Prevalence Of Fetal Alcohol Spectrum Disorders Research Articles

The contributions of Dr. Kathleen K. Sulik to fetal alcohol spectrum disorders research and prevention.

Dr. Kathleen Sulik (Kathy) has spent 35 years studying fetal alcohol syndrome (FAS) and fetal alcohol spectrum disorders (FASD). Beginning with her landmark 1981 Science paper describing the early gestational window when alcohol can cause the craniofacial malformations characteristic of FAS, Kathy has contributed a vast amount of research furthering our knowledge of FASD. After her seminal work that definitively demonstrated that alcohol is the causative factor in FAS, she and her lab went on to explore and define the stage-dependent effects of early gestational alcohol exposure on the face and brain in numerous different ways throughout her career. She explored and discovered numerous mechanisms of alcohol's effects on the embryo, as well as describing several genetic factors that can modify susceptibility to developmental alcohol exposure. She did not restrict her research to the face and brain; her lab described in intricate detail the effects of developmental alcohol exposure on many different organs, including the heart, ears, kidneys, and limbs. In addition to her research, and in conjunction with NIAAA and the National Organization on Fetal Alcohol Syndrome (NOFAS), Kathy developed several FASD prevention curricula that are still in use today. Finally, as part of her drive to eradicate FAS and FASD, Kathy labored tirelessly with public policy makers to change how FASD is viewed by the public, how FASD is identified in affected individuals, and how FASD is studied by researchers. While no article could fully cover Kathy's contributions to FASD research and prevention, or her other contributions to embryology and teratology, this review will attempt to illustrate some of the highlights of Kathy's remarkable career.

Reframing Fetal Alcohol Spectrum Disorder: Studying Culture to Identify Communication Challenges and Opportunities

Implicit cultural understandings challenge those working to increase public awareness and support for programs to prevent and address fetal alcohol spectrum disorder (FASD). Understanding these cultural beliefs reveals key challenges that communicators face; it also helps identify opportunities to foster public engagement and build support for policies and programs that are important for reducing the prevalence of FASD as a public health issue. Through a series of interviews with members of the public in Manitoba, Canada, we identify the cultural models that members of the Manitoban public draw on to make sense of this issue. These models and their implications are used to create a set of recommendations that can improve understanding of the issue, increase issue salience, and generate support for solutions. While the research presented is specific to Manitoba, findings have significance for those working on FASD in other areas and for those working on other public health and science translation projects.

Promoting awareness of fetal alcohol spectrum disorder among health professionals and the public through nursing faculty champions

Fetal alcohol spectrum disorder (FASD) affects all communities and is an underestimated problem worldwide and in China. FASD is the most common preventable cause of intellectual disabilities and behavior problems. However, prevention efforts require knowledge about FASD, importantly, the education of health professionals who communicate that knowledge to the public during care administered in diverse practice settings. Implementing a nursing faculty champions (charismatic advocates for FASD prevention belief, practice, program, policy and/or technology) model to advocate for educating Chinese nurses, nursing students, other health professionals, and the public about FASD is a logical, quality-driven, healthcare action. The actions undertaken by one nurse champion, a Capital Medical University Chinese professor, to promote FASD awareness among Chinese health professionals and the public population will be presented. Through this faculty nurse champion, thousands of Chinese health providers and public citizens were educated regarding FASD. Planned next steps include enrolling more Chinese nursing faculty champions, developing nursing curricula at Capital Medical University, and increasing research attention on FASD. Nurse faculty champions are an effective and practical method to promote FASD awareness among Chinese health professionals and the public.

The Marulu Strategy 2008–2012: overcoming Fetal Alcohol Spectrum Disorder (FASD) in the Fitzroy Valley

Objective:Aboriginal leaders concerned about high rates of Fetal Alcohol Spectrum Disorder (FASD) in the Fitzroy Valley, remote north‐western Australia, introduced restrictions on access to take‐away full‐strength alcohol. Following this, Aboriginal leaders engaged strategic partners in a broader strategy to address FASD in the region. The aim of this study was to develop and implement a community‐led, researcher‐supported, FASD strategy. Methods:A review of literature focusing on community‐led FASD strategies identified key components that informed the Marulu FASD strategy. These included strategy ownership, leadership, and governance by participating communities, and a research framework. Results:Community meetings and workshops led to the development of The Marulu FASD Strategy (2008). Feasibility and community consent to conduct a FASD prevalence study (the Lililwan Project) was confirmed, and implementation was progressed (2010–2013). Concurrent FASD prevention activities were conducted. In 2012, the Marulu FASD Unit was established within a local Aboriginal organisation to sustain and coordinate ongoing strategy activities. Conclusions:Community control of public health initiatives can be achieved when Aboriginal communities prioritise issues of significant concern, and engage strategic partners to overcome them. Implications for public health:The Marulu Strategy forms a template for action to address FASD and other public health issues in Aboriginal communities in Australia and internationally.

Risk for Alcohol-Exposed Pregnancies Among Women at Drinking Venues in Cape Town, South Africa.

South Africa's Western Cape Province has one of the highest rates of fetal alcohol spectrum disorder globally. Alcohol-serving venues are likely important sites to identify women at high risk of having a child with fetal alcohol spectrum disorder. The goal of this study was to examine the risk for alcohol-exposed pregnancies among women who drink in alcohol-serving venues. Cross-sectional surveys were conducted with 200 women of reproductive age at seven drinking venues in a single Cape Town community. Surveys assessed sexual behavior, contraceptive use, and drinking behavior (both current and during previous pregnancies). Women were defined as being at risk for alcohol-exposed pregnancy if they were currently drinking, sexually active in the previous 60 days, and not consistently using modern contraceptives. Almost all participants (95.5%) met criteria for hazardous drinking. In total, 20.3% of the 152 sexually active women were identified as at risk for alcohol-exposed pregnancy, and 2 women were currently pregnant and drinking. A majority of sexually active participants (79.6%) reported consistent use of a modern contraceptive. Most contraceptives (66.1%) were short-acting methods such as injectables. Of the 176 participants who reported previous pregnancies, 64.8% said they drank alcohol during a previous pregnancy and 51.1% met criteria for hazardous drinking during that pregnancy. Given the high rates of alcohol consumption during pregnancy, alcohol-serving venues should be targeted for fetal alcohol spectrum disorder prevention interventions. Efforts should be made to increase uptake of long-acting contraceptives among women who do not wish to get pregnant and to promote alcohol cessation among women with pregnancy intentions.

Fetal Alcohol Spectrum Disorders: What Pediatric Providers Need to Know

Prenatal alcohol exposure is the cause of fetal alcohol spectrum disorders (FASDs), the prevalence of which is similar to that of other developmental disabilities like Down syndrome and autism. Children, adolescents, and adults who live with the disabilities associated with prenatal alcohol exposure face extraordinary challenges throughout their lives. Pediatric providers need to be able to identify patients with FASD because early recognition and intervention is known to improve life outcomes for affected individuals. The purposes of this continuing education activity are to report what is known about the prevalence of FASDs; to detail the spectrum of problems experienced by affected individuals; and to suggest specific strategies for preventing, identifying, and managing FASDs in clinical practice.

Global Prevalence of Fetal Alcohol Spectrum Disorder Among Children and Youth

Prevalence estimates are essential to effectively prioritize, plan, and deliver health care to high-needs populations such as children and youth with fetal alcohol spectrum disorder (FASD). However, most countries do not have population-level prevalence data for FASD. To obtain prevalence estimates of FASD among children and youth in the general population by country, by World Health Organization (WHO) region, and globally. MEDLINE, MEDLINE in process, EMBASE, Education Resource Information Center, Cumulative Index to Nursing and Allied Health Literature, Web of Science, PsychINFO, and Scopus were systematically searched for studies published from November 1, 1973, through June 30, 2015, without geographic or language restrictions. Original quantitative studies that reported the prevalence of FASD among children and youth in the general population, used active case ascertainment or clinic-based methods, and specified the diagnostic guideline or case definition used were included. Individual study characteristics and prevalence of FASD were extracted. Country-specific random-effects meta-analyses were conducted. For countries with 1 or no empirical study on the prevalence of FASD, this indicator was estimated based on the proportion of women who consumed alcohol during pregnancy per 1 case of FASD. Finally, WHO regional and global mean prevalence of FASD weighted by the number of live births in each country was estimated. Prevalence of FASD. A total of 24 unique studies including 1416 unique children and youth diagnosed with FASD (age range, 0-16.4 years) were retained for data extraction. The global prevalence of FASD among children and youth in the general population was estimated to be 7.7 per 1000 population (95% CI, 4.9-11.7 per 1000 population). The WHO European Region had the highest prevalence (19.8 per 1000 population; 95% CI, 14.1-28.0 per 1000 population), and the WHO Eastern Mediterranean Region had the lowest (0.1 per 1000 population; 95% CI, 0.1-0.5 per 1000 population). Of 187 countries, South Africa was estimated to have the highest prevalence of FASD at 111.1 per 1000 population (95% CI, 71.1-158.4 per 1000 population), followed by Croatia at 53.3 per 1000 population (95% CI, 30.9-81.2 per 1000 population) and Ireland at 47.5 per 1000 population (95% CI, 28.0-73.6 per 1000 population). Globally, FASD is a prevalent alcohol-related developmental disability that is largely preventable. The findings highlight the need to establish a universal public health message about the potential harm of prenatal alcohol exposure and a routine screening protocol. Brief interventions should be provided, where appropriate.

Ethical challenges in FASD prevention: Scientific uncertainty, stigma, and respect for women's autonomy.

Fetal alcohol spectrum disorder (FASD) is a leading form of neurodevelopmental delay in Canada, affecting an estimated 3000 babies per year. FASD involves a range of disabilities that entail significant costs to affected individuals, families, and society. Exposure to alcohol in utero is a necessary factor for FASD development, and this has led to FASD being described as "completely preventable". However, there are significant ethical challenges associated with FASD prevention. These challenges revolve around 1) what should be communicated about the risks of alcohol consumption during pregnancy, given some ongoing scientific uncertainty about the effects of prenatal alcohol exposure, and 2) how to communicate these risks, given the potential for stigma against women who give birth to children with FASD as well as against children and adults with FASD. In this paper, we share initial thoughts on how primary care physicians can tackle this complex challenge. First, we recommend honest disclosure of scientific evidence to women and the tailoring of information offered to pregnant women. Second, we propose a contextualized, patient-centred, compassionate approach to ensure that appropriate advice is given to patients in a supportive, non-stigmatizing way.

Ten-year experience of fetal alcohol spectrum disorder; diagnostic and resource challenges in Indigenous children.

Although fetal alcohol spectrum disorder (FASD) can have a disproportionate impact in some Indigenous communities, there is a paucity of literature on its epidemiology. To characterize the epidemiology of Indigenous individuals under the age of 18 years who were diagnosed with FASD at Anishnawbe Health Toronto over a 10-year period. Children who were assessed at Anishnawbe Health Toronto from 2002 to 2012 and met the 2005 criteria for FASD were included. The multidisciplinary team assessed neurodevelopmental abnormalities, FASD facial features and growth parameters and enquired about maternal alcohol consumption, current custody and involvement with the criminal justice system. Forty-nine children were diagnosed with FASD. None of these had full fetal alcohol syndrome (FAS); 12 were diagnosed as partial FAS and 37 with alcohol-related neurodevelopmental disorder (ARND). Thirty-five were male and the median age at diagnosis was 9 years. Nineteen were wards of children's services, and 8 were living with adoptive parents. All children had abnormalities in psychometric testing. Other issues included: behavioural issues (80%); learning disabilities (63%); attention deficit hyperactivity disorder (43%); developmental delay (14%); involvement with the criminal justice system (12%) and alcohol abuse (10%). The morbidity and impairment for ARND was higher on almost every measurement compared with partial FAS. FASD is a preventable cause of lifelong significant morbidity to Indigenous children with a high proportion of children needing foster-care services and involvement with the criminal justice system at an early age. Although ARND is difficult to diagnose, it can result in significant morbidity. Additional resources for culturally sensitive primary prevention and early diagnosis of FASD for Indigenous families are required.

Replication of High Fetal Alcohol Spectrum Disorders Prevalence Rates, Child Characteristics, and Maternal Risk Factors in a Second Sample of Rural Communities in South Africa.

Background: Prevalence and characteristics of fetal alcohol syndrome (FAS) and total fetal alcohol spectrum disorders (FASD) were studied in a second sample of three South African rural communities to assess change. Methods: Active case ascertainment focused on children with height, weight and/or head circumference ≤25th centile and randomly-selected children. Final diagnoses were based on dysmorphology, neurobehavioral scores, and maternal risk interviews. Results: Cardinal facial features, head circumference, and total dysmorphology scores differentiated specific FASD diagnostic categories in a somewhat linear fashion but all FASD traits were significantly worse than those of randomly-selected controls. Neurodevelopmental delays were significantly worse for children with FASD than controls. Binge alcohol use was clearly documented as the proximal maternal risk factor for FASD, and significant distal risk factors were: low body mass, education, and income; high gravidity, parity, and age at birth of the index child. FAS rates continue to extremely high in these communities at 89–129 per 1000 children. Total FASD affect 196–276 per 1000 or 20–28% of the children in these communities. Conclusions: Very high rates of FASD persist in these general populations where regular, heavy drinking, often in a binge fashion, co-occurs with low socioeconomic conditions.

Neuropsychological Aspects of Prevention and Intervention for FASD in South Africa

Twenty years of collaborative epidemiology research in South Africa have revealed the highest reported rates of fetal alcohol spectrum disorders (FASD) in the world. The FASD research in South Africa has now expanded beyond prevalence research to maternal risk factor studies, longitudinal development studies, brain imaging studies, school intervention studies, and comprehensive prevention studies. The burden presented by the high numbers of affected individuals in South Africa is significant and a call to action is needed. This paper will outline the prevalence of FASD, review the South African governmental responses to the problem, report on the FASD research that has been completed, describe the prevention and intervention efforts that have been implemented, and outline how pediatric neuropsychologists and school psychologists can work with stakeholders to improve the lives of affected individuals and their families.

Understanding Fetal Alcohol Spectrum Disorders in China

Fetal alcohol spectrum disorder (FASD) is a term which describes a wide range of possible effects caused by prenatal exposure to alcohol, such as fetal alcohol syndrome, alcohol-related neuro-developmental disorders, and other alcohol-related birth defects. This article will review issues relating to FASD in China, which is the most populated country in the world. Information on the epidemiology of alcohol use during pregnancy, particularly as it relates to the unique cultural aspects of China, is provided. It is clear that schools, the government, mental health services, and the medical community do not have a clear conceptualization of serving children with FASD and that FASD-related research in China is lacking. However, there are some noticeable unique FASD prevention strategies in China, including social pressure, the influence of the one-child policy, premarital education, and mandatory premarital examinations. Prevention strategies promoting a decrease in drinking during pregnancy are provided in the form of mandated alcohol warning labels, new polices on alcohol regulation, and an increase in the education level of women. It is important for psychologists to provide cultural-specific suggestions in order to achieve effective and sufficient prevention and intervention for children with FASD concerns in China.

Challenges and Progress in Building a Comprehensive Statewide System for Fetal Alcohol Spectrum Disorders Prevention in Hawai'i.

Introduction Fetal Alcohol Spectrum Disorders (FASD) has been a maternal and child public health concern in Hawai'i for over the past decade. Methods A historical assessment of FASD related activities was conducted to map the challenges and progress made in building a comprehensive statewide system for FASD prevention and intervention in an island state. Results Progress has primarily been reflected in increasing the number of individuals receiving FASD education and training, as well as some initiatives in public awareness. The creation of a State FASD Coordinator position was significant in catalyzing support for FASD initiatives and extending collaborative networks with national experts/teams, community-based organizations, and other local agencies to leverage resources in a time of economic strain. Major challenges and barriers included loss of the FASD Coordinator position, reliance on external resources and lack of local capacity for training and education integration into existing practice systems, and inadequate surveillance infrastructure. Discussion Lack of funding and resources were a common factor overall, and impeded the development of a state strategic plan which was needed to guide overall efforts and policies into a more coordinated system to reduce and prevent FASDs in Hawai'i.

Replication of High Fetal Alcohol Spectrum Disorders Prevalence Rates, Child Characteristics, and Maternal Risk Factors in a Second Sample of Rural Communities in South Africa

Replication of High Fetal Alcohol Spectrum Disorders Prevalence Rates, Child Characteristics, and Maternal Risk Factors in a Second Sample of Rural Communities in South Africa

Neuropsychological Aspects of Prevention and Intervention for Fetal Alcohol Spectrum Disorders in Australia

The term fetal alcohol syndrome (FAS) was coined in 1973 to describe children with characteristic facial features, growth disorder and developmental delay associated with prenatal alcohol exposure. Yet, it was not until almost 20 years later that Australian researchers published on the public health significance of the range of conditions by then collectively termed fetal alcohol spectrum disorders (FASD). Similarly, the response to FASD within the government and various sectors of Australian society has been variable. Barriers in addressing FASD in the Australian context include a heavy drinking culture and large populations living in regional or remote communities and addressing FASD in high-risk populations such as juveniles in detention, some Aboriginal communities and “fly in-fly out” mining communities. Early Australian research was epidemiological, documenting notifications of FAS to birth defect registries and pediatric surveillance systems. The past decade has seen a rapid growth in Australian research into the full spectrum of FASD. Australian FASD diagnostic guidelines have recently been developed, a national FASD Action Plan has been endorsed, national and population-based data on FASD prevalence has been reported and large FASD intervention and prevention studies are underway within a National Centers of Research Excellence framework. In recent years, there has been a greater focus on neuropsychological aspects of FASD in diagnosis and intervention, with pediatric neuropsychologists playing a key role. A multidisciplinary model in the implementation of FASD prevention, diagnosis and therapy approaches is considered best practice. A key challenge for Australian clinicians, policy makers and researchers is to collaborate on a coordinated, national response to FASD that is data-driven and aligned with international guidelines and study protocols.

Dietary choline levels modify the effects of prenatal alcohol exposure in rats

Prenatal alcohol exposure can cause a range of physical and behavioral alterations; however, the outcome among children exposed to alcohol during pregnancy varies widely. Some of this variation may be due to nutritional factors. Indeed, higher rates of fetal alcohol spectrum disorders (FASD) are observed in countries where malnutrition is prevalent. Epidemiological studies have shown that many pregnant women throughout the world may not be consuming adequate levels of choline, an essential nutrient critical for brain development, and a methyl donor. In this study, we examined the influence of dietary choline deficiency on the severity of fetal alcohol effects. Pregnant Sprague-Dawley rats were randomly assigned to receive diets containing 40, 70, or 100% recommended choline levels. A group from each diet condition was exposed to ethanol (6.0g/kg/day) from gestational day 5 to 20 via intubation. Pair-fed and ad lib lab chow control groups were also included. Physical and behavioral development was measured in the offspring. Prenatal alcohol exposure delayed motor development, and 40% choline altered performance on the cliff avoidance task, independent of one another. However, the combination of low choline and prenatal alcohol produced the most severe impairments in development. Subjects exposed to ethanol and fed the 40% choline diet exhibited delayed eye openings, significantly fewer successes in hindlimb coordination, and were significantly overactive compared to all other groups. These data suggest that suboptimal intake of a single nutrient can exacerbate some of ethanol's teratogenic effects, a finding with important implications for the prevention of FASD.

Neuropsychological Aspects of Prevention and Intervention for FASD in Canada

Fetal alcohol spectrum disorder (FASD) is the leading cause of developmental disability among Canadians. As a result, FASD has emerged as a public health priority in Canada. The current paper provides an overview of FASD in Canada with respect to (1) epidemiology; (2) conceptualizations of FASD by schools, the government, mental health services and the medical community; (3) current research; (4) prevention initiatives; and (5) intervention efforts. Overall, Canada has become a world leader in advancing knowledge about FASD, in part through the establishment of research networks aimed at preventing FASD and improving the lives of individuals affected by the disorder across the lifespan. A nationwide research framework has strengthened the links between research and practice in Canada, and major bodies in Canada appear to be moving towards a more integrated model for conceptualizing FASD, with increased investment in prevention and intervention. Although research and evaluation evidence is emerging, however, the strength of current evidence does not yet allow for prevalence rates or prevention and intervention best practices to be defined with certainty. With quality cross-sectoral research and evaluation that incorporates the lived experiences of parents and individuals with FASD, it will be possible to enhance understanding of facilitators and barriers to service delivery, access and utilization with respect to FASD prevention and intervention in Canada.

P.7.a.002 - Cultural and other aspects of fetal alcohol spectrum disorder prevention and identification in Lithuania

Taiwan has some of the strictest alcohol-related driving laws in the world. However, its laws continue to be toughened to reduce the ever-increasing social cost of alcohol-related harm.This study assumes that alcohol-related driving laws show a spillover effect such that behavioral changes originally meant to apply behind the wheel come to affect drinking behavior in other contexts. The effects of alcohol driving laws and taxes on alcohol-related morbidity are assessed; incidence rates of alcohol-attributable diseases (AAD) serve as our measure of morbidity.Monthly incidence rates of alcohol-attributable diseases were calculated with data from the National Health Insurance Research Database (NHIRD) from 1996 to 2011. These rates were then submitted to intervention analyses using Seasonal Autoregressive Integrated Moving Average models (ARIMA) with multivariate adaptive regression splines (MARS). ARIMA is well-suited to time series analysis while MARS helps fit the regression model to the cubic curvature form of the irregular AAD incidence rates of hospitalization (AIRH).Alcoholic liver disease, alcohol abuse and dependence syndrome, and alcohol psychoses were the most common AADs in Taiwan. Compared to women, men had a higher incidence of AADs and their AIRH were more responsive to changes in the laws governing permissible blood alcohol. The adoption of tougher blood alcohol content (BAC) laws had significant effects on AADs, controlling for overall consumption of alcoholic beverages.Blood alcohol level laws and alcohol taxation effectively reduced alcohol-attributable morbidities with the exception of alcohol dependence and abuse, a disease to which middle-aged, lower income people are particularly susceptible. Attention should be focused on this cohort to protect this vulnerable population.

Prevalence of alcohol consumption during pregnancy and Fetal Alcohol Spectrum Disorders among the general and Aboriginal populations in Canada and the United States

Prenatal alcohol exposure may cause a number of health complications for the mother and developing fetus, including Fetal Alcohol Spectrum Disorders (FASD). This study aimed to estimate the pooled prevalence of i) alcohol use (any amount) and binge drinking (4 or more standard drinks on a single occasion) during pregnancy, and ii) Fetal Alcohol Syndrome (FAS) and FASD among the general and Aboriginal populations in Canada and the United States, based on the available literature. Comprehensive systematic literature searches and meta-analyses, assuming a random-effects model, were conducted. It was revealed that about 10% and 15% of pregnant women in the general population consume alcohol in Canada and the United States, respectively, and that about 3% of women engage in binge drinking during pregnancy in both countries. However, the prevalence of alcohol use during pregnancy in the Aboriginal populations of the United States and Canada were found to be approximately 3–4 times higher, respectively, compared to the general population. Even more alarmingly, it was estimated that approximately one in five women in the Aboriginal populations in both countries engage in binge drinking during pregnancy. Further, among the general population of Canada, the pooled prevalence was estimated to be about 1 per 1000 for FAS and 5 per 1000 for FASD. However, compared to the general population, the prevalence of FAS and FASD among the Aboriginal population in Canada was estimated to be 38 times and 16 times higher, respectively. With respect to the United States, the pooled prevalence of FAS and FASD was estimated to be about 2 per 1000 and 15 per 1,000, respectively, among the general population, and 4 per 1000 and 10 per 1,000, respectively, among the Aboriginal population. The FAS and FASD pooled prevalence estimates presented here should be used with caution due to the limited number of existing studies and their methodological limitations. Based on the results of the current study, it is evident that there is an urgent need for implementing more effective national prevention and surveillance strategies to monitor and lower the prevalence of alcohol consumption during pregnancy and FASD.

Risky Bodies: Allocation of Risk and Responsibility within Fetal Alcohol Spectrum Disorder (FASD) Prevention Campaigns

This paper examines utilization of risk and responsibility discourses within FASD public health promotion messages. In this qualitative case study, using data from 23 semi-structured interviews with those in charge of managing FASD and document analysis, I examine discourses invoked within FASD prevention and awareness campaigns deployed by the province of Alberta, Canada. The research findings demonstrate that within such FASD discourses, the unborn child is depicted as at-risk and the woman carrying the child is seen as being responsible for creating this risk. This is possible due to the neo-liberal tenet of individualism that occludes the structural factors that contribute to alcohol consumption and, perhaps FASD itself. This research on FASD is distinct from other studies on risk and responsibility because it recognizes and explores the separation of bodies that are considered to be at “risk” from those that are deemed to be “responsible” for creating such risk. This paper concludes with an in-depth discussion on the implications of using discourses of risk and responsibility within FASD prevention campaigns.