The main reasons for students experiencing heightened psychological distress include economic effects, changes in academic activities, difficulties adapting to online distance learning methods and uncertainty about the future with regard to academics and careers. Recently, Cheah, Azahadi, Phang, and Abd Manaf (2020) extracted data from a survey conducted on a nationally representative sample of Malaysian adults and revealed that the demographic variables associated with depression and generalized anxiety disorder included younger age, female gender, Indian ethnic group, lower level of education, and being unmarried. Large-scale gatherings are prohibited, but social and recreational activities and businesses are allowed to operate with social distancing measures and temperature checks in place. questionnaire (93.9% response rate). Take the Depression, Anxiety & Stress Test The Cox and Snell R2 of the multiple logistic regression model was 0.332 (p<0.001), and the HosmerLemeshow goodness-of-fit test (2=12.43, p=0.133) indicated acceptable fit of the model. With this screening test, you can know your mental health status, whether you are stressed, worried, or depressed. International Journal of Medical Informatics, 79(11), 736771. Although cut-off scores for depression, anxiety, and stress were evaluated for caseness in the DASS-21, it is a self-reported symptom screening instrument, and it is not intended to be used as a diagnostic tool. there were 255 students locked down in the campus. The age of the participants ranged from 18 to 84 years (M = 35.2, SD = 11.9). Although psychological well-being of the public is expected to improve when restrictions were lifted, nonetheless, the negative mental impact of the people in this study did not decline despite the shift from CMCO to RMCO. Comorbid stress may lead to dysfunction of the mesocortical dopaminergic pathway, the noradrenaline system in the locus coeruleus, increased reactivity of the amygdala, and increased serum proinflammatory cytokines. Asian Journal of Psychiatry, 51, 10209. Depression Anxiety Stress Scales (DASS) was employed as a tool to determine stress, anxiety and depression level. (2007). The cut-offs for depression (moderate 710, severe 1113 and extremely severe 14), anxiety (moderate 67, severe 89 and extremely severe 10) and stress (moderate 1012, severe 1316 and extremely severe 17) were calculated [12]. Furthermore, during the last four weeks of data collection, when the COVID-19 pandemic moved into its seventh month in Malaysia, the percentage of participants with depressive symptoms was highest: the prevalence of depression among the study participants was close to 60% based on the DASS-21-D score. Our study shows that mental health symptoms, especially depression and anxiety, have been overwhelmingly prevalent in the Malaysian population as the COVID-19 pandemic has progressed. However, the prevalence of stress and anxiety were very worrying as our study was based on working adults in a medical university. The Malaysian government has implemented several movement control orders (MCOs) based on the current COVID-19 situation in the country. Manual for the depression anxiety stress scales. de Vries, E., Rincon, C. J., Martnez, N. T., Rodriguez, N., Tiemeier, H., Mackenbach, J. P., et al. Pilot testing was performed with 30 participants to ensure the clarity of the items and also gather suggestions for improvement. Simple logistic regression analyses revealed that there were several variables significantly associated with depression with comorbid anxiety symptoms (p<0.1). The study aims to evaluate stress, anxiety and depression, and to examine the coping responses among adult population during COVID-19 movement control order in Malaysia. Poor health status was the strongest significant predictor for depressive and anxiety symptoms. The prevalence rates of anxiety and depression were 33% and 11% respectively. Development of the World Health Organization WHOQOL-BREF quality of life assessment. PLOS ONE promises fair, rigorous peer review, Various factors, such as low socioeconomic status, low social capital, higher rates of pollution, and physical threats (e.g., violence and higher crime rates), may increase the risk of developing psychological complications among the urban population compared with the rural population (Gruebner et al., 2017). Co-morbid depression in diabetics is associated with hyperglycemia, diabetic complications and increased health care costs. Department of Physiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia, Affiliation: Being so restless that it is hard to sit still. Conclusions: The prevalence of depression, anxiety and stress was lower than in other studies done in similar settings. The prevalence of depression and anxiety has been shown to be higher in the urban population compared with the rural population. (2020a). . Risk factors of depression, anxiety and stress among adults attending primary health clinics in an urban area in Klang Valley, Malaysia. For full functionality of this site, please enable JavaScript. Internet-delivered psychological treatments for mood and anxiety disorders: A systematic review of their efficacy, safety, and cost-effectiveness. Not at all. Mental health status was assessed with depression, anxiety, and stress scale (DASS-21). Copyright: 2021 Wong et al. Videoconferencing and web-conferencing applications are of utmost importance to sustain social communication and social relationships among the people in urban communities when COVID-19 infection is still prevalent and social distancing has become the current norm in daily living. Ivy Chung PLoS ONE 16(3): Nevertheless, social disconnectedness predicted a higher occurrence of anxiety symptoms (Santini et al., 2020). Khoury, B., Sharma, M., Rush, S. E., & Fournier, C. (2015). All the procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Zaliha: Depression And Anxiety Rates Highest In Federal - CodeBlue Nevertheless, the results of these screening tests are diagnosis and require referral to a professional for further evaluation. Perceived health status was the strongest significant predictor for depressive and anxiety symptoms. Specifically, the multivariable analyses revealed a significant increased risk of anxiety and stress in females compared with males. Globally, approximately 5% of adults suffer from depression (WHO, 2021) and in Malaysia 2.3 % (National Health and Morbidity Survey, 2020) -23.9 % (Leong Bin Abdullah et al., 2021) of the adult . The prevalence of depression among university students in Malaysia is relatively high and alarming, which has been found to be between 14.0% to 30.7% in past studies [8][9][10][11][12][13]. Results Inventori ini mempunyai 21 soalan berdasarkan inventori asal DASS21 mengikut penterjemahan Bahasa Melayu . Nevertheless, data on the comparison of the prevalence of these psychological symptoms among the urban population before and after the emergence of COVID-19 as a global pandemic are not available. Where 70% of individuals were stressed, 76% anxious, and 42.3% were depressed within a sample of 716 Malaysian adults. Simple logistic regression analyses indicated that the individual variables significantly associated with depression symptoms (p<0.1) included being single, divorced, or widowed (crude OR=1.87, 95% CI=0.943.72, p=0.074), those who were assessed after COVID-19 was declared as a global pandemic (crude OR=1.49, 95% CI=1.281.86, p=0.013), those with stress symptoms (crude OR=17.60, 95% CI=9.3633.10, p<0.001), higher physical health QoL score (crude OR=0.93, 95% CI=0.910.96, p<0.001), higher psychological QoL score (crude OR=0.93, 95% CI=0.910.95, p<0.001), higher social relationship QoL score (crude OR=0.95, 95% CI=0.930.97, p<0.001), and higher environmental QoL score (crude OR=0.94, 95% CI=0.920.97, p<0.001). Methods: This could possibly be explained because being a high-income earner does not necessarily imply a strong financial situation. Abd Rahman, L. R., Idris, I. zdin, S., & zdin, S. B. Gao, J. L., Zheng, P. P., Jia, Y. N., Chen, H., Mao, Y. M., Chen, S. H., et al. The psychological impact of the COVID-19 epidemic on college students in China. Hence, the total score for each subscale ranges from 0 to 42. Finally, cigarette smoking status was coded into the two following groups: non-smokers were coded as 0 and smokers as 1. BMJ Open, 7, e016242. The discrepancy in the prevalence of anxiety, depression, and comorbid depression and anxiety between our study and other studies in the Malaysian community may be attributed to the different screening tools used. Vimala Ramoo, Schuch, F. B., Stubbs, B., Meyer, J., Heissel, A., Zech, P., Vancampfort, D., Rosenbaum, S., Deenik, J., Firth, J., Ward, P. B., Carvalho, A. F., & Hiles, S. A. Brain, Behavior, and Immunity, 87, 4048. Leong Bin Abdullah, M.F.I., Ahmad Yusof, H., Mohd Shariff, N. et al. BMC Psychiatry, 15, 262. Kyaimon Myint, The Depression Anxiety Stress Scale (DASS-21) was used to assess mental health. PLoS One, 15(4), e0231924. Decreased energy or fatigue. Immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (COVID-19) epidemic among the general population in China. In this study, responses were obtained during the period when the government imposed more lenient containment measures, and the results revealed increasing levels of depressive, anxiety and stress symptoms throughout the study duration. 01 / 07. There are seven items in each subscale; the score of each subscale ranges from 0 to 21. (2020). (2020). 23810140 DOI: 10.1016/j.ajp.2013.01.014 Abstract Introduction: This predisposes them to depression, anxiety and stress, which are fairly common. This study investigated the prevalence of anxiety symptoms, depression symptoms, and depression with comorbid anxiety symptoms among Malaysian urban dwellers and recorded a relatively high prevalence of these psychological complications compared with other Malaysian studies. To fill this research gap, this study investigated the following issues: (1) the prevalence of depression symptoms, anxiety symptoms, and depression with comorbid anxiety symptoms and (2) the association between various demographic factors, QoL, and the psychological complications mentioned above among participants sampled from several urban communities in Malaysia. The variables with p<0.1 were entered into multiple logistic regression models to assess their association with depression symptoms, anxiety symptoms, and depression with comorbid anxiety symptoms. Depression and anxiety in the Malaysian urban population and their Multiple logistic regression analysis revealed that there were only two variables that predicted higher odds of depression symptoms, that is, assessment after COVID-19 was declared as a global pandemic (adjusted OR=2.99, 95% CI=1.416.35, p=0.006) and those with stress symptoms (adjusted OR=16.00, 95% CI=7.8432.63, p<0.001). Subsequently, the RMCO was extended until 31 December 2020. Li, G., Mei, J., You, J., Miao, J., Song, X., Sun, W., Lan, Y., Qiu, X., & Zhu, Z. Depression and Anxiety, 36(9), 846858. Firdaus, G., & Ahmad, A. Our finding of higher odds of depression with comorbid anxiety is in line with the finding reported by a study of the psychological effect of COVID-19 in 4872 Chinese adults, which indicated that the prevalence of depression with comorbid anxiety was 19.4% (Gao et al., 2020). The first draft of the manuscript was written by [Mohammad Farris Iman Leong Bin Abdullah] and all authors commented on previous versions of the manuscript. These findings provide an urgent call for increased attention to detect and provide intervention strategies to combat the increasing rate of mental health problems in the ongoing COVID-19 pandemic. PDF The Comparison of Depression, Anxiety, Stress, and Coping Strategies Depression, Anxiety and Stress among School-going Adolescents of a This number represents an alarming increase from the prevalence of 10.7% estimated by the NHMS in 1996. Cronbachs alpha was calculated for the overall scale and the three subscales to assess reliability in terms of internal consistency. Methodology An online cross-sectional study was conducted via non-probabilistic convenience sampling. It comprises 26 items, with items 1 and 2 assessing the perceived QoL and health status of the respondents, and the other items grouped into four domains (environmental, psychological, physical health, and social relationship domains). Significant predictors at p < 0.05 in a bivariate analysis were exported to the multivariable logistic regression model. Individuals with a poorer health perception had higher odds of developing depression (odds ratio [OR] = 5.68; 95% confidence interval [CI] 3.818.47) and anxiety (OR = 3.50; 95%CI 2.375.17) compared with those with a higher health perception. Study finds Malaysians' stress levels went up during MCO (1998). Nonetheless, it is possible that people experiencing psychological distress or mental health consequences were more likely to respond to the survey. All data were analyzed using the Statistical Package for Social Sciences version 26 (SPSS 26; SPSS Inc., Chicago, Illinois, USA). Depression among the urban poor in peninsular Malaysia: A community based cross-sectional study. Self-perception of physical health conditions and its association with depression and anxiety among Bangladeshi university students. PLoS One, 9(5), e98118. Telehealth and patient satisfaction: A systematic review and narrative analysis. Participants are asked to score each item on a Likert scale ranging from 0 to 3. International Journal of Social Psychiatry, 66(5), 504511. By demographics, young people, particularly students, females and people with poor financial conditions, were more vulnerable to mental health symptoms. These findings further indicate the seriousness of overall mental health problems as the COVID-19 pandemic has progressed. This study received approval from the Human Research Ethics Committee of Universiti Sains Malaysia (code: USM/JEPeM/19030190). As with the association between social relationships and anxiety, cross-sectional data from the assessment of spouse or partner relationships of 4988 Irish adults identified that positive partner interaction was significantly associated with a reduced likelihood of anxiety (Santini, Koyanagi, Tyrovolas, & Haro, 2015). Only 23.4% reported knowing someone (family members, friends, neighbours or colleagues) who had been diagnosed with or died from COVID-19. Anxiety Test - Free mental health tests from Mental Health America A study found that reduced access to routine medical care during the pandemic resulted in greater mental health among people with medical comorbidities [41]. In March 2020, the World Health Organization declared coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a pandemic [1, 2]. This study found a higher prevalence of depressive, anxiety, stress symptoms in women compared with men. Centre for Sport and Exercise Sciences, University of Malaya, Kuala Lumpur, Malaysia, Affiliation: The research assistant alerted the people living in the household by knocking on the door. The research project was resumed from mid-June 2020 and ended in August 2020, which was between 1week and 2months after the MCO was lifted. Most participants had a stable job (n=261, 80.1%), and more than half participated in the study prior to the declaration of COVID-19 as a global pandemic (n=199, 61.0%). The researchers used social network platforms (Facebook, Twitter, Instagram and WhatsApp) to disseminate and advertise the survey, entitled COVID-19 Health and Wellbeing Survey, to the public. Tafet, G. E., & Nemeroff, C. B. Although a higher percentage of participants with a monthly income < MYR4000 reported stress symptoms, in the multivariable logistic regression analysis, the highest income group had higher odds of stress symptoms. International Journal of Mental Health Promotion, 16(5), 279288. Stress, anxiety and depression among students in campus during the The only variable that was protective against depression with comorbid anxiety among the participants was a higher psychological QoL score (adjusted OR=0.82, 95% CI=0.680.98, p=0.041). Wang, C. Y., Pan, R. Y., Wan, X. Y., Tan, Y. L., Xu, L. K., Ho, C. S., et al. Psychosocial stressors may also induce increased levels of serum proinflammatory cytokines (e.g., interleukin-1, interleukin-6, and tumor necrosis factor-), which may be associated with an increased risk of developing depression. Physical activity protects from incident anxiety: A meta-analysis of prospective cohort studies. The inverse relationship between psychological QoL and depression is well documented: Lower psychological QoL was reported in depressive patients, while improvement of psychological QoL occurred in treated major affective disorder patients who had just been discharged from inpatient wards (Olusina & Ohaeri, 2003; Shumye, Belayneh, & Mengistu, 2019). Among the common psychological complications related to urbanization, depression and anxiety are exhibiting a rising trend, not only in the global context but also specifically in Malaysia. Up-to date, Malaysia has experienced the third wave of the spread. In Malaysian population, a few studies have explored the psychometric properties of DASS-21 using Classic Test Theory (CTT) (Musa, et al., 2007; Ramli et al., 2009), but the DASS-21 scale and its depression, anxiety, and stress sub-scales are least explored through the use of modern test theory, specifically item response theory (IRT). This may have increased the risk of developing depression with comorbid anxiety symptoms among the participants (Tafet & Nemeroff, 2016). Subject recruitment and data collection were temporarily halted from mid-March to early June 2020 due to a movement control order (MCO) imposed by the Malaysian government to curb the increasing spread of COVID-19 in the country. Medicine & Health, 15(1), 14. To achieve objective 1 of the study, the descriptive statistics for the demographic characteristics of the participants, the DASS-21 subscale scores, and the WHOQoL-BREF domain scores were computed. The Journal of Neuropsychiatry and Clinical Neurosciences, 28, 7788. Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia, Affiliation: Based on the occupation categories, nearly half were in professional and managerial occupations (50.6%), while general workers and students comprised 7.2% and 29.2%, respectively, of the participants. The exclusion criteria were as follow: having chronic medical conditions, pregnancy or breastfeeding, and have never had SARS-CoV-2 infection. Scores on three subscalesnamely Depression (DASS-21-D), Anxiety (DASS-21-A) and Stress (DASS-21-S)were generated. Worrying too much about different things. The total sum score for the DASS-21 ranges from 0 to 126. This study examined the depressive, anxiety and stress symptoms of the Malaysian public during the implementation of a CMCO and RMCO and explored its associated factors using a cross-sectional study design. The three-factor model of the Malay version of the DASS-21 has also been confirmed, and most of its items have acceptable factor loading (0.39 to 0.73; Musa, Fadzil, & Zain, 2007). Despite the above limitations, this study provided valuable data to fill the gap in the literature on the prevalence of psychological complications and their associated factors in urban communities. A systematic review of 19 studies on the psychological consequences of COVID-19 for the general population found that the rates of depressive symptoms (14.6%48.3%), anxiety symptoms (6.33%50.9%), and stress symptoms (8.1%81.9%) were alarming in the general population (Xiong et al., 2020). (2018). The mental health status of school-going adolescents should be identified and appropriate timely . Finally, since better physical health QoL is protective against anxiety, considering the current situation where social distancing is the new norm in our daily living and to avoid the disruption of continuous follow-up of patients with pre-existing medical illnesses in urban communities, telemedicinewhich involves treating doctors online consultations with those who have pre-existing medical illnessesmay be an alternative to address the increasing prevalence of anxiety in urban communities. More than half the days. Another potential issue is the influence of selection bias on the prevalence of mental health problems seen in this sample. Psychology, Health & Medicine. [view Questions were presented in both English and Bahasa Malaysia in the survey link. Department of Music, Cultural Centre, University of Malaya, Kuala Lumpur, Malaysia, Affiliation: Those assessed after the declaration of COVID-19 as a global pandemic showed increased odds of depressive symptoms (adjusted OR=2.99, 95% CI=1.416.35, p=0.006) and depressive with comorbid anxiety symptoms (adjusted OR=3.19, 95% CI=1.377.45, p=0.005), while the presence of comorbid stress increased the odds of depressive symptoms (adjusted OR=16.00, 95% CI=7.8432.63, p<0.001), anxiety symptoms (adjusted OR=19.72, 95% CI=9.7539.89, p<0.001), and depressive with comorbid anxiety symptoms (adjusted OR=40.44, 95% CI=15.90102.87, p<0.001). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Hossain, S., Anjum, A., Hasan, M. T., Uddin, M. E., Hossain, M. S., & Sikder, M. T. (2020). The present study investigated the prevalence of depression symptoms, anxiety symptoms, and depression with comorbid anxiety symptoms and their associated factors in a random sample drawn from several urban communities in Malaysia. It is intended to help to understand difficulty of one has in the specific areas of functioning during the past 30 days which include understanding and communication, getting around, self care, getting along with people, life activities and participation in society. The first MCO included the closure of schools, higher education institutions and non-essential businesses (namely businesses that geared toward recreation or entertainment and those that provide services beyond the basic necessities), as well as a general prohibition of mass movements and gatherings across the country, including religious, sports, social and cultural activities. Most of the 1825-year-old respondents were college or university students. Online . Next. Kruse, C. S., Krowski, N., Rodriguez, B., Tran, L., Vela, J., & Brooks, M. (2017). Subsequently, the revised questionnaire was further pretested before field administration. In addition, living in an urban area is reported to be protective against anxiety during the COVID-19 pandemic (Cao et al., 2020). The demographic factors associated with depression were ethnicity and marital status, whilethe only demographic factor associated with anxiety was marital status (Kader Maideen, Mohd. The height and weight of the participants were also measured to compute the body mass index (BMI). (2012) which reviewed 65 studies investigating the efficacy of videoconferencing psychotherapy (VCP) for treatment of psychiatric illnesses indicated that VCP produced similar clinical outcomes to conventional face-to-face psychotherapy and was associated with good user satisfaction. Odds ratios (ORs), 95% confidence intervals (95% CIs) and p values were calculated for each independent variable. Hence, our study pinpointed that the increased odds of depression symptoms may persist even after the movement lockdown imposed by the government had been lifted, indicating that the negative psychological impact associated with the COVID-19 pandemic may be independent of the effect of the movement lockdown on mental health. Haridah Alias, Expert Review of Pharmacoeconomics & Outcomes Research, 18(1), 2541. Most participants did not smoke (n=308, 94.5%), and the mean BMI was 26.87 (SD=5.52). Depression, anxiety, and stress among university students in Selangor The first section of the survey collected demographic characteristics, participants health status and their COVID-19 experience. In Malaysia, there were 95% of patients seeking treatment for emotional disorder (depression, anxiety and stress) aged 17 years old and above (1). Psychiatry Research, 293, 113441. This study determined the prevalence of depression symptoms, anxiety symptoms, and depression with comorbid anxiety symptoms, as well as the association between various demographic factors, QoL, and the mentioned psychological complications among participants from urban communities. https://doi.org/10.1007/s12144-021-01492-2, DOI: https://doi.org/10.1007/s12144-021-01492-2. broad scope, and wide readership a perfect fit for your research every time. Moving or talking more slowly. Comparing urban with rural settings, the odds of mood disorder and anxiety disorder are almost 1.4-fold and 1.2-fold higher in the urban population (Gruebner et al., 2017). Hence, our study findings may not be generalized to the entire urban population of the country. Univariable analyses followed by multivariable logistic regression analyses, using a simultaneous forced-entry method, was used to determine the factors influencing depression, anxiety and stress. Psycholological Service, 9(2), 111131. Some limitations of our study should be noted. All pertinent data, materials, and codes for analysis will be made available by the authors upon written request by any party. Again, persistence of stress may induce an increase in amygdala reactivity, which may be associated with anxiety. doi:10.1371/journal.pone.0248916, Editor: Chung-Ying Lin, National Cheng Kung University College of Medicine, TAIWAN, Received: January 20, 2021; Accepted: March 9, 2021; Published: March 25, 2021. NHS Self Assessment Anyone you share the following link with will be able to read this content: Sorry, a shareable link is not currently available for this article. Lancet Public Health, 5, e62e70. Correlates of depression, anxiety and stress among Malaysian - PubMed Results: Among 95 patients, the depression was found in 31 (32.63%), anxiety in 36 (37.89%), and stress in 3 (3.16%). (2020). Cheah, Y. K., Azahadi, M., Phang, S. N., & Abd Manaf, N. H. (2020). Lifestyle Science Cluster, Advanced Medical and Dental Institute, Universiti Sains Malaysia, SAINS@BERTAM, 13200, Kepala Batas, Pulau Pinang, Malaysia, Mohammad Farris Iman Leong Bin Abdullah,Hazwani Ahmad Yusof,Noorsuzana Mohd Shariff&Rohayu Hami, Advanced Medical and Dental Institute, Universiti Sains Malaysia, 13200, Kepala Batas, Pulau Pinang, Malaysia, You can also search for this author in ASEAN Journal of Psychiatry, 8(2), 8289. This is because what triggers a stress response in one individual may not be the same that triggers a stress response in another individual, and it can greatly vary from forgetting to send an email to a death of a loved one. Between 12 May and 5 September 2020, an anonymous online survey was conducted. These findings support the association between high social relationship QoL and lower odds of anxiety found in this study. Are you experiencing symptoms of depression, anxiety or stress? Translation, validation and psychometric properties of Bahasa Malaysia version of the depression anxiety and stress scales (DASS). Zhang, S. X., Wang, Y. F., Rauch, A., & Wei, F. (2020). Material preparation, data collection and analysis were performed by [Mohammad Farris Iman Leong Bin Abdullah], [Hazwani Ahmad Yusof] and [Noorsuzana Mohd Shariff]. The level of significance was set at p < 0.05. Department of Pharmacology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia, Affiliation: Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. The odds of depression (OR = 5.68, 95% CI 3.818.47) and anxiety (OR = 3.50, 95% CI 2.375.17) were markedly higher in respondents who perceived a poorer health status. There were no missing values. Sidik, S., Rampal, L., & Mukhtar, F. (2014). In this study, people with a fair, poor or very poor health status were more likely to report negative mental health impacts compared with those with a very good or good health status. Biofeedback-involved training helps regulate certain involuntary bodily processes, such as blood pressure, pulse rate, blood flow, and muscle tension, to enhance mental health. Another 18 reviews indicated telemedicine was promising for the treatment of psychiatric and medical illnesses, but more research was required to draw a firm conclusion (Ekeland, Bowes, & Flottorp, 2010).