Participation In Daily Activities Research Articles

The Moderating Role of Motivation in the Real-Time Associations of Fatigue, Cognitive Complaints, and Pain With Depressed Mood Among Stroke Survivors: An Ecological Momentary Assessment Study

ObjectiveStroke symptoms fluctuate during the day as stroke survivors participate in daily activities. Understanding the real-time associations among stroke symptoms and depressed mood, as well as the role of motivation for daily activities, informs, and post-stroke symptom management in the context of everyday living. This study aimed to (1) investigate the real-time associations of fatigue, cognitive complaints, and pain with depressed mood and (2) examine the role of motivation for daily activity participation as a potential moderator of these associations in stroke survivors. DesignA prospective cohort study involving 7 days of ecological momentary assessment (EMA), during which participants completed 8 EMA surveys per day. Multilevel modeling was used to analyze data. SettingCommunity. ParticipantsForty community-dwelling stroke survivors (N=40). InterventionsNot applicable. Main Outcome MeasuresEMA measures of depressed mood, stroke symptoms (physical and mental fatigue, cognitive complaints, and pain), and motivation (autonomous motivation, controlled motivation). ResultsHigher levels of within- and between-person physical fatigue, mental fatigue, cognitive complaints, and pain were momentarily associated with greater depressed mood (Ps<.001). Within-person autonomous motivation significantly buffered the momentary associations of physical fatigue (B=-0.06, P<.001), mental fatigue (B=-0.04, P=.032), and pain (B=-0.21, P<.001) with depressed mood. ConclusionsFindings indicate the momentary associations of fatigue, cognitive complaints, and pain with depressed mood in stroke survivors. Autonomous motivation underpinning daily activity participation was found to buffer the associations of fatigue and pain with depressed mood. Promoting autonomous motivation for daily activity participation may be viable for preventing and mitigating poststroke depression.

Fall experiences from the perspectives of people with osteoarthritis: in their own words

Purpose To explore real-life experiences of people with osteoarthritis (OA) to increase understanding of how they perceive contributing factors to falls, circumstances at time of falls, and consequences of falls. Materials and methods Four focus groups of 3–7 people with OA from the Chicago, IL, USA, and neighboring areas were conducted remotely via web-based videoconferencing. Inclusion criteria included history of falls in previous 12 months and hip and/or knee OA. Focus group transcripts were coded and analyzed using a modified grounded theory approach to identify themes. Results Focus group participants (n = 17) described experiences associated with fall-related events that resulted in the identification of four themes: (1) perception of falls and fall risks can be influenced by OA symptoms, (2) ability to remember circumstances of falls are influenced by consequences, (3) behaviors and attitudes that address OA symptoms and avoidance of falls are similar and (4) OA symptoms and falls have common psychological impacts on lives. Conclusion Our study highlights how people with OA define falls, perceive contributing factors to falls, and describe general and OA-related factors that contributed to their fall experiences. The shared experiences contributed to the creation of themes that represented various aspects of the circumstances and impact of falls. Consideration for the identified themes may enhance recording and reporting of falls, contribute to development of improved fall risk assessment tools, and prioritize research into the biopsychosocial effects of falls in people with OA. IMPLICATIONS FOR REHABILITATION Information about circumstances of a fall such as location, activity, and symptoms of osteoarthritis may be beneficial in creating tailored fall prevention training and education. Falls are a common problem for people with lower limb osteoarthritis that can lead to negative changes in activity and quality of life. The psychological impact of osteoarthritis symptoms may be contributing to fear of falling and decrease participation in daily activities. Awareness of the perceptions people with osteoarthritis have about their symptoms may provide educational and training opportunities to address the benefits of different therapeutic treatments. Awareness of perceptions people with osteoarthritis have about their risk of falling may provide educational and training opportunities to address the benefits of different therapeutic treatments.

Protocol for a single group, mixed methods study investigating the efficacy of photovoice to improve self-efficacy related to balance and falls for spinal cord injury

IntroductionMany individuals living with spinal cord injury (SCI) experience falls and a fear of falling, both of which can impact participation in daily activities and quality of life. A single...

The Effect of Implementing a Rehabilitation Nursing Program on Hand Burn Patients’ Daily Functioning: A Randomized Clinical Trial

Background: The physical problems associated with burns can cause patients various difficulties and negatively affect their independence as well as participation in daily life activities. Objectives: This study aimed to evaluate the effect of a rehabilitation nursing program on hand burn patients’ daily functioning. Methods: The present randomized clinical trial was conducted to examine 60 hand burn patients referred to the Shahid Motahari Hospital of Tehran, Iran, between November 4, 2020, and April 19, 2021. The patients were randomly divided into two groups using the block randomization method (n = 30 per group). The intervention group received a 5-week rehabilitation nursing program in two steps: during the acute stage of the disorder (i.e., the time of admission) and during the recovery stage (i.e., before discharge). Data were collected in each step using the General Activities of Daily Living (GADL) questionnaire. The control group received routine care. Inferential and descriptive statistics, such as the independent and paired t-test, as well as the chi-square test and analysis of covariance, were used to analyze the data. Results: The results showed no significant difference in the daily performance of the individuals assigned to the study groups prior to the rehabilitation program (P = 0.29). According to the results of covariance analysis, the overall performance mean scores of the two groups were significantly different after implementing the nursing rehabilitation program, with a significantly higher score (i.e., better performance) recorded for the intervention group (P &lt; 0.001). Also, the means of pre- and post-intervention performance scores were significantly different in the rehabilitation group (P &lt; 0.001), but they were not significantly different in the control group. Conclusions: It was concluded that implementing a rehabilitation nursing program improved the daily performance of patients with hand burns, which offered a valid ground for accelerating the rehabilitation of these patients and shortening the period they needed to return to society.

Physical Activity During Covid-19 Pandemic Lockdowns in Germany – an Overview

Summary In Germany, different ministries are responsible at state level for sport and physical education. The same applies for Covid-19 pandemic decrees. As a result, different rules and regulations have to be followed depending on the place of residence. The same applies to regulations of physical activity in various settings – kindergarten, school, clubs, municipality. The periods of Covid-19 lockdowns have been marked by nationwide closures of kindergartens, schools and in- and outdoor sport facilities. Resulting in an increase in screen time and sedentary activities (Langmeyer et al. 2020) and a notable decrease in children’s daily physical activity to 23.9 minutes (Schmidt et al. 2020). However, during the first lockdown (22. 03. 2020 – 04. 05. 2020), participation in daily activity increased from 108.8 min. per day before the pandemic to 146.8 minutes per day (Schmidt et al. 2021). This development in more casual sporting activities was not sustained into the second lockdown. Daily activity decreased to 62.2 minutes per day (Schmidt et al. 2021). Only organized sport showed a slight increase from 0.0 to 3.7 minutes per day in lockdown two (Schmidt et al. 2021). This was in spite of the fact that high-level athletes were allowed to train and some sport clubs changed to online offerings.

코로나19 이후 청소년의 삶의 변화와 청소년활동 참여가 진로준비도에 미친 영향

The purpose of this study is to investigate the influence of COVID-19-induced changes in daily life and activity participation for youth on their career readiness. To this end, a survey was conducted with 1,056 youths living in Busan, and the results were obtained using the hierarchical regression analysis method. For the analysis, changes in daily life and activity participation were used as independent variables. Changes in daily life consisted of changes in stress and life satisfaction, and youth’s participation in activities was comprised of participation and satisfaction. Accordingly, the relative influence of changes in their stress, life satisfaction, activity participation, and activity satisfaction since COVID-19 on their career readiness was investigated. As a result, it was found that youth activity satisfaction, activity participation, and changes in life satisfaction and stress had a positive effect on their career readiness. In particular, activity satisfaction showed the greatest influence. Career readiness can provide youth with powerful support to actively respond to various changes they are facing in the rapidly changing society since COVID-19 and to achieve their individual career goals. This study confirmed that career readiness is reinforced by youth activity participation satisfaction.

The Effects of stretching exercises and walking in premenstrual syndrome

Introduction: Premenstrual syndrome is a collection of symptoms characterized by the onset of lower abdominal pain, back pain, breast pain, depression, anxiety with limitation in participation in daily activities of women. Different treatment approaches have been followed to treat Premenstrual syndrome, but to treat precisely few exercises have been included. Thus, the study aims to find the effectiveness of stretching exercise and walking in treating Premenstrual syndrome.Subject: 25 women who are diagnosed to have Premenstrual syndrome.Methodology: 25 women with the age group of 14-30 years, diagnosed with Premenstrual syndrome were selected, they were given stretching exercises and walking for 3 months, a week before the onset of the menstrual cycle. The premenstrual syndrome questionnaire has been given before starting the treatment and again filled out after 3 months of treatment.Results: Statistical analysis was done using paired T-test. The outcome measures were physical and mental health. The Statistical analysis showed a significant difference after the treatment of 3 months period.Conclusion: Stretching exercises and walking decreases the premenstrual symptoms and improves the physical and mental health of women.

The effects of fatigue, gross motor function, and gender on participation in life situations of school-aged children with cerebral palsy: A parental perspective

ObjectiveTo investigate the effects of fatigue, gross motor function, and gender on participation in life situations of school-aged children with cerebral palsy (CP) from a parental perspective. MethodsThe study included 209 children with CP aged between 5 and 13 years (mean age, 8.06 ± 2.41 years; girls, 45.5%) and their parents. Fatigue, gross motor function, and participation status were evaluated with the Pediatric Quality of Life (PedsQL), Gross Motor Function Classification System (GMFCS), and the Assessment of Life Habits (Life-H) questionnaire, respectively. The effects of fatigue, gross motor function, and gender on participation were investigated with linear regression analysis. ResultsAccording to parental reports, 79.9% of the children had fatigue. Children in all GMFCS levels experienced fatigue. Fatigue and GMFCS levels were dependent variables, and therefore only simple linear regression analyses were performed. Fatigue explained 38–43% of the variances in daily activities, social roles, and total Life-H scores, while gross motor function explained 48–65% of the variances in scores (p < 0.001). Gender had no effect on participation scores (p > 0.05). ConclusionMore than two thirds of the school-aged children with CP had fatigue. Fatigue and poor gross motor function had a negative effect on participation in daily activities and social roles.

Self-Perception of Hearing Difficulties and Quality of Life in Individuals with Hearing Loss.

Objectives: To characterize the results of the Short Form Health Survey-36 (SF-36), Abbreviated Profile of Hearing Aid Benefit (APHAB), and the Hearing Handicap Inventory for Adults (HHIA) questionnaires in individuals with mild to moderate sensorineural hearing loss and compare them with brainstem auditory evoked potentials (BAEPs). Methods: There were 26 individuals with mild to moderate bilateral symmetrical sensorineural hearing loss who participated in the study. They were aged between 13 and 59 years old, right-hand preference, of both sexes, and were assigned to one of two groups according to the result of a BAEP test: normal (n = 16) or altered (n = 10). All subjects underwent a brief, cognitive screening battery and answered the SF-36, APHAB, and HHIA self-assessment questionnaires. For analysis of results, descriptive measures and inferential analysis were used. Results: On the SF-36 questionnaire, scores below 80 points were found in both groups, signifying minimal impact in the domains of pain, general health, vitality, and mental health compared to the other domains. The results of the APHAB questionnaire showed worse scores on the environmental noise subscale, and evaluation with the HHIA revealed a perception of severe restriction in participation in daily life activities. In a comparison between the groups, normal or abnormal BAEPs, no significant differences were found for any of the questionnaires. Conclusions: The results of the self-assessment questionnaires indicate that individuals with hearing loss can experience reduced quality of life, with limitations and restrictions for participation in daily living. The use of BAEPs as a criterion for dividing the groups was not effective in isolating the central component in the results of the self-assessment questionnaires.

Sensory Processing Impairments in Children with Developmental Coordination Disorder.

The two objectives of this systematic review were to examine the following: (1) the difference in sensory processing areas (auditory, visual, vestibular, touch, proprioceptive, and multi-sensory) between children with and without developmental coordination disorder (DCD), and (2) the relationship between sensory processing and motor coordination in DCD. The following databases were comprehensively searched for relevant articles: PubMed, Science Direct, Web of Science, and Cochrane library. There were 1107 articles (published year = 2010 to 2021) found in the initial search. Full-text articles of all possibly relevant citations were obtained and inspected for suitability by two authors. The outcome measures were sensory processing impairments and their relationship with motor coordination. A total of 10 articles met the inclusion criteria. Children with DCD showed significant impairments in visual integration, tactile integration, proprioceptive integration, auditory integration, vestibular integration, and oral integration processes when compared with typically developing children. Evidence also supported that sensory processing impairments were associated with poor motor coordination in DCD. Preliminary support indicated that DCD have sensory processing impairments in visual, tactile, proprioceptive, auditory, and vestibular areas, which might contribute to participation restriction in motor activities. It is important to apply sensory integration therapy in rehabilitation programs for DCD in order to facilitate participation in daily activities.

Mapping the use of patient reported outcomes at a health organisation to inform integration into hospital data systems.

ObjectivesIncorporating patient reported outcomes into health data linkage research ensures that the patient’s perspective is considered. We aimed to understand the use of patient reported outcomes across an entire healthcare organisation, to inform routine collection and integration of patient reported outcomes into hospital data systems for clinical practice and research. ApproachWe applied a mapping process consisting of 1) an audit of patient reported outcomes used in research projects and data registries, and 2) a survey of clinicians’ use of patient reported outcomes in their clinical practice from January 2015 to March 2021. Patient reported outcomes were then classified as ‘specific’ to a particular disease and/or conditions, or as a ‘generic’ measure that was applicable to a broader population. Patient reported outcomes were also mapped to the health domains they measured, using the World Health Organisation International Classification Framework. Data were described using frequency and proportion. ResultsPatient reported outcomes were used by 22% of research projects (n=144/666), 68% of clinical registries (n=13/19), and 76% of clinical specialties in their clinical care (n=16/21). Of the projects, registries and specialties that used patient reported outcomes, disease specific outcomes were most commonly used: 83% for research projects n=130/144), 69% for clinical registries (n=9/13), and 75% for clinical specialties (n=12/16). Greater than 80% of research projects, clinical registries and clinical specialties measured health domains relating to both body impairments and participation in daily life activities. The most commonly used generic patient reported outcome for research, data registries and clinical practice was the European Quality of Life Five Dimension Five Level (EQ-5D-5L) (research projects n=31/144, 22%; data registries n=2/13, 15%; clinical specialties n=3/16, 19%). ConclusionIn our setting, the EQ-5D-5L had broad applicability across a range of clinical specialties, collection systems and research studies, making it suitable for routine integration into health data systems with potential for linkage with other population data. Sufficient flexibility is required for the collection of population and disease specific measures.

Associations Between Basic Psychological Need Satisfaction and Motivation Underpinning Daily Activity Participation Among Community-Dwelling Survivors of Stroke: An Ecological Momentary Assessment Study

ObjectiveGrounded in the self-determination theory (SDT), this study aimed to examine the real-time associations between basic psychological need satisfaction and motivation underpinning daily activity participation among survivors of stroke. DesignRepeated-measures observational study involving 7 days of ambulatory monitoring; participants completed ecological momentary assessment (EMA) surveys via smartphones 8 times daily. Multilevel models were used to analyze EMA data for concurrent (same survey) and lagged (next survey) associations. SettingGeneral community. ParticipantsForty community-dwelling survivors of stroke (N=40). InterventionsNot applicable. Main Outcome MeasuresEMA measures of basic psychological needs (autonomy, competence, relatedness) and motivation (autonomous motivation, controlled motivation). ResultsIn concurrent analyses, increased autonomy (B=0.21; 95% confidence interval, 0.16-0.26; P<.001), competence (B=0.10; 95% confidence interval, 0.02-0.19; P=.021), and relatedness (B=0.10; 95% confidence interval, 0.06-0.13; P<.001) were momentarily associated with higher autonomous motivation. Conversely, increased autonomy (B=−0.19; 95% confidence interval, −0.27 to −0.10; P<.001) and competence (B=−0.09; 95% confidence interval, −0.17 to −0.01; P=.020) were momentarily associated with lower controlled motivation. Contrary to SDT, increased relatedness was momentarily associated with higher controlled motivation (B=0.10; 95% confidence interval, 0.05-0.14; P<.001). In lagged analyses, no momentary associations were detected between basic psychological needs and motivation (Ps>.05). ConclusionsFindings suggest that basic psychological need satisfaction is momentarily associated with motivation for daily activity participation. Additional research is warranted to examine the associations of different orientations of relatedness with autonomous and controlled motivation. Supporting basic psychological needs may foster autonomous motivation of survivors of stroke to enhance daily activity participation after stroke.

The role of transit accessibility in influencing the activity space and non-work activity participation of different income groups

Improved accessibility by transit service constitutes a critical component in removing spatial barriers in daily mobility for disadvantaged groups. However, the effects of transit accessibility on the daily mobility and activity participation of different social strata remain inconclusive. This study investigates the role of transit accessibility on the activity space of three income groups in Hong Kong. The results show that the availability of transit stations and network accessibility by mass transit rail (MTR) are significantly linked to the spatial extensiveness of activity space of the higher- and medium-income commuters, while bus plays a more important role for the daily mobility of the low-income group. Concerning non-work activity participation, the low-income non-commuters appear less affected by the availability of MTR stations than the other two groups, suggesting a potentially lower ability of using MTR to carry out different daily activities. Our findings offer some in-depth insights into the possible social inequality of using transit service, thereby contributing to a more nuanced understanding of the relationship between transit accessibility and mobility in relation to economic status. Policy recommendations to alleviate transport disadvantage and improve social equity are proposed.

Reliability and Factor Structure of the Parent Effort Scale (PES) Community Scale

Abstract Date Presented 04/02/2022 The purpose of this study was to examine internal consistency, factor structure, test-retest reliability, and scale distribution of the Parent Effort Scale-Community Version (PES-C) among children between ages of 2 and 7 years. The PES-C measures a parent’s effort to support their child’s participation in daily activities in natural community environments. Primary Author and Speaker: Elizabeth Pfeiffer Contributing Authors: Katherine Bevans

OTs’ Perceived Preparedness to Work With Youth Exposed to School Shootings

Abstract Date Presented 04/01/2022 The United States is witnessing a significant rise in school shootings. Students exposed to school shootings often develop emotional disturbances that negatively affect their meaningful participation in daily activities. The purpose of this qualitative study was to explore the self-efficacy of OTs who may encounter students exposed to a school shooting and explore perceived treatment strategies that practitioners may use to positively influence their clients’ mental health. Primary Author and Speaker: Bridget Scheidler Additional Authors and Speakers: Nancy E. Carson Contributing Authors: Karen Snyder

Therapist Perspectives on Adoption of a Telehealth Self-Management Walking Program for Individuals With Lower Limb Amputation

Abstract Date Presented 04/02/2022 The goal of this qualitative study was to understand barriers and facilitators influencing adoption of the Dysvascular Amputation Self-management of Health (DASH) program. DASH was designed to maximize participation in daily physical activity via targeted self-management of step count. We completed focus groups with OTs and physical therapists to understand DASH adoption, and they identified facility-, clinician-, and patient-level factors to consider for larger scale implementation. Primary Author and Speaker: Laura A. Swink Contributing Authors: Laura A. Swink, Meredith L. Mealer, Matthew J. Miller, Chelsey B. Anderson, Paul F. Cook, Jennifer E. Stevens-Lapsley, Cory L. Christiansen

Diabetes-Related Worries and Coping Among Youth and Young Adults With Type 1 Diabetes.

Although mood and anxiety symptoms are common in youth with type 1 diabetes (T1D), little research has described their worries across developmental stages or the strategies they use to cope with these worries. This secondary data analysis aimed to describe and characterize common T1D-related worries and coping strategies from middle childhood through young adulthood. Twenty-three youth (9 children, 7 adolescents, and 7 young adults) completed semistructured qualitative interviews about health-related quality of life. We coded interview transcripts using thematic analysis to generate common themes of diabetes-related worries and coping strategies. Participants' worries fell into four major themes: Managing Blood Glucose, Self-Efficacy for Diabetes Management, Interpersonal Relationships, and Lifestyle Impact, and eight youth denied having diabetes-related worries. Coping strategies fell into the three major themes: Attempts to Change Source of Worry, Attempts to Change Reactions to Worry, and Attempts to Orient Away from the Worry. Youths' worries about various aspects of living with and feeling able to self-manage diabetes are important to consider across pediatric development as they can impact youths' participation in daily activities and future plans. By adolescence, youth report longer-term worries about the health and lifestyle implications of diabetes. Youths' reported coping strategies are generally consistent with existing coping frameworks, though our data suggest some possible refinements. Social support emerged as an important coping strategy for all age groups. Thus, interventions supporting youth in building and strengthening their social networks may be particularly beneficial in helping youth cope with their diabetes-related worries across development.

Participation in Daily Activities Among Women 5 Years After Breast Cancer.

Understanding the long-term participation restrictions after breast cancer (BC) is crucial for developing occupation-based interventions. To (1) compare women's participation during the BC subacute phase (2 yr postdiagnosis) with the chronic (5 yr postdiagnosis) phase, (2) explore factors associated with participation in the chronic phase, and (3) describe strategies women use to overcome participation restrictions. Descriptive longitudinal study. A community health service in Israel. A convenience sample of 30 women (M age = 53.9 yr, SD = 8.3) diagnosed with BC (Stages 1-3). Demographic and BC-related symptom questionnaires; an adapted version of the Activity Card Sort, used to assess retained activity levels (RALs) compared with prediagnosis activity levels in sociocultural, physical, and instrumental domains; the Canadian Occupational Performance Measure; and one open-ended qualitative question, "How were you able to retain your participation in daily activities despite the long-term effects of BC?" Significantly higher total RALs were found in most domains for women in the chronic (M = 0.93 RAL, SD = 0.27) compared with the subacute (M = 0.71, SD = 0.22) phase, t(29) = 4.72, p < .001. Almost half the women achieved clinically significant change in their meaningful activities. Lower levels of participation were significantly correlated with higher symptom severity. The qualitative findings indicated that coping strategies, such as positive thinking and changing priorities, helped in managing women's participation. Participation restrictions and residual BC-related symptoms 5 yr postdiagnosis demonstrated the need for a comprehensive evaluation and early occupational therapy intervention to prevent long-term restrictions. What This Article Adds: This study highlights the value of a comprehensive assessment of daily participation (i.e., participation in various activity domains and in specific individual meaningful activities) of women with BC. The combination of quantitative and qualitative analysis provided a subjective perspective and deeper understanding of the associations among long-term symptoms, participation restrictions, and coping strategies.

Characterizing Accommodations by Parents of Young Children with Autism: A Mixed Methods Analysis.

Symptoms of autism influence families' participation in daily activities, but few studies have broadly explored the types of accommodations caregivers make to their family's routines after their child is diagnosed with autism. The current study used a mixed-methods approach to characterize the rate and types of accommodations made by 171 families and the child and family characteristics that predicted accommodations. Most families (91%) endorsed making accommodations in the past year. Lower income, older child age, marginalized racial/ethnic identity, and higher levels of child problem behavior predicted accommodations in a greater number of domains. Thematic analysis illuminated the types of accommodations caregivers made and their motivation for making these lifestyle adjustments. Findings have important implications for parent-mediated interventions and policy.

Participation in daily activities after acute illness hospitalization among high-functioning older adults: a qualitative study.

To describe high-functioning older adults' experiences of participation in daily activities and perceived barriers and facilitators to participation one- and 3-months post-acute hospitalization. Older adults discharged after acute illness hospitalization are at risk for functional decline and adverse health outcomes. Yet, little is known about the subjective experience of resuming participation in meaningful activities beyond the immediate post-discharge period among high-functioning older adults, a mostly overlooked sub-sample. Qualitative descriptive longitudinal study adhering to the COREQ guidelines. Forty two participants ages ≥65 years (mean age 75, SD ± 7.9) were recruited from internal medicine wards. Semi-structured interviews were conducted at participants' homes one-month post-discharge, followed by a telephone interview 3-months after. Data were analyzed using thematic analysis. Participants perceived the hospitalization as a disruption of healthy and meaningful routines. This first key theme had unique expressions over time and included two sub-themes. At one month: (1) reduced life spaces and sedentary routines. At 3months: (2) a matter of quality not quantity - giving up even one meaningful activity can make a difference. The second key theme was described as a combination of physical and psychological barriers to participation over time. These themes demonstrated the profound impact of the hospitalization on behavior (participation) and feelings (e.g., symptoms). The third key theme was described as a dyad of intrinsic and extrinsic facilitators to participation. Acute illness hospitalization may lead to subtle decreases in participation in meaningful health-promoting activities, even among high-functioning older adults. These changes may impact overall well-being and possibly mark the beginning of functional decline. This study highlights the need for a more comprehensive assessment of participation, relevant for high-functioning older adults, to enable person-centered care. Intervention programs should address the modifiable barriers and facilitators identified in this study.