Proportion Of Family Members Research Articles

Area deprivation index, a marker of socioeconomic disadvantage, may predict severity of COVID-19 in patients and which families may experience worse symptoms of PTSD, anxiety, and depression post-ICU

BackgroundCOVID-19 disproportionately impacted marginalized populations early in the pandemic. Families of patients admitted to the intensive care unit (ICU) experienced significant psychological effects. Little is known about whether individual and patient psychological outcomes after a loved ones stay in the ICU differs by socioeconomic status, as measured by the area deprivation index (ADI).MethodsFamily members of patients with COVID-19 respiratory failure admitted to the ICU at twelve hospitals in five US states were enrolled in a larger study looking at rates of symptoms of post-traumatic stress disorder (PTSD), anxiety, and depression in the months following their loved one's ICU stay. This secondary data analysis includes eight of the twelve hospitals in four of the five states. Each participant was assigned a number indicating a level of neighborhood disadvantage based on the patient’s zip code. Patient and family level characteristics as well as symptoms of anxiety, depression, and PTSD were assessed among each neighborhood.ResultsPatients from the most disadvantaged neighborhoods had the highest proportion of patients that needed to be intubated (p = 0.005). All the patients in the most disadvantaged neighborhoods were a race other than white (p = 0.17). At 12 months post-hospitalization, there was a statistically significant difference in the proportion of family members who experienced symptoms of PTSD, anxiety, and depression between the ADI groups.ConclusionsADI may be a predictor of COVID-19 disease severity for patients on presentation to the ICU. Patients and family members experience psychological effects after a loved one’s admission to the ICU, and these outcomes vary among individuals of different socioeconomic status’, as measured by the ADI. A larger study of family members’ incidence of anxiety, depression, and post-traumatic stress disorder is needed to understand the extent to which these symptoms are impacted by neighborhood level factors as measured by the ADI.

Typologies of duocentric networks among low-income newlywed couples.

The social networks surrounding intimate couples provide them with bonding and bridging social capital and have been theorized to be associated with their well-being and relationship quality. These networks are multidimensional, featuring compositional (e.g., the proportion of family members vs. friends) and structural characteristics (e.g., density, degree of overlap between spouses' networks). Most previous studies of couple networks are based on partners' global ratings of their network characteristics or network data collected from one member of the dyad. This study presents the analysis of "duocentric networks" or the combined personal networks of both members of a couple, collected from 207 mixed-sex newlywed couples living in low-income neighborhoods of Harris County, TX. We conducted a pattern-centric analysis of compositional and structural features to identify distinct types of couple networks. We identified five qualitatively distinct network types (wife family-focused, husband family-focused, shared friends, wife friend-focused, and extremely disconnected). Couples' network types were associated with the quality of the relationships between couples and their network contacts (e.g., emotional support) but not with the quality of the couples' relationship with each other. We argue that duocentric networks provide appropriate data for measuring bonding and bridging capital in couple networks.

Household secondary attack rate of COVID 19 and its associated housing factors affecting transmission

: Overcrowding and household environments are high-risk settings for transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). To calculate the household secondary attack rate among household contacts of confirmed case of COVID-19. 2) To elicit the housing factors affecting the transmission of infection. 3) To know the sociodemographic of the discharge patients.A prospective study was conducted among the COVID 19 laboratory-confirmed discharged patients admitted at District Covid Hospital, Designated Covid health centre from period May 2020 to July 2020. Total 94 patients were able to contact telephonically. Sociodemographic details were taken after informed Verbal consent. Those who are not able to contact telephonically or didn't give consent are excluded. Household secondary attack rate is 14.5%. Mean rooms per person were 2.8 with a standard deviation of 1.38. The mean age of the patients was 39 years with a standard deviation of 14.9. A mild negative correlation between the number of positive COVID-19 cases and rooms per person (r= −0.045, p>0.05) and mild negative correlation was seen with the number of family members and proportion of family members (positive COVID-19 cases in family/total members in the family) being infected by COVID-19 (r= −0.20, p>0.05). Infection control and preventive strategies of household transmission such as good ventilation, isolation precautions of infected person at home, household disinfecting procedures, wearing of mask at home, hand hygiene needs to be encouraged at household level to lower the Secondary attack rate before recommendation of home isolation and home quarantine measures.

Role of Social Support and Ego Network Characteristics on Quality of Life

Mental health courts offer alternatives to incarceration for persons with severe mental illness who are involved in the criminal justice system. These courts have the dual function of ensuring treatment for persons involved in the court as well as ensuring the safety of the public. Persons with severe mental illness who are involved in mental health courts rely on others for support, such as family members. Others may buttress the participant from engaging in criminal activities and provide for needs of the participant. The supportiveness as well as the composition of one’s network members may play a role in the success of mental health court participants, such as successfully completing the mental health court program and avoiding incarceration. Little research has explored how social support impacts mental health court participants. We explored how the composition and sense of support of network members were associated with mental health court participants’ quality of life. We regressed quality of life on social support and network characteristics of 80 participants in two mental health courts. Findings suggest that perceived support is positively associated with quality of life, and the proportion of family in one’s network was negatively related to quality of life. Findings suggest that persons involved in mental health courts need supportive others in their social networks in addition to family. More research is needed to explore the reasons having a higher proportion of family members in one’s network is associated with lower quality of life. Practitioners need to pay attention to and leverage mental health court participants’ social networks to help improve their quality of life.

Evaluating client experience of rehabilitation following acquired brain injury: a cross-sectional study

ABSTRACT Objective: To implement a service-wide approach in the collection of data to evaluate client experience of brain injury rehabilitation. Methods: Mixed methods study. Clients with brain injury and family members of the Liverpool Brain Injury Rehabilitation Unit completed a purpose-designed Patient Experiences Survey for Brain Injury Rehabilitation (PES-BIR) which included closed and free-text responses, as well as the Client Services Questionnaire-8 (CSQ-8). The survey was completed by clients across the inpatient, community rehabilitation, vocational rehabilitation and community-based residential services. Results: 118 questionnaires were completed in relation to 102 clients. The majority of respondents were clients (n = 79, 66.9%) with a small proportion of family members represented (n = 39, 33.1%). High levels of satisfaction were reported (CSQ-8 28.4 ± 3.8) and positive patient experience (PES-BIR total, 37.2 ± 5.5) across all services. Themes identified from the free-text responses suggested that client experience was influenced by communication with the client about their progress and within the team, tailoring of rehabilitation, access to specialist services, integration of care across the rehabilitation continuum and the rehabilitation environment. Implications for practice: Routine collection and evaluation of client experience data in brain injury rehabilitation can be used to evaluate service delivery quality and guide further service improvements.

The Speed of the Internationalisation Process and the Institutional Networks of Family SMEs in the DOC Rioja Wine Industry

Institutional networking is a key element in businesses’ internationalisation processes and is an important strategy for promoting the long-term growth and survivability of family SMEs in the DOC Rioja wine industry. We hold that the proportion of family members in the TMT plays an important role in strategic decision-making and helps to explain the speed of their internationalisation process. This paper contributes to the scant research on the influence of family involvement in the TMT by analysing the moderating effects of two diversities on the relationship between institutional networking and the speed of internationalisation: the family TMT ratio and generational involvement. Using a broad sample of 77 family wineries in DOC Rioja, the results obtained indicate that institutional networking plays a significant role in explaining the speed of internationalisation in family firms and that this relationship is weaker when a larger proportion of family members serve as top managers. The empirical results also have interesting implications for the managers of family firms as it may help them to identify the effective composition of TMTs to be considered when deciding on the process of internationalisation.

Study on consistency of patients with Hodgkin's lymphoma and their families' perception of advance directives

Objective To explore the consistency of patients with Hodgkin's Lymphoma (HL) and their families' perception of advance directives (Ads) and analyze the influencing factors to their perception of Ads. Methods Totally 107 HL patients admitted in the First Affiliated Hospital of Zhengzhou University from January 2017 to December 2018 and 107 corresponding families were selected using convenient sampling. The demographic information of the patients and families as well as the clinical characteristics of the patients were collected. Kappa test was employed to analyze the consistency of the HL patients and their families' perception of Ads. Univariate and multivariate analyses were used to analyze the influencing factors to their perception of Ads. Results Totally 66.36% (71/107) of the HL patients were willing to formulate Ads, higher than 46.72% (50/107) , the proportion of family members who could comply with the Ads willingness of patients, and the difference was statistically significant (χ2=8.387, P=0.004) . The Kappa value was 0.222, and the consistency of Ads perception among the HL patients and their families was poor. Logistic regression analysis revealed that age, religious belief, bereavement experience, systemic symptoms, and Eastern Cooperative Oncology Group (ECOG) Performance Status were influencing factors for the HL patients to formulate Ads willingness, while religious belief and bereavement experience were influencing factors for the families to follow the patients' Ads willingness. Conclusions There is a difference in the perception of Ads between HL patients and their families, and the selection of Ads by family members cannot fully represent the patients themselves; religious beliefs and bereavement experience are common factors affecting the perception of Ads in HL patients and their families. Key words: Hodgkin's lymphoma; Advance directives; Consistency; Influencing factor; Families

Clinicopathological study of SET subtype of ovarian high-grade serous carcinoma

Objective: To investigate the clinicopathological characteristics and significance of solid, endometrioid and transitional (SET) ovarian high-grade serous carcinoma (HGSC). Methods: A total of 408 cases of ovarian HGSC admitted to Peking University People's Hospital from January 2011 to September 2016 were collected. (1) According to the proportion of tumors with SET form in all tumors, they were divided into three groups: HGSC-classic group (<25%), HGSC-SET Ⅰ (25%-50%) and HGSC-SET Ⅱ (>50%) group. The clinical and pathological characteristics of three groups of ovarian HGSC patients were compared respectively. (2) According to the growth pattern, that was, the proportion of pushing/expanding invasive tumors in the whole pelvic disseminated tumors of pelvic disseminated tumors, the three groups were divided into four subgroups: group A (0-25%), group B (26%-50%), group C (51%-75%) and group D (>75%). Differences in progression-free survival (PFS) among the four subgroups in each group were compared respectively. Results: The median age of 408 cases with ovarian HGSC was 63.3 years (47-78 years), including 152 cases premenopausal and 256 cases postmenopausal. Among 408 cases of ovarian HGSC, 290 cases were in HGSC-classic group, 91 cases in HGSC-SET Ⅰ and 27 cases in HGSC-SET Ⅱ group. (1) There were significant differences in age, proportion of menopausal patients, tumor necrosis (including map necrosis or acne necrosis), response rate to primary chemotherapy, 5-year mortality rate and PFS between HGSC-SET Ⅰ and HGSC-SET Ⅱ (P<0.05). There was no significant difference among the above indexes between HGSC-SET Ⅰ and HGSC-SET Ⅱ (P>0.05). In HGSC-classic group, HGSC-SET Ⅰ and HGSC-SET Ⅱ, the proportion of family members or patients with history of epithelial ovarian cancer or breast cancer increased in turn, and the detection rate of serous tutal intraepithelial carcinoma (STIC) in fallopian tube tissue decreased in turn. There were significant differences between the two groups (P<0.05). (2) In HGSC-classic group, there were 147 cases in group A, 124 cases in group B and 19 cases in group C (0 case in group D), with median PFS of 17.4, 17.7 and 16.5 months respectively (P<0.05); 10, 6, 29 and 46 cases in group A, B, C and D in HGSC-SET Ⅰ, with median PFS of 9.6, 12.7, 30.1 months and 39.0 months respectively, which there were significant difference among group A and C and D (all P<0.05); among group B, C and D group in HGSC-SET Ⅱ, there were respectively 3, 12 and 12 cases (0 case in group A), and the median PFS was 13.5, 34.2 and 47.8 months (P<0.05). PFS was positively correlated with the increase of push/expansive infiltration ratio. Conclusions: The detection rate of STIC in ovarian HGSC patients with SET is higher, the effect of primary chemotherapy is better, and PFS is prolonged. PFS was significantly prolonged in patients with pelvic disseminated tumors of HGSC-SET, the infiltration of which were predominated by pushing or expanding boarder.

Risk Factors for Childhood Overweight and Obesity in Ukraine and Germany

Objective:The prevalence of overweight and obesity in childhood and adolescence are rapidly increasing and influenced by genetic, familial, environmental, socioeconomic and cultural factors. The aim of the study was to compare risk factors for childhood obesity in Ukraine (UA) and Germany (DE) using comparable investigative tools.Methods:Two groups of children, aged 8 to 18 years, from DE (93 children) and UA (95 children) were divided into overweight and obese groups. Anthropometric data and detailed medical history were collected.Results:Risk factors in pregnancy (prematurity, weight gain >20 kg, early contractions) were equally frequent in both groups. Positive correlations of body mass index (BMI)-standard deviation score (SDS) between children and mothers were noted. The proportion of family members with diabetes mellitus was lower in the UA group. Obesity was more frequent at one year of age in DE children. The DE group also became overweight at an earlier age and remained overweight over a longer period of time compared to UA. The mean BMI-SDS of obese children was lower in the UA group. In both groups waist circumference to height ratio was >0.5, indicating presence of a cardiometabolic risk factor. About half of the patients in both groups had blood pressure values exceeding the 95th percentile.Conclusion:Similar risk factors for obesity were observed among two groups of children in UA and DE. Differences were observed regarding the prevalence of specific risk factors for childhood obesity. Population-specific distribution of risk factors needs to be considered in order to optimize prevention and treatment strategies.

Ten key messages of the guidelines for family-centered care in intensive care medicine

The family plays an important role in the care of the critically ill patient. There is asubstantial psychological burden to family members during the intensive care management of the patient. The family has to bear the pitiable state of the patient with the feeling of helplessness. The critically ill patient is frequently unable to actively decide on the processes of intensive care. Therefore, the family has to take over the responsibility of representing the values and wishes of the patient and become involved in decision making, for which most family members are not prepared. Aconsiderable proportion of family members suffers from stress, anxiety and depression. This psychological burden also continues after the conclusion of the intensive care management. Therefore, structured approaches are needed to support family members of critically ill patients during the intensive care management. In this short review, we present the ten key messages of the recent guidelines for family-centered care in the intensive care unit by the Society of Critical Care Medicine.

The status and determinants of corporate governance disclosure: The case of the Gulf countries

Corporate Governance Disclosure (CGD) is important for countries aiming to attract international investors and increase foreign investment. CGD helps mitigate the agency problem, improve firm value and enhance capital market efficiency. This research aims to assess the level of CGD in the Gulf countries. The Gulf countries have been selected due to their unique institutional and corporate characteristics. After assessing the CGD level in the Gulf, the association between diversity, board characteristics and CGD is identified while controlling for firm characteristics. Four board characteristics are used: the proportion of independent nonexecutive directors on board, the proportion of family members on board, role duality and board size; whereas diversity variables included proportion of foreign board members, proportion of foreign members in the senior management team, proportion of female board members and proportion of female members in the senior management team. A self-constructed disclosure index is developed to measure CGD. The index includes six sections: ownership structure and investor rights, financial transparency and information disclosure, information on auditors, board and senior management structure and process, information on board committees, and finally, corporate behavior and responsibility. This classification follows most of the international disclosure indices. The sample size includes 270 publicly listed non-financial companies listed on all Gulf stock exchanges, with data taken from 2009 annual reports. The average CGD is 32 percent, the maximum is 63 percent whereas the minimum is 5 percent. Proportion of independent non-executive directors on board, proportion of foreign board members and proportion of foreign members in the senior management team had a significant positive relationship with CGD. This research is considered the first to assess CGD across the six Gulf countries. This study has important regulatory and managerial implications.

The effectiveness of board of directors’ characteristics in mandatory disclosure compliance

PurposeThe purpose of this paper is to investigate the relationship between the characteristics of the board of directors and mandatory disclosure compliance (measured by International Financial Reporting Standards requirements) in firms listed on the Kuwait Stock Exchange (KSE) in 2010.Design/methodology/approachSeveral characteristics are used to assess the effectiveness of the board of directors: number of members, gender diversity, CEO duality, multiple directorships, the proportion of family members on the board and the presence of a member of the ruling family of Kuwait. Mandatory disclosure compliance is measured using a self-constructed, item-based index. A regression model tested the paper’s hypotheses.FindingsAfter controlling for firm-specific characteristics, it was found that board size, gender diversity and multiple directorships were positively correlated with compliance, while CEO duality and the proportion of family members on the board were negatively correlated with compliance.Research limitations/implicationsPotential limitations stem from both the nature of the sample and the dataset. The small sample reflects the size of the KSE and the limited timeframe (a one-year period). Nevertheless, this paper provides some interesting insights. A longitudinal study would provide more comprehensive insights into the relationship between the characteristics of the board of directors and mandatory disclosure compliance over time.Practical implicationsThe findings highlight the effectiveness of board of directors’ characteristics in promoting mandatory accounting compliance. As disclosure is fundamental for the effective functioning of capital markets and sound investments, a direct implication is that the quality of financial reporting can be improved by taking these characteristics into account.Originality/valueThe paper contributes to the literature on the determinants of mandatory accounting compliance. The findings highlight the importance of the board of directors’ role in enhancing transparency and ensuring the quality of financial reporting. The findings will be particularly valuable to those involved in the appointment of directors, who should be aware of the influence of the configuration and characteristics of the board on compliance.

Gambling frequency, gambling problems and concerned significant others of problem gamblers in Finland: cross-sectional population studies in 2007 and 2011.

This study compares past-year gambling frequency, gambling problems and concerned significant others (CSOs) of problem gamblers in Finland by age, from 2007 and 2011. We used random sample data collected in 2007 (n = 4722) and 2011 (n = 4484). The data were weighted, based on gender, age and region of residence. We measured the past-year gambling frequency using a categorical variable, while gambling severity was measured with the South Oaks Gambling Screen. We identified CSOs by a single question including seven response options. Chi-Squared and Fisher's exact tests were used. Overall, the past-year gambling frequency change was statistically significant between 2007 and 2011. Among 18-64-year-old Finnish people, the proportion of non-gamblers decreased. Yet, among 15-17-year-old respondents, non-gambling increased and gambling problems decreased. Among 18-24 year olds, the proportion of close ones with gambling problems also decreased. On the other hand, the proportion of family members with gambling problems increased among the 50-64 year olds. The increase in adult gambling participation was mainly explained by infrequent gambling. The proportion of gambling problems from the gamblers' and CSOs' perspective remained unchanged, yet significant changes were observed within age groups. The short-term changes in under-age gambling problems were desirable. Future studies should explore the adaptation and access hypotheses alongside gambling problems.

Lack of familial aggregation in chronic constipation excluding irritable bowel syndrome: a population-based study.

Despite strong evidence supporting a genetic and gene-environment interaction in the irritable bowel syndrome (IBS), the role of genes and early life in another common functional bowel disorder, chronic constipation (CC), have been little studied. To determine whether familial aggregation occurs in CC and whether risk factors differed in those with family members. A randomly selected population-based cohort from Olmsted County, MN, was surveyed (n = 8,006); 3,831 completed questionnaires (response rate 48 %). Cases were identified based upon their responses to a validated questionnaire and meeting Rome criteria for CC. Controls were matched one to one by age and gender. IBS (by Rome II criteria) was excluded. Recruitment of case and control probands occurred in 2010-2011 by mailing a family information form; then, first-degree relatives (FDR) were mailed a questionnaire. All potential proband participants were not informed of CC status. Overall 1,185 cases who met criteria for CC without symptoms of IBS and 1,185 controls were surveyed; 309 case and 336 control probands provided data. The proportion of family members having CC was not associated with case status, and the constipation status of FDR was not significantly associated with case-controls status of the respective probands. Symptom burden in FDR was associated with gender and SSC score, but not age or proband status. No evidence of familial aggregation was observed in adults from the community with CC (excluding IBS). Our data suggest environmental factors in later life more likely account for adult CC.

The Use of Incentive Compensation Among Board Members in Family Firms

Although previous literature has focused on managerial compensation differences between family and non-family firms, the examination of differences in the compensation structure of family directors versus their non-family counterparts within family firms has received much less attention. We analyze several contingencies related to directors’ kinship ties to the owning family that may influence directors’ total compensation levels and their incentive compensation in family firms. The empirical evidence is provided by a sample of publicly listed family firms from the United States. Our results show that family-member directors receive a lower share of variable pay and a lower level of total compensation than non-family directors within the same firm. In addition, a high family ownership concentration and a large proportion of family members on the board impact negatively on the use of incentive compensation among board members with kinship ties to the owning family.

The Environment Modifies the Relationship Between Social Networks and Secondhand Smoke Exposure Among Korean Nonsmokers in Seoul and California

This study compared risks of secondhand smoke exposure (SHSe) among Korean nonsmokers in Seoul, South Korea and California, United States. Social networks were hypothesized to contain more smokers in Seoul than in California, and smokers were hypothesized to produce more secondhand smoke in Seoul than California, as Seoul's policies and norms are less restrictive. Telephone interviews were conducted with Korean adults in Seoul (N = 500) and California (N = 2830). In all, 69% (95% confidence interval [CI] = 64-74) of Koreans and 31% (95% CI = 29-33) of Korean Americans reported any SHSe. A total of 44% (95% CI = 40-47) of Korean family members smoked versus 29% (95% CI = 28-30) of Korean American family members (t = 7.84, P < .01). A 25% to 75% increase in the proportion of family members that smoked corresponded with a 13% (95% CI = 5-21) higher probability of any SHSe among Koreans compared with 6% (95% CI = 2-10) among Korean Americans. Network interventions in combination with policies and/or health campaigns may help reduce SHSe globally.

Corporate governance and profitability in family SMEs

We analyze the determinants of performance in small unlisted family firms and find, in line with previous studies, a positive effect associated with a family CEO. We contribute by bringing in an additional variable, the proportion of family members employed by the firm and find it to be negatively related to firm performance. There is a significant tendency for family CEOs to employ family members, which – given the negative effect of these – should offset some of the positive performance effects of a family CEO. We also analyze the effect of board size in these already small family boards, where the maximum number of board members is six. We find that even here, board size is significantly negatively associated with firm performance.

Estimating cancer risk in HNPCC by the GRL method

Hereditary nonpolyposis colorectal cancer (HNPCC) is an autosomal dominant syndrome caused by germline mutations of the mismatch repair (MMR) genes. Only a few studies have taken into account the selection of families tested for these mutations in estimating colorectal cancer (CRC) risk in carriers. They found much lower estimates of CRC risks than previous ones, but these estimates lacked precision despite the large number of families. The aim of this study was to evaluate the efficiency of the 'genotype restricted likelihood' (GRL) method that provides unbiased estimates of risks whatever the ascertainment process of families, and to estimate CRC and endometrial cancer risk for carriers of the MMR genes. Efficiency of the GRL method was evaluated using simulations. Risks were estimated from a sample of 36 families diagnosed with HNPCC and carrying a mutation of MSH2 or MLH1, ascertained through a cancer family clinic in Lyon (France). The efficiency of the GRL method was found to be strongly dependent on the proportion of family members tested. By age 70 years, CRC risk was estimated at 47% (95% confidence interval: 12-98%) for men and 33% (95% confidence interval: 24-54%) for women. The endometrial cancer risk was only 14% (confidence interval: 6-20%). As methods allowing for the selection of families lack efficiency, large-scale family studies should be undertaken and data should be pooled to provide reliable and precise estimates of risks for an optimal familial management.

Social Network Structure and Social Support in HIV-Positive Inner City Mothers

It has been documented that social support influences health outcomes of persons with chronic illnesses. The incidence of HIV and AIDS among minority women is growing at an alarming rate, but little is known about social support in this vulnerable population, and even less is known about the social network conveying that support. Guided by the convoy of social networks model, this study describes the social networks in a sample of HIV-positive, urban-dwelling mothers (N = 147) by stage of disease (i.e., asymptomatic, symptomatic, AIDS) and examines relationships between social network structure and social support. Hierarchical linear modeling showed that women's social networks were disproportionately populated by children, and network members of women with AIDS were significantly older than network members of HIV-positive women with or without symptoms. Profile analyses showed that women's perceptions of the quality of social support differed according to the proportion of family members populating different segments of the social network.

The changing hopes, worries, and community supports of individuals moving from a closing long-term care facility.

This study examines client's hopes, worries, and social networks before, one year, and two years following release from a long-term care facility. More clients expressed hopes than worries before closure but, over time, hopes decreased and worries increased significantly. Before closing, independence was cited most often as a hope, followed by work and finances. Criminal opportunities headed up concerns, followed by mental health treatment, finances, living arrangements and independence. Over time, respondents were less excited about independence and living arrangements but more hopeful about social opportunities and everyday practicalities. Worries relating to family increased while concerns about deviance decreased. Respondents reported an average increase in network ties but the proportion of family members decreased while professional supports and ties with former CSH patients increased. The trends highlight particular vulnerability at the one-year point, the necessity of viewing movement into the community as a nonlinear process, and the importance of marking outcomes periodically.