Belgian Women Research Articles

The social gradient in preventive healthcare use: what can we learn from socially mobile individuals?

Little is known about the origins of the stratified nature of preventive health behaviour. In this paper, we introduce theory and methodology from the field of social mobility research. Intergenerational socially mobile individuals can provide insights into the central discussion about how health lifestyles or cultural health capital develop over the life course, as they have encountered different contexts of socialisation, each with its own characteristic health-related practices. We study the use of regular mammography screening by Belgian women using data from the Survey of Health, Aging and Retirement and we operationalise social mobility as occupational mobility using the International Standard Classification of Occupations (ISCO-88). By means of diagonal reference models, we are able to discern the effects of the social position of origin, the social position of destination and social mobility itself, contrary to the less rigorous linear regression approach that prevails in health behaviour research. As expected, the take up of mammography screening is strongly influenced by social position. It seems that both upwardly and downwardly mobile women adapt to the mammography screening practices in their position of destination. This study shows the potential for social mobility research to enrich the debate on health lifestyles.

Coping with menopausal symptoms: an internet survey of Belgian postmenopausal women

Objectives: An internet survey was performed to obtain current data on the actual use of medication, hormonal replacement and over the counter products to cope with menopausal symptoms, in Belgium. Opt-in Internet access panels of TalkToChange and GMI were evaluated as a potential new way to obtain data on insights of women on menopausal issues.

“Bring Joy to Your Home with the Real Frigidaire”: Advertising the Refrigerator to Belgian Female Consumers, 1955–1965

Advertisements provide a link between the symbolical, ideal, practical and informative notions of domesticity and technology and shed light on the material culture of the home and domesticity. In this article, I focus on the home as a material place where technological and consumerist trends develop, how these trends were linked to meanings of domesticity, and how they affected gendered identities, practices, labor, and ultimately tastes of home. I argue that in the normalization of the refrigerator, the promotion of a technology-based domestic life was not uniform in its meanings, entitlements, or strategies. First, the consumer was confronted not with uniformity but with a multitude of meanings, arguments and promises that came with the refrigerator. Second, gender roles and identities were less varied. Third, the hard sell–soft sell dichotomy did not prevail, and emotional or hedonistic appeals were often combined with directly spelled-out advantages. The refrigerator advertisements studied here appeared in a Belgian women's magazine between 1955 and 1965 and constructed family life and tastes of home around elevated standards of comfort, care, aesthetics, and choice, more so than around a scientific rationalization of household work and organization.

"It's my secret": fear of disclosure among sub-Saharan African migrant women living with HIV/AIDS in Belgium.

Patients with HIV not only have to deal with the challenges of living with an incurable disease but also with the dilemma of whether or not to disclose their status to their partners, families and friends. This study explores the extent to which sub-Saharan African (SSA) migrant women in Belgium disclose their HIV positive status, reasons for disclosure/non-disclosure and how they deal with HIV disclosure. A qualitative study consisting of interviews with twenty-eight SSA women with HIV/AIDS was conducted. Thematic content analysis was employed to identify themes as they emerged. Our study reveals that these women usually only disclose their status to healthcare professionals because of the treatment and care they need. This selective disclosure is mainly due to the taboo of HIV disease in SSA culture. Stigma, notably self-stigma, greatly impedes HIV disclosure. Techniques to systematically incorporate HIV disclosure into post-test counseling and primary care services are highly recommended.

Introducing the non-invasive prenatal test for trisomy 21 in Belgium: a cost-consequences analysis

BackgroundThe first- and second-trimester screening for trisomy 21 (T21) are reimbursed for all pregnant women in Belgium. Using a cut-off risk of 1:300 for T21, about 5% of all pregnant...

Prevalence and associated factors of fear of childbirth in six European countries

ObjectivesThis study set out to compare the prevalence, content and associated factors of fear of childbirth in six European countries. MethodA cross-sectional study of 6870 pregnant women attending routine antenatal care in Belgium, Iceland, Denmark, Estonia, Norway and Sweden (Bidens).Main outcome measure: Severe fear of childbirth, defined as a Wijma Delivery Expectancy Questionnaire score of ≥85. ResultsEleven percent of all women reported severe fear of childbirth, 11.4% among primiparous and 11.0% among multiparous women. There were significant differences between the countries for prevalence of severe fear of childbirth, varying from 4.5% in Belgium to 15.6% in Estonia for primiparous women and from 7.6% in Iceland to 15.2% in Sweden for multiparous women. After adjusting for age, education and gestational age, only primiparous women from Belgium had significantly less fear of childbirth, AOR 0.35 (0.19–0.52) compared to Norway (largest participating group). Exploratory factor analyses revealed significant differences between the countries for the six factors extracted. ConclusionFOC appears to be an international phenomenon, existing with similar proportions in the participating European countries, except for primiparous women in Belgium who in our study reported significantly less severe fear of childbirth. Our study suggests that the content of fear of childbirth may differ between countries.

Propaganda and ‘manufactured hatred’: A reappraisal of the ethics of First World War British and Australian atrocity propaganda

Following the end of the First World War, British and Australian atrocity propaganda fell into disrepute. Progressive liberal authors such as British parliamentarian Arthur Ponsonby condemned atrocity propaganda as a series of manipulative lies designed to dupe a naïve populace into supporting a morally meaningless war. However, atrocity propaganda, which focused on the abuse of Belgian women and children at the hands of German soldiers, was not all lies. Yet because propaganda had come to be regarded as a synonym for ‘lies’, very few historians from the mid-20th century onwards were willing to entertain the idea that some aspects of atrocity propaganda were truthful. Therefore, the just war elements contained in atrocity propaganda, which maintained that the British and Australians fought for the rights of small nations and the protection of non-combatants from military abuse, have not been given appropriate consideration until recently. This article contributes to the revision of Australian and British home front attitudes to the war by using atrocity propaganda as valuable primary source material, rather than merely dismissing it as lies, which to date has been the main approach of historians.

Vitamin B12 and folic acid status of term pregnant women and newborns in the Antwerp region, Belgium

Objective: Descriptive study on maternal serum vitamin B12 and folic acid in term pregnancy and in umbilical cord blood that was performed in an inner city hospital with a mixed ethnic population in the region of Flanders in Belgium. Materials and Methods: A prospective cohort study that took place from April 1 until May 31, 2011. Plasma folic acid and vitamin B12 were measured in maternal and umbilical cord blood from all term uncomplicated deliveries in a single regional hospital. Data on age, previous obstetric history, ethnicity, nutritional intake, and use of vitamin supplements were registered. Results: Data were collected from 110 patients, mean maternal serum vitamin B12 was 243.9 pmol/l and mean folic acid level was 43.0 nmol/l. Using a cutoff of respectively 150 pmol/l for vitamin B12 and 7.1 nmol/l for folic acid, 13% of the women were classified as vitamin B12-deficient and 23% were deficient for folic acid. Vitamin B12 deficiency was only seen in autochthonous Belgian women. A correlation between the maternal and umbilical cord levels was noted (R = 0.7 for vitamin B12, R = 0.85 for folic acid), but none of the umbilical cord levels demonstrated deficiency. Number of previous pregnancies and intake of supplements had no influence. Conclusion: Pregnant women in Antwerp, Belgium, frequently show vitamin B12 and folic acid deficiency, although a correlation exists with lower umbilical cord levels, the present limited data did not demonstrate any case of deficiency in umbilical cord blood. The frequency is highest in the autochthonous population and is not influenced by intake of vitamin supplements.

Lifecourses, pensions and poverty among elderly women in Belgium: interactions between family history, work history and pension regulations

ABSTRACTThe precarious financial situation of many elderly women in developed countries is well established. Nevertheless, in-depth insight into the persistent vulnerability of this group remains largely absent. In this article, we demonstrate how a specific focus on the interaction between work history, family history and pension regulations can provide greater insight into the mechanisms that produce poverty among elderly women in Belgium. To that end, we make use of register data on some 9,000 women aged 65–71. Data on the poverty risk of these women is linked to career and family data, spanning over 45 years. We find that pension policy can indeed account for the higher poverty risk of some groups of elderly women (e.g.divorcees) as compared to others (e.g.widows). Similarly, pension policy can, to a large extent, directly or indirectly explain how previous lifecourse events, such as marital dissolution or childbirth, affect old-age poverty risk. However, our study also reveals some unexpected findings. Most notably, pension regulations fail to account for the beneficial situation of married women. Indeed, our analyses suggest that capital (income) may prove more decisive than pension rights in explaining the low poverty risk of married women when compared to other marital groups. Drawing from our findings, we conclude with some suggestions as to where pension policy should go from here.

Exceptionally long-term persistence of DNA adducts formed by carcinogenic aristolochic acid I in renal tissue from patients with aristolochic acid nephropathy.

Aristolochic acid (AA) causes aristolochic acid nephropathy (AAN), first described in women in Belgium accidently prescribed Aristolochia fangchi in a slimming treatment, and also Balkan endemic nephropathy (BEN), through probable dietary contamination with Aristolochia clematitis seeds. Both nephropathies have a high risk of urothelial cancer, with AA being the causative agent. In tissues of AAN and BEN patients, a distinct DNA adduct, 7-(deoxyadenosin-N6-yl)-aristolactam I (dA-AAI), has been detected. DNA adducts can be removed through DNA repair, they can result in mutations through erroneous DNA replication or they can cause cell death. The dA-AAI adduct induces AT to TA transversions in the tumor-suppressor TP53 gene in experimental systems, matching TP53 mutations observed in urothelial tumors from AAN cancer cases. Using thin-layer chromatography 32P-postlabeling and mass spectrometric analysis we report the detection of dA-AAI in renal DNA from 11 Belgian AAN patients over 20 years after exposure to AA had ceased. Our results showed that dA-AAI is an established biomarker of AA exposure, and that this biomarker can be demonstrated to be persistent decades after a distinct AA exposure. Further, the persistence of dA-AAI adducts appears to be a critical determinant for the AA mutational fingerprint frequently found in oncogenes and tumor suppressor genes recently identified by whole genome sequencing of AA-associated urothelial tumors. The potential for exposure to AA worldwide is high; the unprecedented long-term persistence of dA-AAI provides a useful long-term biomarker of exposure and attests to the role of AA in human urothelial malignancy.

Gender, TIMI risk score and in-hospital mortality in STEMI patients undergoing primary PCI: results from the Belgian STEMI registry

The relationship between the predictive performance of the TIMI risk score for STEMI and gender has not been evaluated in the setting of primary PCI (pPCI). Here, we compared in-hospital mortality and predictive performance of the TIMI risk score between Belgian women and men undergoing pPCI. In-hospital mortality was analysed in 8,073 (1,920 [23.8%] female and 6,153 [76.2%] male patients) consecutive pPCI-treated STEMI patients, included in the prospective, observational Belgian STEMI registry (January 2007 to February 2011). A multivariable logistic regression model, including TIMI risk score variables and gender, evaluated differences in in-hospital mortality between men and women. The predictive performance of the TIMI risk score according to gender was evaluated in terms of discrimination and calibration. Mortality rates for TIMI scores in women and men were compared. Female patients were older, had more comorbidities and longer ischaemic times. Crude in-hospital mortality was 10.1% in women vs. 4.9% in men (OR 2.2; 95% CI: 1.82-2.66, p<0.001). When adjusting for TIMI risk score variables, mortality remained higher in women (OR 1.47, 95% CI: 1.15-1.87, p=0.002). The TIMI risk score provided a good predictive discrimination and calibration in women as well as in men (c-statistic=0.84 [95% CI: 0.809-0.866], goodness-of-fit p=0.53 and c-statistic=0.89 [95% CI: 0.873-0.907], goodness-of-fit p=0.13, respectively), but mortality prediction for TIMI scores was better in men (p=0.02 for TIMI score x gender interaction). In the Belgian STEMI registry, pPCI-treated women had a higher in-hospital mortality rate even after correcting for TIMI risk score variables. The TIMI risk score was effective in predicting in-hospital mortality but performed slightly better in men. The database was registered with clinicaltrials.gov (NCT00727623).

Chinese Herbs Containing Aristolochic Acid Associated with Renal Failure and Urothelial Carcinoma: A Review from Epidemiologic Observations to Causal Inference

Herbal remedies containing aristolochic acid (AA) have been designated to be a strong carcinogen. This review summarizes major epidemiologic evidence to argue for the causal association between AA exposure and urothelial carcinoma as well as nephropathy. The exposure scenarios include the following: Belgian women taking slimming pills containing single material Guang Fang Ji, consumptions of mixtures of Chinese herbal products in the general population and patients with chronic renal failure in Taiwan, occupational exposure in Chinese herbalists, and food contamination in farming villages in valleys of the Danube River. Such an association is corroborated by detecting specific DNA adducts in the tumor tissue removed from affected patients. Preventive actions of banning such use and education to the healthcare professionals and public are necessary for the safety of herbal remedies.

Association of Trichomonas vaginalis and Cytological Abnormalities of the Cervix in Low Risk Women

ObjectiveIs Trichomonas vaginalis (TV) an inducing factor for the development of (pre-)cancerous lesions of the cervix?DesignCross sectional study.SettingScreening healthy Belgian women with low infection risk.Sample63,251 consecutive liquid based cervical samples.MethodsReal time quantitative PCR for presence of TV, 18 HPV types and Pap smear analysis of cytologic abnormalities. Main Outcome MeasuresAssociation of TV and HPV with cervix dysplasiaResultsThe overall prevalence of TV DNA was 0.37%, of low risk HPV 2%, of high risk HPV 13.2%, and 8.8 % had cytological abnormalities. Both LR-HPV and HR-HPV were significantly associated with all cytological abnormalities. Presence of TV was associated with LR- and HR-HPV, ASC-US and HSIL, but not with other abnormalities. All women with TV and HSIL also had HR-HPV, while the latter was present in only 59% of women with TV and ASC-US. Amongst HPV negative women, TV was found in 1.3% of women with ASC-US, but only in 0.03% of women with normal cytology (OR 4.2, CL95% 2.1-8.6). In HR-HPV positive women, presence of TV increased the likelihood of cytological abnormalities somewhat (P=0.05), mainly due to an increase in ASC-US and LSIL, but not HSIL. ConclusionsWe conclude that TV infection is associated with both LR and HR-HPV infection of the cervix, as well as with ASC-US and HSIL. TV is a concomitant STI, but is not thought to be a co-factor in the causation of HSIL and cervical cancer. However, TV may cause false positive diagnoses of ASC-US.

Abstract PL02-02: Aristolochic acid-induced nephropathy and urothelial carcinoma: A preventable global disease

Abstract Balkan endemic nephropathy (BEN) is a chronic renal disease affecting residents of rural farming villages located near tributaries of the Danube river. Otherwise rare urothelial carcinomas of the upper urinary tract (UTUC) develop in ~ 50% of patients with BEN. Our studies of the etiology of this disease were informed by reports of a similar syndrome affecting ~ 100 Belgian women who ingested Aristolochia fangchi as part of a weight loss routine (1). In this case, the responsible toxin proved to be aristolochic acid (AA), a component of all Aristolochia plants. In the Balkans, a pilot epidemiologic study confirmed earlier reports that Aristolochia clematitis (birthwort) often is found as a weed growing in cultivated fields. Traditional methods used for harvesting and milling of wheat allowed seeds of this plant to contaminate grain used to prepare bread, a dietary staple among residents of the endemic region. Aristolactam (Al)-DNA adducts were detected in the renal cortex and urothelial tumor tissue of patients with BEN (2). Moreover, a pattern of A:T to T:A mutations unique to AA was demonstrated first in TP53 (3, 4) and, subsequently throughout the genome (5). Based on these observations, it was proposed that the name, BEN, be changed to aristolochic acid nephropathy (AAN). With respect to prevention of BEN, scientific designation of this environmental toxin is important to public health authorities as it legitimizes efforts to change traditional agricultural practices. The experimental methods developed in our studies proved indispensable in our subsequent efforts to demonstrate that AAN and UTUC are prevalent in Asian countries, where Aristolochia herbs have been used for medicinal purposes for centuries. For example, in Taiwan, where the incidence of UTUC and of chronic kidney disease are the highest in the world, at least one-third of the population has been prescribed herbs containing AA (6). Remarkably, the unique TP53 mutational signature for AA established in our studies of BEN was recapitulated in cases of UTUC from Taiwan (7). Moreover, aristolactam-DNA adducts, which persist for decades in the renal cortex, were detected in patients with the signature mutation spectrum in TP53, thereby documenting the relationship between exposure to AA and its mutagenic effects. Millions of people in China are estimated to have ingested Aristolochia herbal remedies, highlighting the potential morbiditity and mortality associated with the medicinal use of this family of herbs (8). Studies designed to document AA exposure in countries where Aristolochia herbs are used in the practice of traditional Chinese medicine are currently underway. Importantly, the nephrotoxic effects of AA are irreversible and its carcinogenic effects may not become manifest until 30 or more years after exposure. Thus, the development of non-invasive, biomarker-based tests that can be used to detect AA-induced UTUC are highly desirable, as this cancer is often curable by surgery if detected early in the course of the disease. (Research supported by grants from the NIEHS (ES04068) Fogarty International Center, Croatian Ministry of Science, Taiwan Dept of Health, Zickler Family Foundation and Henry and Marsha Laufer).

Disclosure Pattern and Follow‐Up After the Molecular Diagnosis of BRCA/CHEK2 Mutations

Five to 10% of all breast cancer cases are due to mutations of high penetrance susceptibility genes, especially BRCA1 and BRCA2. In families with known BRCA mutations, disclosure of genetic test results could induce relatives to undergo genetic testing themselves and adopt cancer risk management strategies, if necessary. This study examines disclosure patterns of individuals tested for mutations in the BRCA1, BRCA2 and CHEK2 genes to first-degree relatives with emphasis on a possible gender difference. It also assesses which management strategy is preferred by mutation-positive women in Belgium and the influence of psychological characteristics on communication and choice of management strategy. Ninety-nine adults from BRCA/CHEK2 families, selected from the Centre of Medical Genetics of Antwerp, were included in the study. They were provided with medical and psychological questionnaires, the latter being the Self-Assessment Questionnaire, which is the Dutch version of the Spielberger State-Trait Anxiety Inventory and the Dutch version of the Coping Inventory for Stressful Situations (CISS-NL). The survey focused on disclosure, coping and management strategies with special attention on possible gender differences. The influence of socio-demographic and medical data on disclosure and cancer risk management as well as the influence of psychological features were examined by means of various statistical analyses. Ninety-nine patients were included, of whom 25 (25 %) were male. Eighty-seven percent of the participants informed all of their adult first-degree relatives about their mutation status without any gender discrimination. Seventy-eight percent of highly-educated participants informed all of their adult first-degree relatives, compared to 98 % of less formally-educated participants (p = 0.006). The majority of mutation-positive women preferred prophylactic surgery to surveillance. Psychological differences appeared to have little influence on disclosure patterns and management strategies. The gender difference seems to be less pronounced than previously assumed. A striking observation, however, is the fact that significantly more participants who were less formally-educated informed all of their adult first-degree relatives, compared to participants who were highly-educated. In our study population, most female mutation carriers opted for prophylactic surgery. Since the study population is small, further studies are needed to enhance the generalizability of these results.

Algofunctional status in Belgian women one year after completion of therapy for breast cancer

Algofunctional status in Belgian women one year after completion of therapy for breast cancer

Spousal influence on mammography screening: A life course perspective

Recently, researchers have challenged the basic tenet that marriage is universally protective for all individuals. We scrutinize socio-economic differences between married couples to shed light on the mechanisms underlying the effects of marriage. We introduce the life course perspective to investigate if differences in positive health behavior between couples are related to their early life conditions. Within the theoretical framework of cultural health capital, we hypothesize that the accumulation of cultural health capital proceeds at the marriage level when partners provide each other with health-related information and norms. For this purpose, we examine the influence of the childhood preventive health care behavior of both wives and husbands on the initiation of mammography screening for a sample of Belgian women (N = 734). Retrospective life histories of both partners are provided by the Survey of Health, Ageing and Retirement (SHARE) and are examined by means of event history analysis. The results show that a partner's cultural health capital affects the initiation of mammography screening by a woman in later life, even after her own cultural health capital and traditional measures of socio-economic status (SES) are taken into account. In line with cumulative advantage theory, it seems that inequalities in cultural health capital are accumulated at the marriage level. In order to shed further light on the spousal influence on health behavior, researchers should revert to early life in order to discern the attribution of premarital and marital conditions.

High Prevalence of Thyroid Disorders in Pregnant Women in a Mildly Iodine-deficient Country: A Population-Based Study

Many countries in Europe remain mildly iodine deficient but relatively few country-level data exist on mild iodine deficiency (MID) and its impact on thyroid function in pregnant women. To determine the prevalence of thyroid disorders in pregnant women in Belgium and to assess the association between iodine status and serum thyroglobulin (Tg). We conducted a national survey of pregnant women in 55 obstetric clinics. Urinary iodine concentration corrected for creatinine (UIC/Cr) and thyroid function were measured. The frequency of elevated serum TSH was 7.2%, indicating either subclinical hypothyroidism (6.8%) or overt hypothyroidism (0.4%). Among those women, 13.8% were thyroid peroxidase antibodies (TPO-Ab) positive. The frequency of low serum TSH was 4.1%, indicating either subclinical hyperthyroidism (3.6%) or overt hyperthyroidism (0.5%). In the entire population, the frequency of positive TPO-Ab and/or Tg antibodies positive women was 4%. Globally, the prevalence of thyroid disorders (abnormally high or low TSH) or thyroid autoimmunity features was 15.3% and 18.6% in first-trimester pregnant women. Women with an adequate iodine status (UIC/Cr = 150-249 μg/g) had a significantly lower median Tg concentration compared to moderately iodine deficient women (UIC/Cr ≤ 49 μg/g), 19 μg/L and 25 μg/L, respectively. The prevalence of thyroid disorders was high, affecting one in six pregnant women in Belgium. Therefore, the iodine status in women needs to be improved and screening for thyroid disease should be performed early in pregnancy. In addition, our data suggest that a median Tg of <20 μg/L may indicate iodine sufficiency in pregnant women.

Overactive bladder symptoms, stress urinary incontinence and associated bother in women aged 40 and above; a Belgian epidemiological survey

This Belgian epidemiological study aimed to assess the prevalence of overactive bladder (OAB) and stress urinary incontinence (SUI) and associated bother in a female primary care population. Data on OAB and SUI were prospectively collected among women ≥ 40 years by general practitioners (GP) during a regular visit for any reason. The validated Bladder Control Self-Assessment Questionnaire (B-SAQ) was used and complemented with a question on SUI and bladder bother. The presence of mild bladder control symptoms (BCS) was defined as an overall B-SAQ symptom score (OSS) ≥ 4 and an overall bother score (OBS) ≥ 1. Descriptive statistics were performed. Data from 7139 women were analysed. About 33.9% had mild BCS. Most women reported overall mild OAB symptoms (46.9%) and 34.9% had moderate-to-(very) severe symptoms. The prevalence of moderate-severe urgency, frequency or nocturia was higher than that of moderate-severe incontinence. Urgency and nocturia were considered the most bothersome symptoms. Moderate-severe SUI affected 17.7% of women. About 16.4% of women reported to be moderately-severely bothered by their bladder in everyday life. The risk of severe symptoms and bother increased with age. About 10% of women had clinically significant BCS (OSS ≥ 7 and OBS ≥ 4). In Belgian women ≥ 40 years visiting a GP for any reason, one in three had mild BCS and might benefit from further evaluation. Up to 10% of these women had clinically significant BCS for which medical therapy might be necessary. This warrants awareness for early diagnosis and intervention.

Women’s prelabour preference for epidural analgesia: a cross-sectional study among women from the Netherlands and Belgium

Background: This study describes variables related to women’s prelabour preference for epidural analgesia (PEA) in two neighbouring countries with a comparable socio-economic and cultural background.Methods: Dutch women in midwifery (n = 164) or obstetrical care (n = 162), and Belgian women (n = 188) of ≥36 weeks gestation with a singleton in cephalic presentation completed questionnaires on demographic factors, received labour analgesia information, perceived attitude of the caregiver towards epidural analgesia (EA), pain catastrophising and coping with labour pain. Multiple logistic regression analysis was performed with PEA as dependent variable.Results: PEA was 9.9% in Dutch midwifery care, 25.5% in Dutch obstetrical care and 38.3% in Belgian care (p value < 0.001). In the Netherlands, maternal age of 35 years or older (OR 4.95; 95% confidence interval (CI) 2.03–12.08), positive attitude of the caregiver towards EA (OR 5.83; 95% CI 2.57–13.23) and a lower degree of coping (OR 3.61; 95% CI 2.24–5.82) were independently associated with PEA. In Belgium, only a lower degree of coping was associated with PEA (OR 4.06; 95% CI 2.45–6.73).Conclusions: In both countries, women with a lower degree of coping had a higher PEA. Care setting in the Netherlands was not an independent variable.