Partner Norm Research Articles

Partner's influences and other correlates of prenatal alcohol use.

To investigate the influence of partners on alcohol consumption in pregnant women within the context of other factors. A Dutch nationwide online cross-sectional study among 158 pregnant women and their partners was conducted. To identify correlates of prenatal alcohol use, including perceived and reported partner norm (i.e. partner's belief regarding acceptability of prenatal alcohol use), partner modeling (i.e. partner's alcohol use during the woman's pregnancy) and partner support (i.e. partner's help in abstaining from alcohol during pregnancy), independent sample T-tests and Chi square tests were conducted. Correlation analyses tested the relationship between perceived and reported partner influence. Multivariate logistic hierarchical regression analyses tested the independent impact of partner's perceived and reported influence next to other correlates from the I-Change Model. Pregnant women who consumed alcohol perceived a weaker partner norm (p<0.001) and less partner modeling (p<0.05), with the partner reporting a weaker norm (p<0.001), more drinking days per week (p<0.05) and weaker support (p<0.05). Perceived and reported partner norm, modeling and support were positively related (respectively p<0.01, p<0.01 and p<0.05). The multivariate analyses demonstrated that pregnant women with a higher education who perceived lower severity of harm due to prenatal alcohol use and a weaker partner norm were more likely to use alcohol (R(2)=0.42). This study demonstrated that perceived partner norm was the most critical of the constructs of perceived and reported partner influences in explaining prenatal alcohol use.

Integration of five health behaviour models: Common strengths and unique contributions to understanding condom use

The purpose of this research was to select from the health belief model (HBM), theories of reasoned action (TRA) and planned behaviour (TPB), information–motivation–behavioural skills model (IMB) and social cognitive theory (SCT) the strongest longitudinal predictors of women's condom use and to combine these constructs into a single integrated model of condom use. The integrated model was evaluated for prediction of condom use among young women who had steady versus casual partners. At Time 1, all constructs of the five models and condom use were assessed in an initial and a replication sample (n = 193, n = 161). Condom use reassessed 8 weeks later (Time 2) served as the main outcome. Information from IMB, perceived susceptibility, benefits, and barriers from HBM, self-efficacy and self-evaluative expectancies from SCT, and partner norm and attitudes from TPB served as indirect or direct predictors of condom use. All paths replicated across samples. Direct predictors of behaviour varied with relationship status: self-efficacy significantly predicted condom use for women with casual partners, while attitude and partner norm predicted for those with steady partners. Integrated psychosocial models, rich in constructs and relationships drawn from multiple theories of behaviour, may provide a more complete characterisation of health protective behaviour.

Condom use intentions among “forced” male bachelors in rural China: findings from a field survey conducted in a context of female deficit

This study investigates condom use intentions and their psychological and socio-demographic correlates among forced male bachelors in rural China, based on the theory of planned behavior. Data are derived from a cross-sectional survey entitled “Older males’ reproductive health and family life survey in rural China” which was conducted by the Institute for Population and Development Study at Xi’an Jiaotong University in China’s JC district, Anhui province in 2008, in collaboration with INED in Paris. Results indicate that condom attitudes, stronger sexual partner norm, and greater perceived behavior control, are positively associated with increased condom use among rural forced male bachelors. Condom use at first sexual intercourse is a significant predictor of the condom use intentions. Younger forced bachelors are more likely to use condoms in the future. These results may help to better understand condom use among forced male bachelors in rural China and also provide theoretical support for HIV/AIDS and STI interventions that encourage condom use at early stages of the sexual life course. Qunlin ZHANG, PhD student, School of Management, Xi’an Jiaotong University, Xi’an, China. E-mail: zhangql616@163.com . Isabelle ATTANE, PhD demographer and sinologist, INED,133, Boulevard Davout, 75980 - Paris, Cedex 20, France. E-mail: attene@ined.fr . Shuzhuo LI, Professor, Institute for Population and Development Studies, School of Public Policy and Administration, Xi’an Jiaotong University, Xi’an, China. E-mail: shzhli@mail.xjtu.edu.cn . Xueyan YANG, Associate professor, Institute for Population and Development Studies, School of Public Policy and Administration, Xi’an Jiaotong University, Xi’an, China. E-mail: xueyanyang@mail.xjtu.edu.cn

Longitudinal Determinants of Consistent Condom Use by Partner Type Among Young Injection Drug Users: The Role of Personal and Partner Characteristics

We investigated the longitudinal influence of individual-, relationship- and social-level factors on condom use by partner type among young injections drug users (IDUs) enrolled in the Collaborative Injection Drug Users Study-III/Drug Users Intervention Trial (CIDUS-III/DUIT) from 2002 to 2004. Based on longitudinal analysis using generalized estimating equations (GEE), consistent condom use with main partners was more commonly reported among males and those with greater self-efficacy for condom use; main partner’s desire for pregnancy and needle sharing were negatively associated with consistent condom use. Among those with casual partners, having fewer sex partners was associated with consistent condom use. Positive attitudes toward condom use and partner norms supporting condom use were associated with greater consistent condom use with both partner types. These findings suggest that intervention strategies targeting individual- and partner-level factors may provide avenues for intervening upon sexual risks among young IDUs.

Sexual risk behaviors of inner-city middle school students: cluster analysis of associated characteristics and time-to-event analysis of behaviors

OBJECTIVE: Evaluation of adolescents' sexual health is an essential function of many healthcare providers. This study aimed to classify adolescents by characteristics believed to be associated with sexual risk behaviors and to determine which subgroup(s), if any, were more likely to engage in sexual risk behaviors (sexual initiation, sexual intercourse with multiple partners, inconsistent use or lack of condom use, and inconsistent use or lack of birth control use) over the course of two years.DESIGN: This was a secondary analysis of data collected from 899 adolescents aged 10-15 years participating in the “Minority Youth Health Project”. Written surveys were administered at baseline and at three, six, 12, 18, and 24 months.MATERIALS AND METHODS: Cluster analysis was conducted to identify similarities in participants based on the following characteristics: partner norms; peer norms; deviant peer involvement; relationship history; parental influence (family structure, parental closeness, parental monitoring); developmental issues (chronological age, onset of puberty compared to peers); substance use; academic achievement/goals; religiosity; and gender. Time to event analysis was used to evaluate whether a subgroup(s) engaged in sexual risk behaviors and the timing of behaviors during the assessment period.RESULTS: Two well-defined subgroups were identified and subsequently labeled “at risk” and “high risk”. Adolescents in the “high risk” group exhibited irresolute peer and partner norms about sex, condom use, and birth control use; deviant peer involvement; history of experimentation with smoking cigarettes, drinking alcohol, smoking marijuana, getting drunk/high; and relaxed parental monitoring. In addition, “high risk” adolescents reported engaging in all sexual risk behaviors approximately two years before their “at risk” peers.CONCLUSIONS: Findings suggest that adolescents can be profiled according to characteristics associated with sexual risk behaviors and that adolescents with particular characteristics were more likely to engage in sexual risk behaviors. Sexual risk behaviors must be evaluated and specific assessment of substance use as well as environmental influences of peers, partners, and parents should be a priority. With additional research, interventions can be designed to modify such characteristics associated with sexual risk behaviors. OBJECTIVE: Evaluation of adolescents' sexual health is an essential function of many healthcare providers. This study aimed to classify adolescents by characteristics believed to be associated with sexual risk behaviors and to determine which subgroup(s), if any, were more likely to engage in sexual risk behaviors (sexual initiation, sexual intercourse with multiple partners, inconsistent use or lack of condom use, and inconsistent use or lack of birth control use) over the course of two years. DESIGN: This was a secondary analysis of data collected from 899 adolescents aged 10-15 years participating in the “Minority Youth Health Project”. Written surveys were administered at baseline and at three, six, 12, 18, and 24 months. MATERIALS AND METHODS: Cluster analysis was conducted to identify similarities in participants based on the following characteristics: partner norms; peer norms; deviant peer involvement; relationship history; parental influence (family structure, parental closeness, parental monitoring); developmental issues (chronological age, onset of puberty compared to peers); substance use; academic achievement/goals; religiosity; and gender. Time to event analysis was used to evaluate whether a subgroup(s) engaged in sexual risk behaviors and the timing of behaviors during the assessment period. RESULTS: Two well-defined subgroups were identified and subsequently labeled “at risk” and “high risk”. Adolescents in the “high risk” group exhibited irresolute peer and partner norms about sex, condom use, and birth control use; deviant peer involvement; history of experimentation with smoking cigarettes, drinking alcohol, smoking marijuana, getting drunk/high; and relaxed parental monitoring. In addition, “high risk” adolescents reported engaging in all sexual risk behaviors approximately two years before their “at risk” peers. CONCLUSIONS: Findings suggest that adolescents can be profiled according to characteristics associated with sexual risk behaviors and that adolescents with particular characteristics were more likely to engage in sexual risk behaviors. Sexual risk behaviors must be evaluated and specific assessment of substance use as well as environmental influences of peers, partners, and parents should be a priority. With additional research, interventions can be designed to modify such characteristics associated with sexual risk behaviors.

Improving condom use intentions and behavior by changing perceived partner norms: An evaluation of condom promotion videos for college students.

To examine the effectiveness of 2 condom promotion videotapes on self-efficacy, intentions, and behavior. Two hundred twenty college students completed social-cognitive and behavioral measures and were then randomly assigned to receive one of two 30-min condom promotion videotapes (male or female student presenters) or to a wait-list control condition. Participants who watched 1 of the videotapes completed immediate posttest measures, and 85% of participants completed a 4-month follow-up. Self-efficacy for condom use, intentions to use condoms, use of condom during last sex, and consistent condom use over the last month. Participants who received either video reported greater self-efficacy to refuse to have unprotected sex and intentions than controls at follow-up. Individuals who received either video were more likely than controls to report using a condom during last sex with a regular partner, and those who watched the female presenter were more likely to report consistent condom use. Participants benefited in terms of self-efficacy and intentions from receiving either video, but both men and women benefited more in terms of condom use behavior from receiving the female video. Future research is needed to determine whether opposite-sex speaker videos could be beneficial with a larger (and more sexually active) sample and whether these effects are maintained over time.

Beliefs that Condoms Reduce Sexual Pleasure—Gender Differences in Correlates Among Heterosexual HIV-Positive Injection Drug Users (IDUs)

Studies consistently find that negative condom beliefs or attitudes are significantly associated with less condom use in various populations, including HIV-positive injection drug users (IDUs). As part of efforts to reduce sexual risk among HIV-positive IDUs, one of the goals of HIV interventions should be the promotion of positive condom beliefs. In this paper we sought to identify the correlates of negative condom beliefs and examined whether such correlates varied by gender, using a subsample (those with an opposite-sex main partner; n = 348) of baseline data collected as part of a randomized controlled study of HIV-positive IDUs. In multivariate analyses, we found more significant correlates for women than for men. With men, perception that their sex partner is not supportive of condom use (negative partner norm) was the only significant correlate (Beta = -0.30; p < 0.01; R (2) = 0.18). Among women, negative partner norm (Beta = -0.18; p < 0.05); having less knowledge about HIV, STD, and hepatitis (Beta = -0.16; p < 0.05); lower self-efficacy for using a condom (Beta = -0.40; p < 0.01); and more episodes of partner violence (Beta = 0.15; p < 0.05) were significantly associated with negative condom beliefs (R (2) = 0.36). These findings suggest important gender-specific factors to consider in interventions that seek to promote positive condom beliefs among HIV-positive IDUs.

Unprotected Sexual Behavior Among Heterosexual HIV-Positive Injection Drug Using Men: Associations by Partner Type and Partner Serostatus

Few studies have examined sexual risk behaviors of HIV-positive, heterosexual, injection drug using (IDU) men. We investigated such behaviors and associations with risk among sexually active, HIV-positive IDU men who reported only female sex partners in the 3 months prior to baseline interview. We examined associations separately for four non-exclusive groups of men by crossing partner type (main or casual) and partner serostatus (HIV-positive or HIV-negative/unknown). Of 732 male participants, 469 (64%) were sexually active with only female partners. Of these 469 men, 155 (33%) reported sex with HIV-positive main partners, 127 (27%) with HIV-negative or unknown serostatus main partners, 145 (31%) with HIV-positive casual partners, and 192 (41%) with HIV-negative/unknown serostatus casual partners. Significant multivariate associations for unprotected sex with HIV-negative or unknown serostatus main partners were less self-efficacy to use condoms, weaker partner norms supporting condoms, and more negative condom beliefs. Similar correlates were found for unprotected sex with HIV-positive main and casual partners. In addition, alcohol or drug use during sex was a significant correlate of unprotected sex with HIV-positive main partners, while depression was significant for HIV-positive casual partners. For unprotected sex with HIV-negative/unknown status casual partners, self-efficacy for condom use, sex trade, and education were significant multivariate correlates. A combination of broad and tailored intervention strategies based on the relationship pattern of men's lives may provide the most benefit for reducing unprotected sex with female partners.

Multi-partnered heterosexuals' condom use for vaginal sex with their main partner as a function of attitude, subjective norm, partner norm, perceived behavioural control and weighted control beliefs

This paper examines the extent to which an integrated theoretical behavioural prediction model can explain the intentions of 215 male and 181 female multi-partnered heterosexuals (MPHs) to always use condoms for vaginal sex with their regular partners. For female MPHs, all five of the immediate psychosocial determinants of intention (i.e. attitude, subjective norm, partner norm, perceived behavioural control and the mean of weighted control beliefs) were significant independent predictors of condom use intentions R = 0.81). For male MPHs, only attitude (beta = 0.45) and partner norm (beta = 0.41) contributed R = 0.77). Behavioural, normative and control beliefs underlying the MPHs intentions to always use condoms for vaginal sex with their regular partners are identified as critical intervention targets. independently to the explanation of these intentions

Multi-partnered heterosexuals' condom use for vaginal sex with their main partner as a function of attitude, subjective norm, partner norm, perceived behavioural control and weighted control beliefs

This paper examines the extent to which an integrated theoretical behavioural prediction model can explain the intentions of 215 male and 181 female multi-partnered heterosexuals (MPHs) to always use condoms for vaginal sex with their regular partners. For female MPHs, all five of the immediate psychosocial determinants of intention (i.e. attitude, subjective norm, partner norm, perceived behavioural control and the mean of weighted control beliefs) were significant independent predictors of condom use intentions R = 0.81). For male MPHs, only attitude (beta = 0.45) and partner norm (beta = 0.41) contributed R = 0.77). Behavioural, normative and control beliefs underlying the MPHs intentions to always use condoms for vaginal sex with their regular partners are identified as critical intervention targets. independently to the explanation of these intentions

Factors influencing MSMs' intentions to always use condoms for vaginal, anal and oral sex with their regular partners

A revised behavioural prediction model integrating components of several psychosocial theories was used to predict men who have sex with mens' (MSM) (N = 139) intentions to always use condoms with their regular partner for anal, oral and vaginal sex. The behavioural model successfully predicted MSMs' condom use intentions for all three behaviours (R = 0.70, R = 0.75 and R = 0.78 for vaginal, anal and oral sex, respectively). Consistent with expectations, the relative importance of the underlying theoretical determinants differed for the three behaviours in question. For condom use for vaginal sex, the partner norm (beta = 0.54) and the mean of the weighted control beliefs (beta = 0.28) were most important. For condom use for anal sex, the partner norm (beta = 0.50), attitude (beta = 0.28) and perceived behavioural control (beta = 0.17) were most important. With respect to oral sex, attitude (beta = 0.51) and partner norm (beta = 0.38) were most important in independently influencing MSMs' intentions to always use condoms.

Factors influencing IDU and non-IDU female commercial sex workers' intentions to always use condoms for vaginal sex with their regular partner

This paper discusses the factors influencing female commercial sex workers' (N = 172) intentions to use condoms with their regular partners during vaginal sex. While 73 of these women were at risk for HIV/STD transmission and acquisition primarily because of their commercial sex work (CSWonly), 99 were at risk because of both commercial sex work and injecting drug use (CSWs/IDUs). For CSWs/IDUs, attitudes (beta = 0.42), partner norm (beta = 0.24) and the mean of the weighted control beliefs (beta = 0.23) were significant independent predictors of intention R = 0.77). Although attitude (beta = 0.43) and partner norm (beta = 0.28) were also significant independent predictors of intention among CSWonly, they were not concerned with control issues, but instead considered the normative proscriptions of their most important others (i.e. the subjective norm; beta = 0.22; R = 0.74). For both CSWonly and CSWs/IDUs, the behavioural belief that using condoms makes you more relaxed, and the normative belief (or partner norm) that your main partner thinks you should or should not use condoms were identified as critical targets for an intervention. In addition, for CSWs/IDUs the control belief concerning the partners' openness to condom use was also identified as a critical target for an intervention.

The role of theory in developing effective interventions: Implications from Project SAFER

This paper summarizes the results of project SAFER, in which a revised integrated theoretical model was used to predict and understand condom use intentions in seven non-overlapping groups at high risk for acquiring or transmitting HIV and other STDs. Despite highly significant demographic, behavioural and psychosocial differences among the seven groups, the model successfully predicted intentions in all seven groups (R ranged from 0.70 to 0.81). Consistent with expectations, the relative importance of the five immediate psychosocial determinants of intention (i.e. attitude, subjective norms, partner norm, perceived behavioural control and the mean of weighted control beliefs) varied across both populations and behaviours. Although the critical target beliefs for a behaviour change intervention also varied across populations and behaviours, two beliefs emerged as potential targets for a national campaign. A distinction is made between identifying critical target beliefs and developing interventions to change those beliefs. Strategies for changing beliefs are discussed.

Multi-partnered heterosexuals' condom use for vaginal sex with their main partner as a function of attitude, subjective norm, partner norm, perceived behavioural control and weighted control beliefs

Multi-partnered heterosexuals' condom use for vaginal sex with their main partner as a function of attitude, subjective norm, partner norm, perceived behavioural control and weighted control beliefs

Theoretical determinants of condom use intentions for vaginal sex with a regular partner among male and female injecting drug users

The factors influencing 90 male and 42 female injecting drug users' (N = 132) intentions to always use a condom while having vaginal sex with a regular partner were analyzed. For male IDUs, the partner norm (beta = 0.40), the mean of the weighted control beliefs (beta = 0.26), attitude (beta = 0.22) and perceived behavioural control (beta = 0.15) were important predictors of intention (R = 0.81). In contrast, for female IDUs, only the partner norm emerged as an independent predictor of intention (R = 0.72). Thus interventions directed at female IDUs will be most effective if they change the women's beliefs that 'my regular partner thinks we should always use condoms for vaginal sex'. For male IDUs, two behavioural beliefs and two control beliefs were identified as critical targets for an intervention: the behavioural beliefs that consistent condom use would make me feel more relaxed and cleaner, and the control beliefs concerning the regular partner's openness to condom use and the likelihood that she would suggest using them.

Analyzing data to obtain information to design targeted interventions

The utility of the Theory of Planned Behaviour as a predictor of condom use behaviours is investigated and a revised integrative behavioural prediction model is suggested. According to the revised model, there are five immediate determinants of condom use intentions: Attitude, subjective norm, partner norm, perceived behavioural control and the mean of weighted control beliefs. An analytic strategy for testing this model and for identifying critical beliefs to be targeted for behaviour change interventions is described. The analytical approach involves five steps necessary to identify key determinants of a given behaviour in a given population. Step 1, the 'correlational analysis' investigates whether the elicited beliefs do in fact underlie the theoretical factors that are assumed to represent the direct psychosocial determinants of intention, and whether those determinants do predict condom use intentions. The 'direct determinant' regression analysis investigates the extent to which the five theoretical factors differentially contribute to our understanding of intention. For those direct determinants that independently explain intention, the underlying behavioural, normative and control beliefs are investigated in step 3, 'the individual indicator analysis'. In step 4, the critical targets for an intervention are identified and, in step 5, a method to identify alternate targets for an intervention is presented.

Understanding the unprotected sexual behaviors of gay, lesbian, and bisexual youths: an empirical test of the cognitive-environmental model.

The cognitive-environmental model (CEM; M. Fishbein et al., 1991) was used to understand the unprotected sexual behaviors of 156 gay, lesbian, and bisexual youths. Unprotected anal sex among the males was associated directly with poor protection skills (e.g., incorrect use of barrier methods, such as condoms), poor intentions to use barrier methods, and poor norms by sexual partners concerning barrier methods. Furthermore, the association between low self-efficacy and increasing unprotected anal sex was attributed to poor intentions. Direct associations of unprotected oral sex with poor intentions and poor partner norms also emerged, as did an indirect relation between unprotected oral sex and low self-efficacy via poor intentions. These last 3 findings were replicated when examining unprotected oral or vaginal-digital sex among the females. Relations among the CEM factors supported some CEM-theoretical propositions.

Using the theory of planned behavior to predict intention to use condoms among female sex workers margaret

This study tested the utility of the Theory of Planned Behavior (TPB) for Understanding and predicting condom use intentions among female commercial sex workers. Interviews were conducted with 634 sex workers recruited on the street in southern California. The interview assessed sex workers' intentions to have their main (e.g., husbands, steady boyfriends) and paying male partners use condoms, as well as attitudes, perceived subjective and partner norms, and perceived behavioral control relative to condom use with each of these two partner types. Reported frequency of condom use and strength of intention to use condoms were considerably lower for main than for paying partner. Similarly, condom-use attitudes, perceived behavioral control, subjective norms, partner norms. and beliefs were less positive for condom use with main versus paying partners. Compared to sex workers without a main partner, those with a male main partner had significantly stronger intentions to use condom with paying partners, as well as more positive attitudes, perceived behavioral control, subjective norm, and paying partner norm toward using condoms with paying partners. The TPB accounted for 44% and 47% of the variance in condom use intentions with main and paying partner (p's<0.001), respectively. Attitudes toward condom use and perceived behavioral control over using condoms were positively associated with intention to use condoms with both main and paying partners (p's < 0.001), partner norms were positively related to intentions to use condoms with main but not paying partners, and subjective norms wm not related to condom use with either type of partner.

Adolescent gender differences in HIV-related sexual risk acts, social-cognitive factors and behavioral skills

Variations in perceived HIV risk, peer and partner social norms regarding safe sex, self-efficacy, outcome expectancies, and risk-reduction skills (condom use competence and safe sex negotiation) based on gender and sexual risk level were assessed among 132 heterosexual, sexually active, inner city adolescents. Lower sexual risk status was significantly associated with positive partner norms toward safer sex and with favorable partner reaction outcome expectancies. Interaction effects between gender and sexual risk level were found. Outcome expectancies related to approval from others for safer sex were lowest for females in the low-risk group and for males in the high-risk group. Females perceived peers as more positive about safer sex practices, while males perceived sexual partners as more positive. Additionally, females had higher self-efficacy for making condom use enjoyable and planning to avoid risk situations, but were less comfortable than males when demonstrating condom skills. Adolescents' HIV prevention programs must be tailored for gender and risk status.

Number of pregnancies, outcome expectancies, and social norms among HIV-infected young women.

In this descriptive study, researchers examined pregnancies, sexually transmitted diseases (STDs), and sexual behaviors among 67 HIV-infected young women, as well as the women's outcome expectancies and peer and partner norms regarding pregnancy. Many of the women (69%) had been pregnant; 42% had been pregnant at least once since learning their HIV status, with 71% choosing to carry to term, resulting in 25% (N = 5) of the babies infected. The women had positive outcome expectancies related to pregnancy, which were significantly correlated with peer and partner social norms. Lack of knowledge regarding infant transmission, high rates of STDs, and inconsistent condom use all indicate a need for improved intervention regarding pregnancy and decision-making. Suggestions for better methods of providing information to HIV+ young women are provided.Factors that influence pregnancy and knowledge of the consequences of HIV seropositivity were explored in interviews with 67 HIV-infected young US women (mean age, 19.9 years) recruited from AIDS medical clinics in New York, New York; San Francisco, California; Los Angeles, California; and Miami, Florida. 69% of respondents had been pregnant prior to their HIV diagnosis. Since learning of their HIV serostatus, 42% had been pregnant at least once and 71% of these women carried the child to term; five of the infants were HIV-positive. Of the 33 women who had children, 23 reported that the child lived at home with them. The average correct HIV/AIDS knowledge score was 71%. 38% were unaware that a pregnant HIV-positive woman can lower the risk of maternal-fetal transmission by taking medication and 17% did not know that breast-feeding can transmit HIV. Women who became pregnant after learning they were HIV-positive were no more likely to get these items correct, suggesting that HIV-infected women are not being counseled adequately about pregnancy. Although 68% thought the infant of an HIV-infected mother was at high risk of HIV transmission, 43% expected their peers would be supportive if they wanted a baby and 56% anticipated a positive response from their partner. Most women believed they would be able to care for a baby, without the need for parental involvement or foster care placement. Positive outcome expectancies related to pregnancy, as well as partner and peer social norms, may influence young HIV-positive women's pregnancy-related decisions.