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Improving Customer Service Using the Theory of Constraints

Initiatives to improve a customer’s experience are often focused on the sales cycle or the purchase process.  However, focusing on the dissatisfied customers who contact the call center provides excellent opportunities to turn around customers’ negative experiences.  The benefits can be substantial. In successful organizations, with well-trained reps, calls from dissatisfied customers result in an additional sale as often as 75% of the time.

This article talks about how to examine the workflow of a call center, and its goal or intent, and then apply the Theory of Constraints continuous improvement steps to that workflow.

Improvement through the application of the theory of constraints

The Theory of Constraints (TOC) is a paradigm or management theory that states that any manageable system is limited only by identifiable constraints.  Achieving goals within that system is therefore influenced by one or more of those constraints.  It’s analogous to the adage ‘a chain is only as strong as its weakest link.’ The constraint in a system is that weak link.

Examples of constraints

For instance, a constraint in a call center might be the duplication of effort.  Perhaps the operator has to type in customer information several times, or load data from separate systems.  This is a constraint that prevents the department from operating as efficiently as possible.  Optimizing this aspect of the call center will improve performance and allow the department to more easily achieve its departmental goals.

Another example of a constraint might be slow response time, once the operator presses ENTER or keys in information.  If the operator has to wait for the computer to respond, there will be empty time that they have to fill with a customer who is already displeased.

Identify the constraint to embark on improvement

Once the weak link, or constraint, is identified in the workflow, it can be improved upon.  By applying a continuous improvement mindset to that workflow, one can improve it in a series of steps that might look like this:

  1. Define the goal or intent of the call center
  2. Determine the metrics which show success or that the goals are achievable---the Key Performance Indicators (KPI’s)
  3. Identify the constraints, or weak links
  4. Choose one constraint to focus on
  5. Define measurable metrics to define improvement in this area
  6. Enlist the involvement of others to resolve
  7. Employ measures to ensure early identification of that constraint in future

Continuous improvement is the key to a successful response to a changing environment

The continuous improvement loop is defined in steps 4 – 7.  Choose one issue to focus on.  Define measurements that indicate how that issue is currently operating.  Then, enlist the assistance of others to find a better way.  Finally, employ a system to ensure that the constraint doesn’t re-appear.  Once the most severe, or highest constraint is resolved, then move on to the next one until the department’s goals are achieved.

All departments must work well together to understand the cause of the constraint, and improve the overall experience.  Early identification of a problem is an important key to keeping it all on track.

Change should be evolutionary, not revolutionary

Most cost-saving initiatives do not focus on existing, internal customer service systems.  Instead, they typically concentrate on two potential solutions: the introduction of interactive-voice-response (IVR) automated voice menus, or outsourcing customer service to centralized call centers.  However, changes don’t have to be revolutionary to be impactful.  Small, incremental changes can allow the organization to evolve gradually, experiencing improvement each step along the way.

Bridge the knowledge gap by involving AdvantageCS

How can AdvantageCS help?  With our in-depth understanding of the industry and technical knowledge, AdvantageCS may be the catalyst needed to implement a change effort towards continuous improvement at your organization. Let’s talk!

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Preserving Cultural Values

I was moved as I stood in the warm sunshine of Kauai earlier this month, listening to this musical native Hawaiian welcome by the students and staff of Kula Aupuni Niihau A Kahelelani Aloha (KANAKA) charter public school.

Some of these students come from the small island of Niihau, off the shores of Kauai, and some are first-generation high school students.

This is a unique form of chartering that I have found fascinating in my travels. KANAKA is one of a number of Hawaiian-focused or Hawaiian-immersion schools established to continue the cultural traditions of their families, as well as to prepare them for the future. The genesis of this school occurred in 1993 when parents from the Niihau community residing on Kauai initiated a home school program for students whose primary language is the Niihau dialect of Hawaiian.

The school has existed in its current charter school form since 1999. The program implements a bilingual education program. English is taught to raise functional skills in a western dominated world. Niihau cultural values and language are preserved using the language they live.

The classes are small. The school is financially supported by Hawaiian nonprofit organizations committed to preserving the cultural traditions of the families on the island. This has allowed for a nice facility for student learning, in the former offices of a sugar plantation.

Led by Principal Hedy Sullivan, (right),  the school focuses on project-based learning to reinforce Hawaiian cultural values. Technology is blended with traditional learning techniques to increase English, language arts, math, science, and social studies skills. What I observed was true personalized learning, given the small student to teacher ratio.

Is this K-12 school of about 60 students too small to be sustained as a charter, even if it preserves cultural heritage? Some would say yes. Others would ask: are the students learning? Are they achieving good academic results? Is the connection to their cultural origins motivating them to learn? If the answers to those questions are also yes, I suggest that enrollment size may not be the critical factor, if there is funding support.

This is a chartering discussion that goes beyond Hawaiian-focused schools. Rural charter schools face similar challenges. Perhaps we can learn from one another.


The Global Sports Top

When Together Street asked me to write about the origins of my favourite item of clothing for Fashion Revolution Week, I first had to get my head around a few things. Firstly, the thought of me being involved with anything resembling 'fashion'. Secondly, I wondered if the origins of my item of clothing would be as gritty as Logan and finally, the idea of favouring some clothes over others. This last point was a genuine issue; I see clothes as functional and having to pick one to research was melting my brain. But then this happened and I knew. If anything was ever going to be my favourite item, it was my Irish rugby top after we finally won the Grand Slam.

Let's rewind for a moment. Once upon a time, there was a young man with terrible hair called Brian O'Driscoll and the old Lansdowne Road Stadium was the only stadium anyone (in Ireland) had ever known. I give you: 2004. My shirt is from a time when Ireland were fully committed to their traditional roots of heroic acts and not winning anything, and (thankfully) it's not as tight-fitting as the tops worn by today’s team and their supporters.

The first step I took in trying to find out more about the origins of my top was to contact the manufacturer. Unsurprisingly, they couldn't give me much information so I cheated a bit and looked into the story behind the latest go-faster tops from Canterbury. Before I got in touch with the company the only thing I knew about the shirt was that it was made of polyester and something called Vapordri+ technology. I don’t know what that means and I don’t expect anyone to tell me, but Canterbury states it'll keep you “comfortable whether training or cheering your team on” (because we all know how hard supporting can be).

I got in touch with Canterbury to ask about the raw materials, how these materials are produced, how many components there are and how and where the shirts are made. They were pretty responsive; within a day their Customer Service department had forwarded my questions to the right person and sent me the following answers:

  • The shirt is put together at a factory in China that specialises in rugby shirts
  • There are several components that are made throughout China/Taiwan including the crest, the knitted fabric and heat transfers
  • The fabric is knitted at a Chinese mill
  • The basic raw materials (polyester and cotton for their Classic version) are bought in — they didn’t say where they came from

They also pointed me towards their parent company Pentland’s corporate social responsibility report that sets out broader targets, and it was interesting to see that they were one of the founding members of the Ethical Trading Initiative, an organisation that seeks to improve workers’ conditions throughout the supply chain. The report included a lot of good stuff,  but they only provided information about Tier 1 factories that are used as production and assembly sites. There was no information about where the raw materials come from or how they're processed, and no specific information regarding the making of Canterbury's clothes.

Though the response was quick and they did send some details, it hasn’t helped me to really understand how ethical the process is. Pentland does have some broad requirements (such as workers receiving a living wage) but there are no specific details as to what that looks like in this case. Are we talking about absolute minimum or is it a comfortable wage?

What I did learn about was the complexity of the system. In my head, there was a single factory that brought in all of the raw materials and then completed all of the processes on site. Instead there is a factory in Taiwan that only produces crests and there are containers of heat transfers roaming the earth looking for a shirt to transfer to. We may know that a lot of clothing is made by hand and it can feel quite simple, but this highlighted the global scale of these logistics.

Looking at the story of my shirt hasn’t changed my understanding of what ethical means (still quite blurred) but it has illuminated how difficult it will be to change things. Making one ethical shirt on scale involves changing practices, wages and technologies at various sites across several countries. The effort and energy to make that happen is phenomenal (and expensive) and that is just one shirt. We all want ethical clothing but we also need to have patience —  easy ethical shopping will be a long time coming.

Matthew Gaston


Tony Burke, a member of Young Americans for Liberty, asks UC Irvine students to sign a petition to Congress protesting the national debt. (JEBB HARRIS/AP)

Authorization and appropriations

These are the two steps of the federal spending process. Once Congress receives the president’s budget, lawmakers can authorize funding for a federal agency or program by enacting legislation. The amount authorized can be clear-cut or indefinite (e.g. “such sums as may be necessary”) and can be good for a fiscal year or multiple years. A federal agency or program can then tap funds from Treasury once Congress passes an appropriations measure. This is done annually. Appropriations measures establish an agency’s budget authority, which gives that agency responsibility to spend the funds based on specified criteria.

Not all federal agencies and programs go through this two-step process. Some programs, such as Social Security and Medicare, are entitlements, which means that the federal government is required to pay benefits to everyone who qualifies, regardless of cost.

Interactive Graphic: A primer on the federal budget process

Interactive Graphic: How spending and revenue changed over time

Interactive Graphic: 30 years of spending priorities

Bush-era tax cuts

President George W. Bush renewed his fight for hundreds of billions of dollars in tax cuts over the next decade on April 15, 2003. (SUSAN WALSH/ASSOCIATED PRESS)

Bush and the GOP say the laws have helped to bolster the economy and add jobs. Critics of the tax cuts say that they give outsized benefits to wealthy Americans and deprive the government of needed revenue at a time of record annual deficits. Despite strong opposition from some members of his own party, President Obama in December signed into law an $858 billion package that maintained the Bush tax cuts for two years. The law also called for a one-year payroll tax holiday and extended emergency unemployment benefits. Many see the short-term extension as a stopgap measure that gives leaders a chance to devise a major overhaul of the federal tax code.

Read: Analysis: Deficit talk gets serious

Read: Biden deficit task force off to rocky start

Read: S&P lowers its outlook on U.S. debt

Budget authority

This is the responsibility given to government agencies by law for how to spend federal funds. With budget authority, Congress can specify the amount of funds available to an agency and for how long.

Read: How do $38.5B in cuts become $350M?

Read: CBO report reduces initial impact of budget deal

Continuing resolution/continuing appropriations

Legislation used by Congress to fund federal agencies and programs at current or reduced levels until formal appropriations measures are passed. On April 9, President Obama signed a continuing resolution, or stopgap bill, into law to avert a government shutdown that would have affected 800,000 workers.

Read: Rubin: CR confusion

Read: No win-win deal?

Read: Summary of fiscal 2011 continuing resolution

Debt ceiling or debt limit

The debt ceiling is the legal limit on borrowing by the government. Before 1917, Congress had to approve each issuance of debt as it came up. To give the Treasury more flexibility in borrowing, lawmakers established a limit covering nearly all government debt. The ceiling has been raised almost 100 times since then. Under George W. Bush, the national debt soared with the costs of wars in Iraq and Afghanistan, the new tax cuts and higher spending on government programs. The debt has climbed even higher under President Obama, fueled by a massive $814 billion economic stimulus package and the collapse of tax revenues during the recession.

Today, the United States is facing a debt limit of $14.3 trillion. Treasury Secretary Timothy F. Geithner has warned that if the limit is not raised by early July the nation may default on its debt obligations, roiling global financial markets. Republican lawmakers say they need a commitment from the White House for more spending cuts in exchange for voting to raise the limit. The White House has rejected the inclusion of spending caps or other changes to the budget process in legislation, arguing that ensuring the government’s solvency is too important to be held hostage to other issues. Vice President Biden is leading talks with lawmakers in hopes of reaching a compromise on deficit reduction that could clear the way for the debt limit vote to go forward.

Motion Graphic: Showdown over the debt ceiling

Read: Why is everyone in Washington talking about the debt ceiling?

Graphic: Raising the debt ceiling

Video: The Fast-Fix: Dealing with the debt

Default means the failure to make good on financial obligations. The U.S. debt is more than $14 billion, within striking distance of the legal limit on borrowing. On April 4, Treasury Secretary Timothy F. Geithner warned lawmakers that if they don’t raise the debt limit, he would be forced to make do with using tax revenues, which come nowhere near covering the nation’s bills. Some Republicans argue that Geithner could avoid default by paying interest to the nation’s creditors before other obligations. But Treasury officials say they will be forced to halt payment if they can no longer borrow, and that the failure to meet any commitment would be viewed by the market as a default, potentially triggering another financial crisis.

Read: Treasury plans for debt showdown

The nation’s deficit represents the annual gap between spending and revenue. When a government runs a budget deficit, it means it has spent more money in a given fiscal period than it has brought in. According to a recent estimate from the nonpartisan Congressional Budget Office, the federal government will incur a $1.5 trillion deficit this year, which would be the widest budget gap in U.S. history. The CBO projects that the gap will narrow as the economy recovers, tax collections return to normal levels and the government stops spending so much on food stamps, unemployment support and health care for the poor. However, without significant changes in federal tax and/or spending policy, deficits will remain elevated throughout the decade, adding around $10 trillion to the national debt by 2021. A political consensus has emerged in Washington that such skyrocketing deficits would pose serious economic risk. Obama and congressional Republicans have offered plans for trimming borrowing over the next 10 to 12 years by an estimated $4 trillion to $4.4 trillion dollars.

Read: Poll: More see budget deficit as big problem

Read: Gerson: How serious are we really about the deficit?

Read: Klein: No on taxes = yes on deficits

Any federal programs that guarantee payment to individuals who meet a certain criteria set by law are called entitlements. These programs include Social Security, Medicare, Medicaid, veterans’ compensation and pensions. Payouts for these programs, especially Social Security, constitute more than half of all federal government spending.

Read: Two very different approaches to a budget deal

Read: Dems have called for entitlement reforms, GOP has rejected tax increases

Fiscal year

The fiscal year covers a 12-month period that a business, government or other entities use as a framework for their yearly accounting statements. For the U.S. government, the fiscal year is the period that begins on October 1 and ends on September 30.

Gang of Six

This combination image from file photos shows the six-member bipartisan group of U.S. senators, referred to as the “Gang of Six.” They are, clockwise from top left, Sen. Tom Coburn, R-Okla., Sen. Dick Durbin, D-Ill., Sen. Saxby Chambliss, R-Ga., Sen. Mark Warner, D-Va., Sen. Kent Conrad, D-N.D., and Sen. Mike Crapo, R-Idaho. (AP)

Read: ‘Gang of 6’ takes deficit fight to public

This joint federal-state health entitlement program serves certain categories of people with lower incomes such as children, pregnant women and people with disabilities. The number of people on Medicaid has soared in recent years to more than 50 million, putting an enormous strain on state budgets. The Congressional Budget Office forecasts that nearly 100 million Americans will be on Medicaid by 2021. Republicans have proposed making Medicaid into a program that provides block grants to states. That would save money because the amount of federal funding would not vary according to how much a state spends. Opponents say it would also force states to dramatically scale back the program, pushing as many as 11 million people who need the aid off coverage by 2021.

Read: Wonkbook: The GOP hearts ObamaCare?

Read: Klein:What cutting Medicaid means

Read: Klein: Guidelines for controlling health-care costs

Seniors attend a "Medicare Monday" seminar at the Holly Creek retirement community in Centennial, Colo. (John Moore/GETTY IMAGES)

Read: Klein: RyanCare vs. the public option

Read: GOP faces tough questions on Medicare

Read: Klein: The wrong argument on health-care costs

National Commission on Fiscal Responsibility and Reform

Last year, Obama created a presidential commission to study “policies to improve the fiscal situation in the medium term and to achieve fiscal sustainability over the long run.” Obama directed the commission to balance the budget - not counting interest on the debt - by 2015.

Read: Bowles and Simpson: There’s still hope for dealing with debt

Read: Obama turns to deficit commission’s blueprint for reducing debt

Read:: The commission’s ‘Moment of Truth’ report

National debt

This is the amount of money the federal government owes to creditors. When Congress approves spending and tax policies that create budget deficits, the Treasury must borrow money to cover the excess costs. The debt is the accumulation of many years of deficit spending. The United States owes creditors a little over $14.2 trillion. About $4.6 trillion is owed to other government accounts, particularly the Social Security trust fund. The rest -- known as publicly held debt -- is owed to outside investors, including individuals, pension plans, financial institutions here and abroad, and foreign governments such as China and Japan. While the entire debt is subject to the legal limit on borrowing, economists typically consider only the publicly-held debt when assessing the nation’s fiscal condition.

The national debt clock

This is one of the many debt clocks that exist. There is no official debt clock or one that the government endorses.

Read: S&P lowers its outlook on U.S. debt

Graphic: Raising the debt ceiling

National Commission on Fiscal Responsibility and Reform Co-Chairmen Alan Simpson, right, and Erskine Bowles, testify on Capitol Hill March 8. (J. Scott Applewhite/AP)

Read: Wonkbook: Ryan, Obama, Simpson-Bowles would all bust debt ceiling

Read: Klein: Simpson-Bowles on health-care costs

Read: Klein: Ryan vs. Simpson-Bowles

Social Security

Trays of social security checks await mailing from the U.S. Treasury. (Bradley C Bower/AP)

Read: Fact Checker: Excessive rhetoric on Social Security

Stopgap budget bill

See definition for continuing resolution.


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Finding an item that fits perfectly can be challenging. When your weight fluctuates, garment fits change and it’s even tricker. I run into this challenge with my clients regularly. Here are some suggestions that I’ve offered to them over the years.

Slight Fluctuations

When your weight fluctuates a little (less than 5 pounds either way), your items might fit ok, but not look and feel as perfect as they once did. This isn’t too serious, because items are still wearable. You don’t need to start thinking about bigger or smaller sizes, and in some cases you will just wear certain items less frequently until you return to the weight where they feel fab.

These types of weight fluctuations are unnoticeable in fluid and oversized fit tops, knitwear, coats, jackets and dresses, so those are handy and forgiving items to keep on hand. Jeans, stretchy bottoms, wide trousers, leggings, fit-and flare-dresses, A-line skirts, cocoon coats and vests are great too. You’ll see and feel the weight fluctuation the most in tailored items that do not have stretch and follow the contour of the body like sheath dresses, woven pencil skirts, and tailored woven trousers.

Moderate Fluctuations

It is harder to manage when your weight fluctuates regularly to the extent that you need one size up or down in many wardrobe items (typically 8 to 10 pound fluctuations.) My clients in this situation tend to keep two sizes in their wardrobe. It’s a costly exercise, but a kind strategy to your body and psyche because you have items that fit and make you feel fab at both extremes of your weight range.

Significant Changes

If your weight changes and stays at the new level for a longer period, you will need clothes in several sizes up or down to maintain good fit. My clients who have gained weight tend to pass on items that are several sizes too small. Some want to hold onto them, but I discourage that because it can exacerbate negative body image. Sometimes we agree to pop the items in a holding zone as a compromise. In the case that a client fits back into the items at some point, they’re usually not interested in wearing them anyway. Starting afresh is best.

When you are on a weight loss programme over a long period of time, and gradually losing a significant amount of weight, you ideally need clothing that fits properly along the way. Budget permitting, you deserve the reward of seeing your body in great fitting clothes as your body changes. There are ways to keep the cost to a minimum. Each time you lose weight that warrants another size down, purchase a very small mix-and-match capsule that gets you through to the next milestone. Assess your wardrobe needs each time you need to purchase a capsule in a smaller size. Don’t forget to be refitted for a bra and knickers, do laundry more frequently, be patient, and don’t try to replace everything at once. Be thrifty and shop the sales. Pass on the clothing that is several sizes too big.

Forum member Toban recently lost a significant amount of weight and shared how she maintained good fit throughout that leg of her style journey. She offers tangible solutions that are well worth a read. Congratulations, Toban.


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Alumni Profile

"In Russia, you go all in. All of your classes are in Russian and it’s a commitment; you’re committing to live in a different culture. And that being said, you have to know that going in and have to know that things will be different and there will be things you don’t like, as well as things you love."

Laura Kurek (Moscow Fall 2014)

Laura KurekAlumna Laura Kurek reflects on her academic experience, how she was able to incorporate her interests from home into her study abroad program, and how students can get the most out of their study abroad experience.

When Laura first got to Moscow in the Fall of 2014, as a participant in the Russian Language and Area Studies Program (RLASP) her first impression was that the air "smelled so good." Coming from a Slavic background and having been a part of the Russian program at Georgetown for the past two years, Laura was already familiar with many aspects of Russian food, language, and culture, so she didn't find many things that went against her expectations of Moscow. She liked the feel of the city, the aesthetics, and if anything, was almost surprised that young adult Russians dressed exactly the same as young adults back in the U.S.

After arriving in Moscow, Laura was able to ease right into her academic program. Whether it was learning verbs of motion from her dance teacher or simply learning the "ins and outs" of Russian language from her grammar teacher, Laura enjoyed every aspect of her academic experience. Laura recalls,

Our lecturer for music was the director of a conservatory in Moscow and he would sing and play the piano almost every lecture, and every class was almost like a performance. I loved it, it was fantastic. Our video teacher knew the famous directors in Moscow and had an in to that whole subset of culture and I felt really lucky to have these people as our professors because they weren't just someone who had some exposure to English, but wanted to teach Americans.

While Laura loved her academic experience, she realized it was not an experience she could simply breeze through. She realized Russia was a new and unique country and seized the opportunity to totally immerse herself.

In Russia, you go all in. All of your classes are in Russian and it's a commitment; you're committing to live in a different culture. And that being said, you have to know that going in and have to know that things will be different and there will be things you don't like, as well as things you love.

Laura took her commitment seriously and worked hard to make Moscow her own. She explored the city, visited new cafes, made new friends, and found activities outside of class that matched her interests back in the U.S. As an avid runner, she knew she wanted to continue running while studying abroad, but was initially told it was uncommon for people in Russia to run outside. After expressing her interest to a Russian friend, it was suggested she should sign up for a marathon which was taking place in Moscow in two short weeks. Seizing the opportunity, Laura signed up immediately. Two weeks later she participated in the marathon on a sunny, 50 degree day in Moscow. As Laura ran the course, a group of Russian peer tutors from the program, as well as the fellow students on her program showed up to cheer her on throughout the course. Not only did it feel good to run again, but with an 8:1 male to female ratio, Laura felt she was helping promote the culture of running for women.

Laura's activities didn't stop at running. As a singer on campus here in the States, Laura knew she needed to keep up with her singing while abroad. She asked the resident director about opportunities to use and develop these skills. Based on his extensive knowledge of the local music scene in Moscow, the resident director was able to get Laura in touch with the Moscow Oratorical Society. Laura soon started practicing with their choir, meeting once a week to learn the Latin mass by Camille Saint-Saens from a very lively, fast-talking, and Russian-speaking choir director. Listening to the director describe and teach singing and breathing techniques opened Laura up to a whole new vocabulary. It also helped her continue an activity she thoroughly enjoys.

What Laura got out of her Russian experience was more than just a better understanding of the language. It gave her a wider perspective and increased her knowledge of both the Russian people and herself. Laura says that her time in Russia has helped her to be more vocal and comfortable in expressing herself. It also has provided her with a better understanding of the Russian culture.

The media paints countries in different ways... But you go there and whether or not you agree with how they think or what they think, you can understand why they think it, given the history and culture and the state of information flow in Russia. And that was just fascinating to me.

Now, back in the U.S., Laura has found that her time abroad has only further fueled her passion for Russia and the Russian language. As a student at Georgetown University, she is more excited about her Russian language class and wants to learn more about this fascinating culture. In the future she hopes to return to Russia after university to continue her study of Russian and ultimately follow a career that involves knowledge of the region, as well as use of the language.

For those who plan to study abroad in Russia, Laura suggests that students immerse themselves as much as they can into the local culture and language, visiting every cafe, museum, and site that the city has to offer and, of course, hang out with the locals more than the Americans. Most importunately, though, she advises students to put their all into language learning, and not be held back by their own fears of making mistakes.

"It is inevitable that you will be self-conscious at times about your language skills, but the fact is that everyone is. It's just a fact of learning another language. It's a very personal thing, language and how we express ourselves, but just fight against that feeling of self-consciousness because that will only hinder your language acquisition entirely and the more you kind of put yourself out there and make mistakes, the quicker you will learn, the quicker you'll master something that's really cool and really rewarding. It's such a rewarding feeling because language is tricky and never really ends."

Start your journey today.


1.7" Hadrosaur Finger Bone - Alberta (Disposition #000028-29)

This is a nicely preserved Hadrosaur finger bone from the Horseshoe Canyon Formation in Alberta, Canada. It comes from an unidentified species of hadrosaur and is Upper Cretaceous in age, between 74-67 million years old.

There are multiple species of Hadrosaur that come out of the Horseshoe Canyon Formation. The Hadrosaurs that have been identified are Edmontosaurus, Hypacrosaurus, Parksosaurusa and Saurolophus. Due to the bone similarities of these dinosaurs, bones of the feet especially, as well as the unrecorded specifics from the original collector, I cannot provide an accurate genus/species identification.

Hadrosaurs are frequently referred to as duck-billed dinosaurs and are members of the ornithischian family Hadrosauridae They were fairly common herbivores which roamed Asia, Europe and North America during the Upper Cretaceous Period. Many species of hardrosaurs had distinct crests on their head, some of which had air filed chambers that may have produced a distinct sound. These crests may have been used for both audio and visual display purposes.
Unidentified Hadrosaur
Alberta, Canada
Horseshoe Canyon Formation
1.7" wide
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The Five Minute Tartar Remedy

Anyone would love to put on their best smiles. Smiling has been one of the best positive gestures when it comes to socializing and self mood. It makes you look friendly, approachableyoung, and attractive. However, not everyone have the confidence to smile, especially when there are tartar on their teeth.

What is tartar?

Tartar is what happens when you don’t brush your teeth regularly. When you go for hours or days without brushing your teeth, bacteria begins to accumulate in your mouth. This causes plaque – a soft and sticky film that’s loaded with bacteria, which then causes gum disease and tooth decay when not removed through regular brushing and flossing. When the plaque hardens on the teeth’s surface, it forms a yellow and brown deposit located at or slightly below the gumline. This deposit is called tartar.

When tartar accumulates, it causes an inflammation of the gum tissue which can be severely painful. The gum swelling makes it difficult to eat, or speak. In the world of medicine, this condition is called Gingivitis and its top two symptoms are gum inflammation and bleeding. Gingivitis can be cured with medicine, proper oral hygiene, treatments, and home remedies but when these are not done at the soonest possible time, the condition can develop into periodontitis.

This leads us to the question: What is Periodontitis?

Periodontitis is far more complicated than gingivitis. It’s a condition where the tissue surrounding the tooth is inflamed, which then causes the gums to shrink and the teeth to loosen. The worst case scenario for periodontitis is tooth loss which makes things a lot worse because we all know how expensive dentures are these days.
All hope is not lost because tartar formation is preventable. The solution is quite simple: you just have to floss and brush your teeth after each meal. This is easy for those who work at home because they have easy access to their trusty toothbrush. However, this raises a concern for those who have busy schedules and are spend most of their time outside the house. Some people bring their toothbrushes with them to school or to their office so they can maintain good oral hygiene. Others, however, end up brushing their teeth twice or once a day.


Article Text

Indicators of deprivation, voting patterns, and health status at area level in the Republic of Ireland
  1. C Kelleher1,
  2. A Timoney2,
  3. S Friel1,
  4. D McKeown3
  1. 1Department of Health Promotion, Clinical Science Institute, National University of Ireland, Galway, Republic of Ireland
  2. 2Ballsbridge, Dublin, Republic of Ireland
  3. 3Department of Public Health, Western Health Board, Merlin Park Hospital, Galway
  1. Correspondence to:
 Professor C Kelleher, Department of Health Promotion, Clinical Science Institute, National University of Ireland, Galway, Republic of Ireland;
 cecily.kelleher{at}

Study objective: To determine what relation, if any, exists between mortality patterns, indicators of deprivation, general lifestyle and social attitudes, as exemplified by general election voting pattern, in the Republic of Ireland. A relation has been demonstrated previously between voting and mortality patterns in the United Kingdom.

Design: Cross sectional ecological study using three data sources. Standardised mortality ratios (SMR) were based on mortality rates at county level and 1996 census data from the Central Statistics Office, 1997 general election first preference voting data in all 41 constituencies were aggregated to county level. Selected reported measures of health status, lifestyle and social circumstances are from the first ever National survey on lifestyles, attitudes and nutrition (SLAN). This study comprised adults over 18 years sampled by post using the electoral register from 273 representative district electoral divisions. Univariate inter-relations were examined at individual level for the dataset as a whole, adjusting for age and at aggregated level for 26 county borough areas, which included the two largest cities and for 22 county areas, which afforded correlation with voting pattern, using the method of Pearson's correlation coefficient.

Participants: 1 806 932 votes were cast nationally at the 1997 general election, representing a voter turnout of 65.92 %. There was an overall response rate of 62% to SLAN comprising 6539 adults (47% male). The demographic pattern of survey respondents was consistent with that of the general population over 18 years.

Main results: At individual level there was a large number of highly significant inter-relations between indicators of deprivation, various measures of self rated health status and lifestyle factors. Aggregated at 26 county level percentage unemployed (r=0.408, p=0.038), and level of education (r=0.475, p=0.014) related significantly to SMR and inversely to both fruit and vegetable consumption (r=−0.672, p=0.001) and excess alcohol consumption among men (r=−595, p=0.003). Those rating their health as fair or poor were more likely to report a poor quality of life (r=0.487, p=0.022), to have none or primary school education only (r=0.428, p=0.047), or to have a means tested medical services card (r=0.428, p=0.047). There was no significant relation between SMR and voting pattern for the two main political parties (67.28% first preferences) but a significant relation with left wing voting (r=0.446, p=0.037). Fianna Fail voting pattern was inversely related to level of dissatisfaction with health (r= −0.59, p<0.05). There was a positive significant relation between left wing voting and dissatisfaction with health (r=0.51, p<0.02) and rate of smoking (r=0.47, p=0.03). Smoking pattern also related positively to rates of voter abstention (r=0.526, p=0.12).

Conclusions: These data are consistent with those in other countries in showing a relation between deprivation indicators and lifestyle, but differ in that no relation with SMR and the votes cast for the main parties was seen in a country with a mainly centre right voting pattern. The relation between left wing voting pattern and some indicators of deprivation and lifestyle suggest that party political voting patterns and affiliations could be a useful indicator of vertical social capital. However, its variability as a measure across countries suggests that the inter-relation between sociocultural and economic factors and the consequent influence on health status is not straightforward.

  • voting pattern
  • SMR
  • deprivation
  • social capital

Statistics from

Although rates of coronary heart disease mortality in the Republic of Ireland rank among the highest in the developed world and there is relatively poor overall life expectancy compared with other European Union countries,1 little is known about the contribution of social variations to this pattern of ill health. Only a small number of area-based studies have examined this question 2,3 and until a national survey on lifestyles, attitudes and nutrition (SLAN) was undertaken in 1999 no large scale nationally representative individual level risk factor datasets existed.4 What evidence we do have suggests that social variations in health status do exist however.5 Such variations are seen in some form in every country. Recent debate on the issue, either of general indicators like all cause mortality, or for specific conditions like cardiovascular disease, cancers, homicide or accidents has focused on both neo material 6 or neo Durkheimian explanations that take account of the psychosocial impact of relative inequality.7–9

While many indicators of material deprivation exist, there are fewer that might express sociopolitical attitudes, related more recently in health research to concepts of social cohesion or social capital that incorporate immediate family and social networks, as well as indicators of community and civil participation.10,11 Contributions to this debate come mainly from larger, industrialised nations, making it difficult to disentangle the direct health effects of material deprivation from those symbolic of societal breakdown. This has not prevented policy shifts in relation to optimal strategies to promote population health. In recent years, more holistic, community development and settings based approaches have been adopted by international agencies like the World Health Organisation and many governments worldwide, even in tackling traditional individual level risk behaviours that are often class related, like smoking, alcohol consumption, and diet.12 The combination of evidence is threefold. Firstly, individual level studies demonstrate the effectiveness of social support in reducing risk of heart disease and various forms of mental ill health.13 Secondly, in particular settings like the work environment there is persuasive evidence of the part played by social relations in influencing relative risk of ill health across social classes.14 Most ambitious is the attempt to examine how a framework of social and economic structures at a macro level might have direct psychosocial consequences in society at large.8 This has translated into advocacy of more widespread exploitation of community networks to promote a sense of social capital,12 though there have been calls also for a broader conception that takes account of both horizontal but also vertical aspects of social networks and structures with a policy dimension, like local or central government.6

Usually voting pattern is used as a measure of social apathy or exclusion, as in the case of studies from the United States on degree of trust, which include indicators such as voter turnout.15 However, political affiliation in itself surely reflects social attitudes as it tells us what social policies people as individuals and groups support. In countries with continued representative rates of voter turnout this could be a useful indicator of social capital. The more intriguing question is whether it is the consequent social relations created or the policies in themselves that have a direct health impact. Davey Smith and Dorling 16 showed a strong relation in the United Kingdom between voting patterns at constituency level for Conservative and Labour parties and mortality, and subsequent work in the United States 17 and Russia 18 indicated the same phenomenon but to a lesser degree. What therefore might be the pattern of relation between health status and voting where the political system is less clearly ideological along traditional left/right lines?

Ireland is a particularly relevant example in the context of the debate about deprivation and social capital. It is a country with high rates of morbidity and mortality, a long history of migration and economic disadvantage and yet has a strong tradition of social cohesion in some key respects like family support and church going 19 and a political system that is not traditionally polarised along ideological lines.20 In this sense it is the possible exception in which to examine the rule. The objective of this study therefore was to see how self reported lifestyle, sociodemographic and health patterns within the national SLAN survey related at an area level to mortality and in turn how these indicators related to voting patterns.

Three data sources were used in this study. Individual level data were included on selected variables collected as part of the national health and lifestyle survey SLAN in 1998.4 The methodology for that study, which has been described previously, involved a multistage cluster sample technique with random selection of individuals from the electoral register in 273 urban and rural district electoral divisions across the country so that information on a representative sample of people from each county equivalent area was available. Two questions relating to self reported quality of life and satisfaction with health, measured using a five point Likert scale, were taken from the quality of life instrument developed in 1993 by the World Health Organisation (WHOQoL). Self reported general health on a five point scale from excellent to poor was also recorded. Lifestyle practices were included in relation to current daily cigarette smoking, fruit and vegetable consumption of at least four items per day (the national target), and alcohol consumption of over 14 units per week in women and 21 units per week in men. Eligibility or not for general medical services, a means related system of entitlement to comprehensive health services, was recorded also. Level of deprivation was assessed in this study by means of three variables, private home ownership or otherwise, education from primary through to tertiary level and employment status, categorised in accordance with standard census questions.

Crude mortality rates are not available routinely from the Central Statistics Office at a level below that of county. In order therefore to calculate standardised mortality ratios (SMRs) a county equivalent level was decided upon. At this level it is possible to separate out Cork city and county into two and the greater Dublin area into four geographical distribution divisions. SMRs for these areas were then calculated using a standard indirect method based on mortality data of all adults over 18 years from the 1997 vital statistics report and denominator population data at county level from the 1996 census.

Electoral data from the 1997 general election data 21 were used to establish percentage of first preference votes in each constituency. The voting system in Ireland, of proportional representation by the single transferable vote in multiple seat constituencies, has been said to promote a clientist, non-ideological political system. The two largest parties in the Republic of Ireland, Fianna Fail and Fine Gael, have their origins in the Civil War that followed on the foundation of the State in 1922; Fianna Fail was founded in 1926 and Fine Gael in 1933. Neither party traditionally is notably ideological in economic terms, though both are regarded by analysts generally as being to the right of centre.20 The Labour party was established in 1912 and is a traditional socialist party, though seen to be to the ideological right of counterparts in Europe, including the British Labour party. There were two smaller ideological parties, not represented in all constituencies in general elections. The Democratic Left party arose from a strongly left wing Marxist Leninist background and is also the culmination of a series of breakaway splinters from a much earlier republican tradition. The Progressive Democrats, established in 1985, has a liberal market economy ethos and a relatively more liberal social agenda on issues like abortion and divorce.

There are 41 political constituencies in the Republic of Ireland, constituted according to a number of factors but principally population density, each returning between three and five deputies. Constituency borders may not necessarily relate to county borders or to public administration units. There are for instance 11 constituencies in Dublin city and county, five constituencies in the largest county, Cork, where the second largest city is located. Several of the larger counties have at least two constituencies, while some of the lower population density counties are paired into one constituency. The only way to achieve comparability between regional voting patterns and mortality rates was to treat each of the entire Dublin and Cork areas as one county and to retain as amalgamated units each constituency comprising two counties, giving 22 data points for this part of the analysis. The Progressive Democrats were represented in 15 of these areas only. Votes for the Labour party and Democratic Left (who coalesced into one party shortly after the general election) were taken together as one unit to indicate left pattern voting and were represented in 21 areas. There was a range of independent candidates and a number of other parties including the Greens, not a strong force at general elections; these were categorised together as others for this analysis. Proportion of abstainers for each constituency was calculated as the difference between eligible voters on the register and percentage turnout.

Simple univariate analyses were undertaken. Pearson's correlation coefficient was used to assess associations between variables, both at individual level in the SLAN dataset as a whole, where age adjusted partial correlation coefficients are reported and at aggregated level. Two area based matrices were assembled, first assessing SMR in relation only to the SLAN variables and therefore utilising the 26 area points with breakdown possible of the two largest population areas, Dublin and Cork and then including in addition the voting patterns, with Dublin and Cork treated as a single unit, and just 22 data points. There were insufficient area based data points for multivariate statistical assumptions to be satisfied in relation to the aggregated data.

The final response rate for SLAN was 62.2% and the total number of respondents was 6539 (47.0% male). The overall correlation matrix confirmed a large number of highly significant relations, albeit some with rather low levels of correlation. When these were age adjusted the pattern remained the same except that the relation between employment status and education, previously direct, became inverse, suggesting age as a confounder. Table 1 illustrates the partial age adjusted correlation coefficients for all variables. Self rated general health, quality of life, satisfaction with health were all intercorrelated, and each related significantly to employment status, education, tenure, medical card possession, smoking status and fruit and vegetable consumption. Smoking rates were also significantly related to tenure and to medical card possession. This confirmed the appropriateness of examining patterns of inter-relation of these variables at an area level. The standardised mortality ratios in descending order for each of the 26 county borough areas are presented in table 2, together with the total percentages for each of the health, lifestyle and deprivation variables. This table shows some variation in SMR by county, ranging from a high of 123.67 in Cork county borough to a low of 83.93 in Fingal, an area of Dublin county. Likewise there was some variation in the other measures. Notably there are relatively high rates of home ownership throughout most of the country.

Table 1

Partial correlations, age adjusted, from SLAN

Table 2

Relation between standardised mortality ratio, selected indicators of deprivation, health status and lifestyle in 26 county level areas

The total population at the 1996 census was 3 526 719. Of 2 714 262 adults over 18 registered to vote, 1 806 932 votes were cast at the 1997 general election, representing a turnout of 65.92%. Overall Fianna Fail obtained 39.33% of first preference votes, Fine Gael 27.95%, Labour and Democratic Left combined 12.91%, the Progressive Democrats 4.68% and others 15.13%. The voting pattern in 22 county level areas, including turnout, is presented in table 3. The correlations between voting patterns, standardised mortality ratios, eligibility for general medical services and the selected variables from SLAN are presented in table 4. The higher the vote for Fianna Fail (r=−0.534, p=0.011) or Fine Gael (r = −0.630, p= 0.002) the lower the vote for left wing parties. There was no significant relation between mortality and voting pattern for either of the main parties, Fianna Fail and Fine Gael. The higher the Fianna Fail vote the higher was the percentage of homeowners (p = 0.429, p = 0.046). There was a significant positive correlation (r=0.446, p=0.037) between combined left voting pattern and SMR. The higher the Fianna Fail vote the lower the rate of those dissatisfied with their health (r = −0.578, p = 0.005). Conversely, Left wing voting patterns correlated significantly with dissatisfaction with health (r = 0.467, p<0.028) and rates of regular smoking (r = 0.470, p =0.027). There were higher rates of regular smokers in constituencies with high rates of voting abstainers (r = 0.526, p<0.012). There was a significant negative relation between Left wing voting pattern and overall eligibility for general medical services (r = −0.505, p=0.017), which did not remain significant when only medical card holders under 55 years old were considered.

Table 3

Voting patterns at county level areas in the Republic of Ireland at General Election 1997, together with the percentage of votes cast for the different political parties in each of the areas and the percentage of abstainers

Table 4

Aggregated pattern of voting, health and safety indicators, selected deprivation indicators and lifestyle variables across 22 county areas

There was no relation between SMR and GMS eligibility. There were a number of other inter-relations at area level. For instance the higher the percentage rating their health fair or poor, the higher the proportion reporting a poor quality of life (r= 0.487, p=0.007) none or primary education (r=0.648, p<0.001) and general medical services eligibility (r= 0.556, p=0.007). The percentage unemployed correlated significantly with level of education (r=0.454, p=0.034) and medical card ownership (r=0.428, p =0.047). There was an inverse relation between percentage unemployed and both fruit and vegetable (r=−0.672, p=0.001) and excess alcohol consumption among males (r= −595, p=0.003). As it was not possible to relate SMRs to voting patterns for constituencies in the two larger cities we compared the correlation matrix for 26 areas with that for 22, to see whether the pattern of relationp between health status, deprivation or lifestyle indicators would be much altered generally. It was in fact almost identical, with the exception that percentage unemployed now related significantly to SMR (r=0.408, p=0.038) as did percentage with primary school education only (r=0.454, p=0.034), though the direction of the relation remained the same.

In this study we combine for the first time, aggregated individual measures of self rated health and lifestyle, socioeconomic circumstances, personal and health service access with ecological level data on voting patterns and mortality.

Relation between patterns of deprivation and health status in Ireland

This study confirms at individual level in Ireland both the clear inter-relation between deprivation indicators such as level of education, housing tenure and rates of unemployment and in turn their correlation with lifestyle risk factors. Though little of the variance is explained, our purpose in this paper was to establish only that such relations existed in order to study the area patterns so no further detail is given at this stage. It is unknown how social class variations have contributed over the years to patterns of ill health in Ireland because of the lack of robust epidemiological data. What we do know from more recent work is that health inequalities do exist in Ireland5 and that the country is now changing fast in socioeconomic terms.22 A clear social gradient in relation to health and lifestyle variables at individual level in this dataset for both men and women has already been reported.4

Despite the poor health profile of Irish people compared with their European counterparts, variation in mortality at county level is not as wide as is seen in other countries, like its close neighbour the United Kingdom and the relation with standard deprivation indicators is weak or inconsistent. There was some variation in the various indicators of self reported health status and lifestyle at area level. Certainly SMRs were higher in urbanised areas in particular but the relation with classic deprivation indicators like education and employment status was lost when the two large cities were absorbed to county level. This confirms in fact findings of the two previous studies of almost a decade ago. Johnson et al found a relation between deprivation and area SMRs within Dublin city.2 However, Howell et al found the pattern at county level was much weaker across the country as a whole and that the deprivation index used, a modification of that of Townsend did not relate to SMR.3 One explanation is the inappropriateness of the measure in a country with high levels of home ownership of varying standards and an education system reformed beyond recognition in the past 30 years.22 In fact the inverse relation between education and unemployment in the dataset as a whole is explained by the fact that older people are more likely to have primary school education only and younger people to be unemployed. The geographical scale of the county and the relatively low population density may also be a problem. Yet there are coherent sociological reasons for considering area variations at this level, in that local government operates at a county level, regional health boards are comprised of counties and there is a strong county affinity exemplified by sporting organisations like the Gaelic Athletic Association.

Voting pattern and health

There was some evidence of a relation between left wing voting and SMR and of indicators of adverse lifestyle and deprivation, yet the voting pattern was relatively inconsistent and nothing like that of the United Kingdom. The important finding however is the fact that there is no relation with right wing or centrist voting. This is explicable mainly because of the lack of class polarisation in party political affiliation, which is clientist and often personality based. To an extent this reflects the proportional representation system but the proportion of the total population supporting the two main centrist parties is enormous, so it is not a matter of a failure of power to detect a significant relation. What do these findings signify about the association between voting pattern and health status? The original study by Davey Smith and Dorling 16 was an assertion that voting patterns could be interpreted as a proxy for material circumstances in the different constituencies in the United Kingdom, and that the attitudes reflected in voting were a result of complacency about the provisions of the Welfare State among voters in the more affluent constituencies. In a follow up study on the 1997 election they found similar strong positive relations between SMRs and Labour party voting and the converse for the Conservative party.23 As quoted by Sinnott,20 voters in Ireland have consistently ranked themselves in the centre or to the right of centre in their political attitudes. The spectrum of difference between the Irish Labour party and Fianna Fail and Fine Gael, both remarkably similar to each other and closer to British Conservatives, was much narrower than the expressed differences in the United Kingdom between Labour and the Conservatives. This may well help to explain the less polarised relation between voting pattern and health status in Ireland compared with Britain.

  • Both at individual and at area level there is a relation between measures of deprivation, lifestyle and health status in the Republic of Ireland.

  • Standardised mortality ratio relates to deprivation measures only when inner city areas are discriminated in the analysis and not in the country as a whole.

  • Party political affiliation is a potentially useful and subtle measure of vertical social capital, as it reflects both sociopolitical attitudes and their policy consequences and has now been demonstrated to relate to health status in several countries. However a new concept of citizenship might be the most appropriate public health strategy, rather than the presently used indicators.

  • This study shows a significant relation between left wing voting, SMR, dissatisfaction with health and smoking status. However, it also shows a continuing level of social homogeneity in voting pattern in Ireland by the majority of people. This is in the face of high rates of ill health relative to other countries and despite the prevalence of features usually associated with social cohesion like high church attendance and tight knit family structures.

  • The likelihood that health inequalities will widen in Ireland, despite economic growth, due to increasing urbanisation, suggests the appropriateness of direct measures to reduce income inequality and the impact of deprivation, rather than a more holistic social cohesion approach.

Social capital, deprivation, and voting pattern

However, there may be a much wider debate on what voting patterns signify, to do with concepts of social capital and cohesion, as patterns in other countries are also seen but not in the same straightforward way. A number of studies in the United States assert relations between measures of social inequality, level of voting, and ill health.15,24 Kondrichin and Lester 17 analysed the Reagan/Carter presidential election pattern in the United States, finding a negative correlation between mortality rate and the Republican vote. The same authors 18 also analysed patterns in Russia at the 1993 election, finding an inverse relation between crude death rates and the percentage vote for the new constitution but not with the percentage voting for the Communist party. The combination of perceived dissatisfaction with health among those who are left voting and the converse for the majority party that we found suggests at least some psychosocial as well as material aspect to disadvantage. A majority of respondents were satisfied with their health in the SLAN survey and in this analysis that translated into satisfaction with their health on the part of Fianna Fail voters, the majority party. However the inter-relation between economic inequality, the sociopolitical systems that bring that about or fail to address it and the impact on individual wellbeing is not straightforward. In the United States where economic and political structures are comparable in the country as a whole, even if income distribution varies greatly,9 cross state comparisons may well reflect relative discontent with material disadvantage but how true is that of less politically polarised and arguably more socially cohesive societies?

It is beyond the scope of this paper to address what explains these patterns but there is some relevant evidence. The social history of Ireland in the time since it became an independent republic is one of considerable general economic hardship and migration right up to the 1980s, and yet with strong indicators of so called social cohesion including tight knit family structures, high rates of church going and a socially conservative mainly rural culture. Analysis, for instance, of religious practices show the Irish as among the most consistent church going Christians anywhere. Nor has this waned as much as might be expected. Indeed, even though there has been strong dissent in recent years from the position of the Roman Catholic church on matters of private sexual practice and challenges to its authority generally, Christian values remain strong, even among the young.19

Furthermore, Ireland has long been known as a European oddity in the low level of political left wing support it enjoys.20 By the 1980s a new class structure more typical of other European countries was in place. Party political allegiances were fairly constant in the past 30 years, Fianna Fail attracting a majority support of all social classes, Fine Gael being relatively more middle class and the Labour party having more working class support but also, like the others, receiving support across all classes. Although the emergence of a more ideological political system may be associated with signs of urban deprivation and a widening of the gap between rich and poor, traditional social and political values continue to be relatively important in the country as a whole. Yet this level of social consensus has apparently not translated into a better health profile, either in the past or in terms of contemporary health, based on these data.

Methodological issues

Though SMR data could not be related to voting pattern at constituency level in the cities we were able to compare the SLAN indicators at that level and hence indirectly assess whether deprivation would polarise patterns more. This suggests the effect of the relation between voting pattern and SMR may have been weakened for those inner city areas where absolute deprivation is greatest, but not greatly. Even there the rate of support for Fianna Fail is relatively strong. The indicator of both potential morbidity and possible disadvantage, eligibility for comprehensive general medical services related inversely with left wing voting, and not at all to SMR, which on the face of it is surprising as the scheme is means tested. However eligibility also relates strongly to age, which is likely to be the explanation here, given the fact that the pattern was much weaker for those less than 55 years of age and it is likely also that shifts in party political allegiance are due to more young people deserting the traditional parties. We have to be cautious in interpreting these lifestyle data because the sample for SLAN is necessarily smaller than for either voting data or SMRs and hence some of the variations seen may be due to lack of statistical precision rather than real between county variations. Furthermore, we do not have individual level data on voters' health profile. There were trends that could be explained by demographic patterns of party support including gender and age as well as class but these did not reach statistical significance. The study necessitated multiple variables in relatively few area points, so that there was arguably insufficient power to assess whether quite strong correlations were significant and also the possibility of statistically significant but incoherent correlations. We tackled this in two ways. Though this paper primarily relates to area patterns we included the individual level correlations to be sure that there were genuine inter-relations between deprivation indicators and lifestyle. The pattern was coherent and consistent with the findings in other countries in the overall data that have more power and precision. Furthermore the aggregated findings accord broadly with those of the one previous comparable study.3 The methodological problems in this study are common to many small countries and while they need to be acknowledged they are in themselves a good explanation as to why this debate is dominated by large scale data from highly populated industrialised countries.

This study has importance for the international debate on social capital and deprivation. The simple fact is that social breakdown coexists with poverty, deprivation, adverse lifestyle and poor health outcome in most industrialised countries, making an assessment of the relative contribution and causal directions of these inter-relations highly problematic. Physical measures of social capital cited to date might not necessarily be reflected in actual economic disparities and more importantly might not in themselves reflect the true underlying attitudes people have towards each other. This is why Ireland is a good example. In a small country with a complex proportional representation system mainstream party voting tells us what social and economic policies most voters are happy to support. Furthermore, social variations in the country as a whole are as marked at individual as area level across most of the country. On the strength of these data at least, the case for a macro-level shift in public policy rests securely on its direct impact on material disadvantage and empowerment of the poor, rather than a promotion of a politically cohesive consensus approach in itself. The findings suggest also that a more subtle conception of social capital is needed to explain or tackle health variations.

We are grateful to Professor Michael Laver, Trinity College Dublin for early advice on means of accessing voting data, to Dr Eamon O'Shea of the Department of Economics, NUI Galway and Dr Hanno Ulmer, University of Innsbruck, for helpful comments on the area level analyses.

Funding: The Survey on Lifestyle, Attitudes and Nutrition (SLAN), was funded by the Health Promotion Unit of the Irish government's department of Health and Children. Cecily Kelleher is the principal investigator of an inter-departmental Unit on Health Status and Health Gain, which is being funded over five years by the Health Research Board of Ireland.

Conflicts of interest: none.

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Nokia shuts down its VR department

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Trump has since issued a statement to clarify his words.

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