and talked with their child about Boost (83.5 %). High, medium and low parental involvement was found among 30.5 %, 29.6 % and 39.4 % of the students respectively. Parental involvement was highest among women. More men agreed that the parental newsletters provided new information. Students with a medium and high level of parental involvement ate 47.5 and 95.2 g more FV per day compared to students with low level/no parental involvement (p = 0.02).

Conclusions: Students with a high level of parental involvement ate significantly more FV at follow-up compared to students with a low level/no parental involvement. Parental involvement in interventions may improve adolescents' FV intake if challenges of implementation can be overcome.

Trial Registration: ISRCTN11666034 . Registered 06/01/2012. Retrospectively registered.
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http://dx.doi.org/10.1186/s12966-016-0435-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5080706PMC
October 2016

The role of curriculum dose for the promotion of fruit and vegetable intake among adolescents: results from the Boost intervention.

BMC Public Health 2015 Jun 5;15:536. Epub 2015 Jun 5.

Centre for Intervention Research in Health Promotion and Disease Prevention, National Institute of Public Health, University of Southern Denmark, Øster Farimagsgade 5A, 2nd floor, Copenhagen, K, 1353, Denmark.

Background: Multi-component interventions combining educational and environmental strategies have proved effective in increasing children and adolescents' fruit and vegetable intake. However such interventions are complex and difficult to implement and several studies report poor implementation. There is a need for knowledge on the role of dose for behaviour change and for assessment of intervention dose to avoid conclusions that intervention components which are not implemented are ineffective. This study aimed to examine 1) the association between dose of a class curriculum and adolescents' fruit and vegetable intake in a school-based multi-component intervention, 2) if gender and socioeconomic position modify this association.

Methods: We carried out secondary analysis of data from intervention schools in the cluster-randomized Boost study targeting 13-year-olds' fruit and vegetable intake. Teacher- and student data on curriculum dose delivered and received were aggregated to the school-level and class-level (only possible for student data). We analysed the association between curriculum dose and students' (n 995) self-reported fruit and vegetable intake (24-h recall questionnaire) after finalization of the intervention using multi-level analyses. Potential moderation was examined by analyses stratified by gender and socioeconomic position.

Results: Average dose received at class-level was significantly associated with students' fruit and vegetable intake (10 g (CI: 0.06, 20.33) per curricular activity received). In stratified analyses the association remained significant among boys only (14 g (CI: 2.84, 26.76) per curricular activity received). The average dose delivered and received at the school-level was not significantly associated with students' intake.

Conclusions: We found a dose-response relationship between number of curricular activities received and adolescents' fruit and vegetable intake. The results indicate that curriculum dose received only mattered for promotion of fruit and vegetable intake among boys. Future studies should explore this gender difference in larger samples to guide the planning of school-based curricular interventions with regards to the optimal number of curricular activities required to promote behavioural change in subgroups with low fruit and vegetable intake at baseline.

Trial Registration: Current Controlled Trials ISRCTN11666034.
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http://dx.doi.org/10.1186/s12889-015-1840-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4456704PMC
June 2015

Lunch frequency among adolescents: associations with sociodemographic factors and school characteristics.

Public Health Nutr 2016 Apr 20;19(5):872-84. Epub 2015 May 20.

1National Institute of Public Health,University of Southern Denmark,Øster Farimagsgade 5,1353 Copenhagen K,Denmark.

Objective: To investigate: (i) how lunch frequency of adolescents varies between schools and between classes within schools; (ii) the associations between frequency of lunch and individual sociodemographic factors and school characteristics; and (iii) if any observed associations between lunch frequency and school characteristics vary by gender and age groups.

Design: Cross-sectional study in which students and school headmasters completed self-administered questionnaires. Associations were estimated by multilevel multivariate logistic regression.

Setting: The Danish arm of the Health Behaviour in School-Aged Children study 2010.

Subjects: Students (n 4922) aged 11, 13 and 15 years attending a random sample of seventy-three schools.

Results: The school-level and class-level variations in low lunch frequency were small (intraclass correlation coefficient <2·1 %). At the individual level, low lunch frequency was most common among students who were boys, 13- and 15-year-olds, from medium and low family social class, descendants of immigrants, living in a single-parent family and in a reconstructed family. School-level analyses suggested that having access to a canteen at school was associated with low lunch frequency (OR=1·47; 95% CI 1·14, 1·89). Likewise not having an adult present during lunch breaks was associated with low lunch frequency (OR=1·44; 95% CI 1·18, 1·75). Cross-level interactions suggested that these associations differed by age group.

Conclusions: Lunch frequency among Danish students appears to be largely influenced by sociodemographic factors. Additionally, the presence of an adult during lunch breaks promotes frequent lunch consumption while availability of a canteen may discourage frequent lunch consumption. These findings vary between older and younger students.
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http://dx.doi.org/10.1017/S1368980015001457DOI Listing
April 2016

Implementation of strategies to increase adolescents' access to fruit and vegetables at school: process evaluation findings from the Boost study.

BMC Public Health 2015 Feb 6;15:86. Epub 2015 Feb 6.

Centre for Intervention Research in Health Promotion and Disease Prevention, National Institute of Public Health, University of Southern Denmark, Øster Farimagsgade 5A 2nd floor, 1353, Copenhagen K, Denmark.

Background: Access to fruit and vegetables (FV) is associated with adolescents' FV consumption. However, little is known about implementation of strategies to increase access to FV at schools. We examined the implementation of two environmental components designed to increase access to FV at Danish schools.

Methods: We used data from 20 intervention schools involved in the school-based multicomponent Boost trial targeting 13-year-olds' FV consumption. The environmental components at school included daily provision of free FV and promotion of a pleasant eating environment. Questionnaire data was collected by the end of the nine-month intervention period among 1,121 pupils (95%), from all school principals (n = 20) and half way through the intervention period and by the end of the intervention among 114 teachers (44%). The implementation of the components was examined descriptively using the following process evaluation measures; fidelity, dose delivered, dose received and reach. Schools with stable high implementation levels over time were characterised by context, intervention appreciation and implementation of other components.

Results: For all process evaluation measures, the level of implementation varied by schools, classes and over time. Dose received: 45% of pupils (school range: 13-72%, class range: 7-77%) ate the provided FV daily; 68% of pupils (school range: 40-93%, class range: 24-100%) reported that time was allocated to eating FV in class. Reach: The intake of FV provided did not differ by SEP nor gender, but more girls and low SEP pupils enjoyed eating FV together. Dose delivered: The proportion of teachers offering FV at a daily basis decreased over time, while the proportion of teachers cutting up FV increased over time. Schools in which high proportions of teachers offered FV daily throughout the intervention period were characterized by being: small; having a low proportion of low SEP pupils; having a school food policy; high teacher- and pupil intervention appreciation; having fewer teachers who cut up FV; and having high implementation of educational components.

Conclusions: The appliance of different approaches and levels of analyses to describe data provided comprehension and knowledge of the implementation process. This knowledge is crucial for the interpretation of intervention effect.

Trial Registration: Current Controlled Trials ISRCTN11666034.
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http://dx.doi.org/10.1186/s12889-015-1399-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4334355PMC
February 2015

Barriers and facilitators for teachers' implementation of the curricular component of the boost intervention targeting adolescents' fruit and vegetable intake.

J Nutr Educ Behav 2014 Sep-Oct;46(5):e1-8. Epub 2014 Jul 19.

National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark.

Objective: To examine barriers and facilitators to teachers' implementation of the curricular component of the school-based, multicomponent Boost intervention to promote fruit and vegetable intake among 13-year-olds guided by concepts of Diffusion of Innovations Theory and findings of previous implementation studies.

Design: Five focus group and 2 individual interviews.

Setting: Denmark.

Participants: Twenty-two seventh-grade teachers from 7 of 20 intervention schools. Four schools (15 teachers) with a high implementation level and 3 (7 teachers) with a low implementation level were selected to obtain maximum variation in teachers' view.

Phenomenon Of Interest: Teacher perceptions of implementation of a curricular component.

Analysis: Situational Analysis including an introductory phase of systematic coding.

Results: Teachers' commitment to the Boost curriculum was hindered by intervention duration and extra workload and motivated by a pre-intervention workshop and the thoroughness of the project. Detailed implementation manuals were helpful for some teachers but a barrier to others because they limited opportunities for adaptation.

Conclusions And Implications: Implementation of curricular activities in school-based interventions may be supported by a predefined teaching schedule, detailed teacher manuals, clear learning objectives, and a pre-intervention workshop to enhance motivation. Situational Analysis may contribute to future implementation studies by highlighting the importance of contextual factors.
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http://dx.doi.org/10.1016/j.jneb.2014.06.003DOI Listing
October 2015

A six-step protocol to systematic process evaluation of multicomponent cluster-randomised health promoting interventions illustrated by the Boost study.

Eval Program Plann 2014 Oct 23;46:58-71. Epub 2014 May 23.

Centre for Intervention Research in Health Promotion and Disease Prevention, University of Southern Denmark, National Institute of Public Health, Øster Farimagsgade 5A 2nd Floor, 1353 Copenhagen K, Denmark. Electronic address:

Background: In multicomponent interventions it is important to examine the implementation of each component to enable valid assessments of the effectiveness of each component. Many studies do not systematically document, evaluate and report the level of implementation and there is a lack of systematic approaches to conduct process evaluation studies to guide researchers and evaluators. The aim of this study was to present a systematic approach to plan process evaluation of the implementation of randomised multicomponent interventions.

Methods: Building on existing process evaluation frameworks and concepts, we developed a six-step protocol: 1. Brainstorm of processes necessary for full implementation and potential barriers and facilitators to implementation; 2. Application of process evaluation concepts to ensure inclusion of important implementation processes; 3. Measurement of proximal outcomes; 4. Identification of relevant data sources; 5. Selection of methods and timing of data collection of process measures; 6. Development of instruments. The protocol was applied to the Boost study, a multicomponent school-based dietary intervention.

Results And Conclusions: The protocol was readily applicable for planning process evaluation of environmental and educational intervention components in a school setting. The protocol ensures systematic assessment of the implementation processes that are crucial for interpretation of intervention effects.

Trial Registration: Current Controlled Trials ISRCTN11666034.
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http://dx.doi.org/10.1016/j.evalprogplan.2014.05.004DOI Listing
October 2014

Implementing a free school-based fruit and vegetable programme: barriers and facilitators experienced by pupils, teachers and produce suppliers in the Boost study.

BMC Public Health 2014 Feb 11;14:146. Epub 2014 Feb 11.

Centre for Intervention Research in Health Promotion and Disease Prevention, National Institute of Public Health, University of Southern Denmark, Øster Farimagsgade 5A 2nd floor, 1353 Copenhagen K, Denmark.

Background: Multi-component interventions which combine educational and environmental strategies appear to be most effective in increasing fruit and vegetable (FV) intake in adolescents. However, multi-component interventions are complex to implement and often poorly implemented. Identification of barriers and facilitators for implementation is warranted to improve future interventions.This study aimed to explore implementation of two intervention components which addressed availability and accessibility of FV in the multi-component, school-based Boost study which targeted FV intake among Danish 13-year-olds and to identify barriers and facilitators for implementation among pupils, teachers and FV suppliers.

Methods: We conducted focus group interviews with 111 13-year-olds and 13 teachers, completed class observations at six schools, and conducted telephone interviews with all involved FV suppliers. Interviews were transcribed, coded and analysed using qualitative analytical procedures.

Results: FV suppliers affected the implementation of the FV programme at schools and thereby pupils' intake through their timing of delivery and through the quality, quantity and variety of the delivered FV. Teachers influenced the accessibility and appearance of FV by deciding if and when the pupils could eat FV and whether FV were cut up. Different aspects of time acted as barriers for teachers' implementation of the FV programme: time spent on having a FV break during lessons, time needed to prepare FV and time spent on pupils' misbehaviour and not being able to handle getting FV. Teacher timing of cutting up and serving FV could turn into a barrier for pupils FV intake due to enzymatic browning. The appearance of FV was important for pupils' intake, especially for girls. FV that did not appeal to the pupils e.g. had turned brown after being cut up were thrown around as a part of a game by the pupils, especially boys. Girls appreciated the social dimension of eating FV together to a larger extent than boys.

Conclusions: Limited time and pupils' misbehaviour were barriers for teachers' implementation. Establishing FV delivery to schools as a new routine challenged FV suppliers' implementation. Food aesthetics were important for most pupils' FV intake while the social dimension of eating FV together seemed more important to girls than boys.

Trial Registration: Current Controlled Trials ISRCTN11666034.
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http://dx.doi.org/10.1186/1471-2458-14-146DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3946026PMC
February 2014

The Boost study: design of a school- and community-based randomised trial to promote fruit and vegetable consumption among teenagers.

BMC Public Health 2012 Mar 14;12:191. Epub 2012 Mar 14.

Centre for Intervention Research in Health Promotion and Disease Prevention, University of Southern Denmark, National Institute of Public Health, Øster Farimagsgade, Copenhagen K, Denmark.

Background: The aim of the Boost study was to produce a persistent increase in fruit and vegetable consumption among 13-year-olds. This paper describes the development, implementation and evaluation of a school-and community-based, multi-component intervention guided by theory, evidence, and best practice.

Methods/design: We used the Intervention Mapping protocol to guide the development of the intervention. Programme activities combined environmental and educational strategies and focused on increasing access to fruit and vegetables in three settings: School: Daily provision of free fruit and vegetables; a pleasant eating environment; classroom curricular activities; individually computer tailored messages; one-day-workshop for teachers. Families: school meeting; guided child-parent activities; newsletters. Local community: guided visits in grocery stores and local area as part of classroom curriculum; information sheets to sports-and youth clubs.The Boost study employed a cluster-randomised controlled study design and applied simple two-stage cluster sampling: A random sample of 10 municipalities followed by a random sample of 4 schools within each municipality (N = 40 schools). Schools were randomised into a total of 20 intervention-and 20 control schools. We included all year 7 pupils except those from school classes with special needs. Timeline: Baseline survey: August 2010. Delivery of intervention: September 2010-May 2011. First follow-up survey: May/June 2011. Second follow-up survey: May/June 2012.

Primary Outcome Measures: Daily mean intake of fruit and vegetables and habitual fruit and vegetable intake measured by validated 24-hour recall-and food frequency questionnaires.

Secondary Outcome Measures: determinants of fruit and vegetable intake, positive side-effects and unintended adverse effects. Implementation was monitored by thorough process evaluation.

Discussion: The baseline data file included 2,156 adolescents (95%). There was baseline equivalence between intervention-and control groups for sociodemographics, primary outcomes, and availability at home, school and sports-and youth clubs. Significantly larger proportions of pupils in the control group had parents born in Denmark. The study will provide insights into effective strategies to increase fruit and vegetable intake among teenagers. The study will gain knowledge on implementation processes, intervention effects in population subgroups with low intake, and opportunities for including local communities in interventions.
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http://dx.doi.org/10.1186/1471-2458-12-191DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3375189PMC
March 2012
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