Number Of Stressful Life Events Research Articles

23-Prenatal stress, mood, and gray matter volume in young adulthood

This study aimed to determine whether prenatal stress, measured by the number of stressful life events during the first 20 weeks of pregnancy, might relate to mood dysregulation and altered brain structure in young adulthood. Participants included 93 mother – offspring pairs from a community-based birth cohort from the Czech Republic (European Longitudinal Study of Pregnancy and Childhood; ELSPAC-CZ). MRI analyses focused on overall cortical gray matter (GM) volume and GM volume of cortical regions previously associated with major depression. Higher prenatal stress predicted more mood dysregulation, particularly higher anxiety, fatigue and anger, lower overall cortical GM volume (corrected for brain size) and lower GM volume in mid-dorsolateral frontal cortex, anterior cingulate cortex and precuneus in young adulthood. We observed no Prenatal Stress by Sex interactions for any of the above relationships. We conclude that prenatal stress is an important risk factor that relates to worse mood states and altered brain structure in young adulthood irrespective of sex. Our results point to the importance and long lasting effects of prenatal programming and suggest that offspring of mothers who went through substantial stress during pregnancy might benefit from early intervention that would reduce the odds of mental illness in later life.

Prenatal Stress, Mood, and Gray Matter Volume in Young Adulthood.

This study aimed to determine whether prenatal stress, measured by the number of stressful life events during the first 20 weeks of pregnancy, might relate to mood dysregulation and altered brain structure in young adulthood. Participants included 93 young adults from a community-based birth cohort from the Czech Republic. Information on prenatal stress exposure was collected from their mothers in 1990-1992. Magnetic resonance imaging (MRI) and mood-related data were collected from the young adults in 2015. MRI analyses focused on overall gray matter (GM) volume and GM volume of cortical regions previously associated with major depression. Higher prenatal stress predicted more mood dysregulation, lower overall GM volume, and lower GM volume in mid-dorsolateral frontal cortex, anterior cingulate cortex, and precuneus in young adulthood. We observed no prenatal stress by sex interactions for any of the relations. We conclude that prenatal stress is an important risk factor that relates to worse mood states and altered brain structure in young adulthood irrespective of sex. Our results point to the importance and long-lasting effects of prenatal programming and suggest that offspring of mothers who went through substantial stress during pregnancy might benefit from early intervention that would reduce the odds of mental illness in later life.

Stressful life events and depressive symptoms in mothers and fathers of young children

BackgroundParents of young children generally report more depressive symptoms than parents of adult children or people without children, mainly because the presence of young children increases exposure to significant stressors (such as stressful life events). However, most studies on the depressogenic role of stressful life events in parents of young children have focussed on mothers. MethodsUsing data from 1138 families with young children in Norway, we investigated gender differences in the effect of stressful life events after a child's birth on the development of parental depressive symptoms in 3 follow-ups at child's ages 3–6 years. We also explored if gender differences in disposition (personality) may explain any gender differences in the depressogenic effect of life events. ResultsNesting parents within families, we found a female gender bias for both neuroticism and depressive symptoms but no gender difference in the number of life events reported. Importantly, the number of stressful life events predicted the level and course of depressive symptoms similarly for mothers and fathers. Personality traits did not change the association between stressful life events and depressive symptoms in either mothers or fathers. LimitationsGiven the study design, causality cannot be inferred. ConclusionsThere was no gender difference in the depressogenic effect of stressful life events in our sample. There was no evidence for a female dispositional sensitivity to the depressogenic effect of stressful life events, either. Stressful life events put both mothers and fathers of young children at risk of depression.

C-reactive protein, brain-derived neurotrophic factor, interleukin-2, and stressful life events in drug-naive first-episode and recurrent depression: A cross-sectional study.

Aims:The aim of the study is to assess and compare serum C-reactive protein (CRP), brain derived neurotrophic factor (BDNF), and interleukin-2 (IL-2) levels in patients with first-episode depression (FED), recurrent depressive disorder (RDD), and healthy controls (HCs) and to determine the relationship between the above-specified inflammatory markers, severity of depression, and stressful life events.Materials and Methods:Consecutive drug-naive patients with FED and RDD (n = 85) and 50 HCs were studied. Serum concentrations of CRP, brain-derived nerve growth factor (BDNF), and IL-2 were measured. All participants were assessed using Mini-International Neuropsychiatric Interview Plus, Beck's depression inventory, and presumptive stressful life events scale.Results:The FED and RDD groups had statistically significant lower serum concentration of BDNF and higher IL-2 compared to the HC group, whereas no statistically significant difference was observed with regard to CRP level. No statistically significant differences were observed with regard to the severity of depression and serum concentrations of CRP, BDNF, and IL-2 in the FED and RDD groups. No significant correlation was found between severity of depression and serum concentration of CRP, BDNF, and IL-2 in both the groups. Serum CRP concentration was significantly higher in patients with ≥2 stressful life events. No significant difference was observed between number of stressful life events and BDNF and IL-2 in patients with depression.Conclusion:FED and RDD are associated with lower serum concentration of BDNF and higher IL-2 compared to the HCs, whereas there appears no difference with regard to CRP level. Multicentric studies are needed to further elucidate the role of inflammatory markers in depression.

Evaluation of coping as a mediator of the relationship between stressful life events and cancer-related distress.

Lifetime stressful life events (SLEs) may predispose oncology patients to cancer-related distress (i.e., intrusive thoughts, hyperarousal, avoidance). Coping may influence cancer-related distress by mediating this relationship. This study sought to (a) determine the prevalence and impact of lifetime SLEs among oncology outpatients receiving chemotherapy and (b) examine the relationship between SLEs and cancer-related distress and the mediating role of coping on this relationship. Patients (n = 957), with breast, gastrointestinal, gynecologic or lung cancer, who were undergoing chemotherapy, completed the Life Stressor Checklist-Revised (LSC-R), a measure of lifetime SLEs. Cancer-related distress was assessed with the Impact of Event Scale-Revised. Coping strategies since beginning chemotherapy were assessed with the Brief COPE; 2 latent variables (engagement and disengagement coping) were identified based on these scores. LSC-R scores (number of SLEs and perceived impact during the prior year) were evaluated in relation to demographic and clinical characteristics. Structural equation modeling was used to evaluate the relationship between LSC-R and Impact of Event Scale-Revised scores and the mediating role of engagement and disengagement coping on this relationship. On average, patients reported 6.1 (SD = 4.0; range = 0-23 out of 30) SLEs. Patients who were not married/partnered, had incomes <$30,000/year, or who had lower functional status or greater comorbidity had higher LSC-R scores. The relationship between more SLEs and more severe cancer-related distress was completely mediated by disengagement coping. Engagement coping did not mediate this relationship. Disengagement coping, including behavioral disengagement, avoidance, and denial, should be targeted to mitigate cancer-related distress. (PsycINFO Database Record

What a difference a year makes: comparing relationships between stressful life events, mood and life satisfaction among older adults, and their working-age counterparts

ABSTRACTObjectives: Stressful life events (SLEs) have been linked to depression, anxiety, and reduced life satisfaction. The inoculation hypothesis of aging suggests older adults may be less vulnerable to poor psychological outcomes following SLEs than working-age adults. The current study compared relationships between SLEs, mood and life satisfaction among older adults (65+), and adults aged 50–64, and investigated whether group identification and loneliness moderate these relationships.Method: A community-based sample of 121 Scottish participants responded to measures of SLEs (modified Social Readjustment Rating Scale), symptoms of depression and anxiety (Hospital Anxiety and Depression Scale), life satisfaction (Life Satisfaction Index A), group identification (Group Identification Scale), and loneliness (UCLA Loneliness Scale).Results: In the 50–64 age group, the number of SLEs was significantly associated with greater symptoms of depression and anxiety, and reduced life satisfaction. Group identification and loneliness did not moderate these relationships. There were no significant relationships in the older adult group.Conclusion: The finding of relationships in working-age, but not older adults, supports the inoculation hypothesis of aging. Further research to better understand changes across the lifespan, and inter-relationships with related variables, would be valuable from both theoretical and clinical perspectives.

The role of stressful life events on the cortisol reactivity patterns of breast cancer survivors

Objective: Atypical patterns of cortisol secretion following an acute stressor have been commonly reported in breast cancer survivors. Stressful life events have been associated with blunted acute cortisol levels in other populations. The purpose of this study was to explore the role of stressful life events on cortisol secretion patterns of breast cancer survivors following an acute stressor.Design: The Trier Social Stress (TSST) was used to elicit a moderate stress response in breast cancer survivors (n = 19) and a control group (n = 17). Saliva samples were collected before, during and after the TSST to provide cortisol concentrations. During recovery, we recorded the frequency and subjective impact of stressful life events in the past year using the Life Experience Survey.Results: Simple regressions analyses were performed; results suggest no group differences between the total number of stressful life events and their subjective impact. However, the total number of stressful life events as well as their subjective impact correlated negatively with the peak cortisol concentration in breast cancer survivors.Conclusions: The cumulative effect of stressful life events, positive and negative, may impact the endocrine stress system of breast cancer survivors more so than that of women with no history of cancer.

Psychosocial characteristics associated with symptom perception 1 year after gastric bypass surgery—a prospective study

BackgroundThe experience of symptoms after bariatric surgery, such as pain, dumping, and fatigue, may affect behavior, quality of life, and the need for healthcare consultations. Attention to and interpretation of symptoms are influenced by psychological and contextual factors. Prospective studies of psychological factors predicting physical symptom perception after bariatric surgery are scarce. ObjectivesTo explore associations of preoperative negative affect and history of stressful and traumatic events with frequency and intensity of self-reported symptoms 1 year after Roux-en-Y gastric bypass (RYGB). SettingUniversity hospital. MethodsQuestionnaire data were collected before and 1 year after RYGB from 230 patients. Negative affect and stressful events were measured preoperatively. The participants reported the number and impact of various physical symptoms postoperatively. ResultsThe most common symptoms reported to have a high impact on behavior were fatigue (32.8%) and dumping (28.4%). Reporting more symptoms was associated with preoperative anxiety (r = .22, P = .001) and the number of stressful life events (r = .21, P = .002). Participants with a probable preoperative anxiety disorder reported a higher impact of fatigue, pain, dumping, and diarrhea after surgery, while those with a probable mood disorder and a history of traumatic sexual/violent events reported a higher impact of dumping. ConclusionPreoperative anxiety symptoms and stressful experiences were associated with a higher perceived impact of symptoms, such as dumping, fatigue, and pain after RYGB. The evaluation of psychological characteristics associated with symptom perception may be relevant when managing symptoms that are not responsive to other treatment measures.

Psychosocial Stress and Brain Function in Adolescent Psychopathology.

The authors sought to explore how conduct, hyperactivity/inattention, and emotional symptoms are associated with neural reactivity to social-emotional stimuli, and the extent to which psychosocial stress modulates these relationships. Participants were community adolescents recruited as part of the European IMAGEN study. Bilateral amygdala regions of interest were used to assess the relationship between the three symptom domains and functional MRI neural reactivity during passive viewing of dynamic angry and neutral facial expressions. Exploratory functional connectivity and whole brain multiple regression approaches were used to analyze how the symptoms and psychosocial stress relate to other brain regions. In response to the social-emotional stimuli, adolescents with high levels of conduct or hyperactivity/inattention symptoms who had also experienced a greater number of stressful life events showed hyperactivity of the amygdala and several regions across the brain. This effect was not observed with emotional symptoms. A cluster in the midcingulate was found to be common to both conduct problems and hyperactivity symptoms. Exploratory functional connectivity analyses suggested that amygdala-precuneus connectivity is associated with hyperactivity/inattention symptoms. The results link hyperactive amygdala responses and regions critical for top-down emotional processing with high levels of psychosocial stress in individuals with greater conduct and hyperactivity/inattention symptoms. This work highlights the importance of studying how psychosocial stress affects functional brain responses to social-emotional stimuli, particularly in adolescents with externalizing symptoms.

Exposure to stress across the life course and its association with anxiety and depressive symptoms: Results from the Australian Women’s Wellness After Cancer Program (WWACP)

ObjectivesEarlier life stressors can increase the risk of persistent anxiety and depressive symptoms in women after cancer, though our understanding of the underlying mechanisms is limited. In this study, we tested alternative life course models to determine which best described associations between exposure to stressors in childhood, adolescence, and adulthood, and self-reported health in women previously treated for breast, gynaecological, and blood cancer. Study designData were drawn from 351 Australian women within 2 years of completing active cancer treatment who were participating in the Women’s Wellness After Cancer Program (WWACP) randomised controlled trial. A model-building framework compared “accumulative risk” and “sensitive period” stress exposure hypotheses with the saturated model to determine best fit. Main outcome measuresSymptoms of anxiety and depression were measured using the Center for Epidemiologic Studies Depression Scale (CES-D) and the Zung Self-rating Anxiety Scale (SAS). ResultsParticipants with the greatest number of stressful life events (SLEs) reported higher anxiety scores and more depressive symptoms. Alternative life course models for psychological distress (measured through the CES-D and SAS) and stress were compared with the saturated model (i.e., the accumulative risk). The more restrictive “sensitive period” models were the best fit for depressive symptoms though none was significantly better than another. In contrast, an “early sensitive” model provided the best fit for anxiety data. ConclusionsAnxiety scores were higher in women with early life stressors. This study highlights the need for whole-of-life supportive care approaches for women previously treated for cancer, which should include targeted strategies for effective management of stress, anxiety and depression.

Cumulative Impact of Stressful Life Events on the Development of Takotsubo Cardiomyopathy.

The role of stressful life events in the onset of Takotsubo cardiomyopathy (TC) is unclear. This study sought to examine associations between type, timing, and number of stressful life events and onset of TC. A case-control study conducted among consecutive incident female TC cases and myocardial infarction (MI) controls admitted to two emergency departments in New England. Healthy female controls (HC) were recruited from a volunteers' registry. Information about the timing, type, and number of triggers during the 6months preceding hospitalization was systematically collected using the PERI Life Events Scale about 1month post-discharge. Group differences were evaluated using ANOVA, chi-square, and Kruskal-Wallis statistics. Generalized linear models were used to adjust for confounding variables. Between March 2013 and October 2015, 107 women were enrolled (45 TC, 32 MI, and 30 HC). Specific stressful events (death of a relative or close friend (p=0.006); illness or injury to a relative or close friend (p=0.001) were more prevalent in TC cases than MI and HC controls. The onset of TC was associated with exposure to multiple stressful life events during the 6months preceding the index hospitalization (p<0.001) but not with exposure to an acute, recent event (p=0.96). TC onset was associated with specific life events (death or illness to close relative or friend) and with the number of stressful life events occurring in the 6months preceding hospitalization. These findings suggest that grief and cumulative stress could play a major role in the onset of TC.

Multifactorial discrimination as a fundamental cause of mental health inequities

BackgroundThe theory of fundamental causes explains why health disparities persist over time, even as risk factors, mechanisms, and diseases change. Using an intersectional framework, we evaluated multifactorial discrimination as a fundamental cause of mental health disparities.MethodsUsing baseline data from the Project STRIDE: Stress, Identity, and Mental Health study, we examined the health effects of discrimination among individuals who self-identified as lesbian, gay, or bisexual. We used logistic and linear regression to assess whether multifactorial discrimination met the four criteria designating a fundamental cause, namely that the cause: 1) influences multiple health outcomes, 2) affects multiple risk factors, 3) involves access to resources that can be leveraged to reduce consequences of disease, and 4) reproduces itself in varied contexts through changing mechanisms.ResultsMultifactorial discrimination predicted high depression scores, psychological well-being, and substance use disorder diagnosis. Discrimination was positively associated with risk factors for high depression scores: chronic strain and total number of stressful life events. Discrimination was associated with significantly lower levels of mastery and self-esteem, protective factors for depressive symptomatology. Even after controlling for risk factors, discrimination remained a significant predictor for high depression scores. Among subjects with low depression scores, multifactorial discrimination also predicted anxiety and aggregate mental health scores.ConclusionsMultifactorial discrimination should be considered a fundamental cause of mental health inequities and may be an important cause of broad health disparities among populations with intersecting social identities.

Stressful life events increase aggression and alcohol use in young carriers of the GABRA2 rs279826/rs279858 A-allele

Research of GABRA2 gene in alcohol use and impulse control suggests its role in aggressive behaviour. The purpose of the present study was to examine the effects of GABRA2 genotype and stressful life events on aggressive behaviour, alcohol use frequency and occurrence of alcohol use disorder in a population representative sample of adolescents followed up from third grade to 25 years of age. The sample consisted of the younger cohort of the longitudinal Estonian Children Personality, Behaviour and Health Study. Aggressive behaviour was rated with the activity scale of af Klinteberg, Illinois Bully Scale and Buss-Perry Aggression Questionnaire. Stressful life events and alcohol use were self-reported. Life history of aggression and lifetime occurrence of psychiatric disorders were estimated in a structured interview. The sample was genotyped for GABRA2 rs279826 and rs279858 polymorphisms that are in strong linkage disequilibrium and yielded very similar findings: Higher number of stressful life events reported at age 15 was associated with increased fighting in A-allele carriers, but not in GG homozygotes. At age 25, A-allele carriers with more stressful life events scored higher on physical aggression than those with less stress, and this was also observed regarding life history of aggression. A-allele carriers exposed to higher stress had consumed alcoholic beverages more frequently at age 15, and by age 25, they had alcohol use disorder with higher prevalence. The results of the present study suggest that the GABRA2 genotype interacts with stress in young people with impact on the development of alcohol use and aggressive behaviour.

Growth mindset of anxiety buffers the link between stressful life events and psychological distress and coping strategies

Beliefs about the malleability of global attributes like personality and intelligence – known as mindsets – are well-established predictors of resilience to challenges in educational contexts. Recent research further suggests that mindsets about anxiety may act in a similar fashion with mental health resilience. In this study we examined whether anxiety mindset would moderate relations between history of stressful life events and psychological distress and coping. Consistent with predictions, relations between number of stressful life events and posttraumatic stress symptoms, depression, substance use, and motivations for non-suicidal self-injury were weaker among those with more of a growth mindset relative to those with more of a fixed mindset. These initial results suggest that anxiety mindsets function in a similar way for mental health resilience as how mindsets of intelligence function for academic outcomes.

Predictors of WAIS–R vocabulary in late life: Differences by race

ABSTRACTBackground: Vocabulary scores tend to be significantly related to education in heterogeneous groups of older adults, even after controlling for confounding variables. However, there may be other factors that impinge on cognitive functioning for certain demographic groups, particularly those whose educational opportunities were limited, and who may have experienced considerable stress as a result of their minority status. Objectives: This study sought to explore possible predictors of vocabulary scores among African American and White older adults. Method: In this study, samples of African American (N = 165) and White (N = 146) community-dwelling older adults reported their level of education, perceived health status, and number of stressful life events, and were administered the Wechsler Adult Intelligence Scale–Revised (WAIS–R) Vocabulary subtest. Results: Among the White participants, level of education was the only significant predictor of vocabulary score after controlling for perceived health and exposure to stress. Among African American participants, education was also a significant predictor of vocabulary score. However perceived health and number of stressful life events were also significantly predictors of vocabulary score. Conclusions: Findings indicate that for certain cohorts of older adults, especially those who may have experienced stressful life circumstances and health disparities as a result of racial inequality, education may not be the only variable that predicts verbal intelligence. The importance of investigating cognitive functioning within a broader sociocultural context is discussed.

A study of risk factors associated with depression in medically ill elderly patients

Background: Medically ill elderly patients are more prone to develop depression. Stressful life events which the patient experiences as well as the absence of perceived social support all act as risk factors for developing depression. Moreover, if the coping mechanisms are faulty the risk of developing depression increases. Aim: This study was conducted to assess the prevalence of depression in medically ill elderly patients and the risk factors associated with faulty coping mechanisms, perceived social support, and stressful life events. Materials and Methods: This was a cross-sectional study conducted at a tertiary care hospital, wherein 100 patients fulfilling the inclusion and exclusion criteria were chosen. Patients were administered a semi-structured questionnaire to obtain details about sociodemographic profile and diagnosed medical illnesses. Geriatric Depression Scale, Coping Inventory for Stressful Situations, Multidimensional Scale of Perceived Social Support, and Presumptive Stressful Life Event Scale were used. Results: Prevalence of depression was 72% among the medically ill elderly patients. Depressed patients used more of emotion-oriented coping and less of task-oriented and avoidance coping mechanisms the perceived social support in the form of family and friends was significantly less in depressed patients. The more the number of stressful life events experienced by the patients the more depressed they were. Conclusion: Early identification of risk factors and early diagnosis of depression may help us in carrying out timely interventions and thus improve the quality of life of our patients.

Predictors of Postpartum Depression in Partnered Mothers and Fathers from a Longitudinal Cohort.

Postpartum depression (PPD) is a growing mental health concern in new mothers and fathers. The purpose of this study was to determine the predictors of depression at 3 months postpartum, comparing depressed couples to couples with only one depressed partner or no depressed partner, using data from the Alberta Pregnancy Outcomes and Nutrition study. Data from mothers and fathers were collected at second trimester and 3 months postpartum. Results showed predictors of PPD in mothers to be low household income, high prenatal depressive symptoms, and postnatally, low social support and higher number of stressful life events. Fathers had similar predictors, including low household income, high prenatal depressive symptoms, and postnatally low social support and smoking. Compared with non-depressed couples, factors that predicted PPD in both mothers and fathers in couples included low income, high prenatal depressive symptoms in mothers and low prenatal social support reported by fathers.

Life stress as potential risk factor for depression and burnout

Objective: Depression and burnout are two psychopathological labels that have been subject to an extensive discussion over the last decades. The crucial question is whether they can be seen as conceptually equal or as two distinct syndromes. One argument for the distinction is that depression impacts on the whole life of a suffering person whereas burnout is restricted to the job context. Depression has been shown to be affected by life stress. The more stressful life events a person experiences, the more he or she is susceptible for developing a depression. As there is the widespread but controversial opinion that burnout is a prodromal syndrome of depression, the present study examined whether the number of stressful life events is also associated with an increased risk for burnout. Methods: N = 755 healthy participants and N = 397 depressed patients completed the Maslach Burnout Inventory (MBI), the Beck Depression Inventory (BDI II) and reported the extent of experienced life stress. Results: A significantly closer relation between depression and life stress than between burnout and life stress was found in the healthy (z = 3.01, p = .003) as well as in the depressed sample (z = 3.41, p = .001). This finding was supported in both samples by means of a path analytic approach where the associations between life stress, burnout, and depression were controlled for possible mediator and moderator effects, also considering the influence of age. Conclusion: By considering the influence of life stress it could be demonstrated that depression and burnout are not identical although they share substantial phenotypic variance (r = .46–.61). Most important, the trivariate associations are the same in a representative employee sample and in an inpatient clinical sample suggesting the same underlying mechanisms covering the whole range from normal behavior to psychopathology. However, only longitudinal data can show if burnout necessarily turns into depression with the consequence that the burnout – life stress association approaches the depression – life stress association over time. © 2015 The Authors. Published by Elsevier GmbH. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Knowledge of the Unknown Child: A Systematic Review of the Elements of the Best Interests of the Child Assessment for Recently Arrived Refugee Children

Decision-making regarding an asylum request of a minor requires decision-makers to determine the best interests of the child when the minor is relatively unknown. This article presents a systematic review of the existing knowledge of the situation of recently arrived refugee children in the host country. This research is based on the General Comment No. 14 of UN Committee on the Rights of the Child. It shows the importance of knowing the type and number of stressful life events a refugee child has experienced before arrival, as well as the duration and severity of these events. The most common mental health problems children face upon arrival in the host country are PTSD, depression and various anxiety disorders. The results identify the relevant elements of the best interests of the child assessment, including implications for procedural safeguards, which should promote a child rights-based decision in the asylum procedure.

Adversity and children experiencing family homelessness: Implications for health.

This study tests links between adversity and health problems among children in family emergency housing. Children who experience family homelessness are at risk to also experience high levels of stress, health problems, and need for pediatric care. Understanding the connection between stress and health holds the potential to reduce persistent health disparities. Analyses tested whether experiencing a greater number of stressful life events during the early years of life was related to worse health conditions, emergency health care utilization, and hospitalizations. Parents noted children's experience of negative stressful life events, health problems, emergency room (ER) use, and hospitalization. Two cohorts of kindergarten-aged children staying in emergency family housing participated in the study in 2006-07 (n = 104) and in 2008-09 (n = 138), with the results examined separately. In both cohorts, more health problems were acknowledged for children exposed to more negative stressful life events. Stressful life events were not related to ER use but did relate to hospitalization for the 2006-07 cohort. Results affirm links between stress in early childhood and health problems among children living in emergency housing. Findings are consistent with the hypothesis that adversity in early childhood contributes to income and racial disparities in health.