Severe Psychological Disorders Research Articles

Protein Profiles and Novel Molecular Biomarkers of Schizophrenia Based on 4D-DIA Proteomics.

Schizophrenia is a severe psychological disorder. The current diagnosis mainly relies on clinical symptoms and lacks laboratory evidence, which makes it very difficult to make an accurate diagnosis especially at an early stage. Plasma protein profiles of schizophrenia patients were obtained and compared with healthy controls using 4D-DIA proteomics technology. Furthermore, 79 DEPs were identified between schizophrenia and healthy controls. GO functional analysis indicated that DEPs were predominantly associated with responses to toxic substances and platelet aggregation, suggesting the presence of metabolic and immune dysregulation in patients with schizophrenia. KEGG pathway enrichment analysis revealed that DEPs were primarily enriched in the chemokine signaling pathway and cytokine receptor interactions. A diagnostic model was ultimately established, comprising three proteins, namely, PFN1, GAPDH and ACTBL2. This model demonstrated an AUC value of 0.972, indicating its effectiveness in accurately identifying schizophrenia. PFN1, GAPDH and ACTBL2 exhibit potential as biomarkers for the early detection of schizophrenia. The findings of our studies provide novel insights into the laboratory-based diagnosis of schizophrenia.

The Effect of Group-Based Patience Therapy on Reducing Anxiety Levels

The earthquake at the end of 2022 which occurred in Cugenang Cianjur, West Java, left quite a deep psychological impact on some of the people, especially marked by the emergence of symptoms of anxiety. If intervention is given too late, it will result in more severe psychological disorders. The aim of this research is to examine how much influence patience therapy has on reducing anxiety levels in earthquake victims. The patience therapy used is an approach that integrates targets into aspects biopsikososiospiritual. The research design used is experimental design in the shape of pre test-post test control group design. The population in this study were all students at the Girls' Islamic Boarding School in Cugenang Cianjur. Sampling in this research used Purposive sampling technique. The sample used in this research consisted of 12 subjects who were earthquake survivors in Cugenang Cianjur.A measuring tape used HRS-A Scale from Hamilton which consists of 14 statements which have a validity value of 0.81 and a reliability of 0.91, which includes four aspects, including physiological aspects, cognitive aspects, affective aspects and behavioral aspects. Measurement results on pre test-post test showed a reduction in anxiety levels of 53.4%. Meanwhile, statistical analysis using the independent mann whitney showed a score of 0.00 (p<0.05), which means that patience therapy was significantly effective in reducing anxiety levels in survivors of the earthquake natural disaster in Cugenang Cianjur.

Efficacy of EMDR in Body Dysmorphic Disorder and Associated Cognitive-Emotional Features

Body dysmorphic disorder (BDD) is a severe psychological disorder that significantly impacts functioning and quality of life. Eeye movement desensitization and reprocessing (EMDR) presents as an emerging alternate psychological intervention. This study aimed to examine the efficacy of EMDR in BDD symptoms and associated cognitive-emotional features. These features include appearance-based rejection sensitivity, body shame, and self-compassion. Our study utilized a multiple-baseline across-subjects design, monitoring four randomly allocated female patients with BDD over a 10-session/90-minute EMDR treatment phase and two follow-up sessions at 1 and 3 months, respectively. Our results showed that EMDR significantly reduced BDD symptoms (recovery percentage [RP] = 60.54), appearance-based rejection sensitivity (RP = 36.56), and body shame (RP = 54.82) and increased self-compassion (RP = 51.79). Therefore, our study suggests that EMDR may be an effective treatment for BDD patients.

A Systematic Review on The Efficacy of VRET For Agoraphobia

This systematic review paper aims to evaluate the efficacy of Virtual Reality Exposure Therapy (VRET) for Agoraphobia, a severe psychological disorder characterized by avoidance behavior and sometimes panic attacks. The paper presents a qualitative assessment of 15 studies published after 2000, using Scopus databases. The experiments were evaluated for eligibility based on their abstracts and full content, and only English-language published articles were included. The review shows that VRET is a promising therapy for Agoraphobia, with similar efficacy to In Vivo Exposure (IVE), but with certain advantages such as better control over exposure content and higher patient satisfaction. However, implementing VRET may be difficult for some patients due to cybersickness and higher costs. The paper concludes with a diagram of the 15 experiments evaluated and emphasizes the importance of further research on the efficacy of VR therapy for anxiety disorders, including Agoraphobia.

Exploring the symptom patterns of depression and anxiety among teachers during COVID-19: A latent profile analysis.

The present study used the latent profile analysis (LPA) approach to explore the symptom patterns of depression and anxiety among Chinese teachers during COVID-19 and its relationship with fear of COVID-19 and suicidal ideation. A sample of 6,121 teachers from primary and secondary schools in a district-level administrative unit in southern China was used. The LPA was employed to identify different symptom patterns of depression and anxiety. We subsequently used logistic regression to analyze the effects of demographic variables on the different profiles. The Bolck-Croon-Hagenaars method assessed the relationships between each profile and fear of COVID-19 and suicidal ideation. The study identified five significant latent profiles and two subtypes in the moderate psychological disorder group. We also found that gender, professional title, and age significantly influenced the distribution of the profiles. The risk for both fear of COVID-19 and suicidal ideation was highest in the severe psychological disorder group. The high anxiety subtype had a significantly greater fear of the new coronavirus epidemic than the high depression subtype, which had a significantly higher level of suicidal ideation than the high anxiety subtype. The profiles we identified have distinct features that confirm their unique patterns of symptom endorsement. Our study may have important implications for early warning and intervention in teacher mental health. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Peran Orang Tua Dalam Meminimalkan Risiko Bullying Pada Anak-Anak

Adolescence marks a crucial transition from childhood to adulthood, encompassing emotional, social, physical, and psychological growth. However, this period often presents adolescents with psychological hurdles as they navigate self-identity and explore their surroundings. Among these challenges, bullying emerges as a significant concern, globally pervasive, particularly within school environments. Bullying exerts detrimental effects on its victims, precipitating severe psychological disorders such as anxiety, fear, and depression. Thus, the pivotal role of parents in aiding children through this ordeal cannot be overstated. Parents play a crucial role in offering emotional support, recognizing signs of bullying, and fostering effective coping mechanisms. They can cultivate a safe and nurturing atmosphere at home, encouraging engaging activities and participation in supportive communities. Through proper guidance and support, children can bolster their self-assurance and enhance their mental well-being, effectively confronting the adversities of bullying.

Esrar Kullanım Bozukluğu Tedavisinde Kullanılan İnternet Tabanlı Psikososyal Müdahale Programları: Bu Programların Etkinlikleri ve Sınırlılıkları

This review focuses on the internet-based psychosocial intervention methods used in the treatment of cannabis use disorder, reviewing their effectiveness and limitations in light of the available information. Cannabis use disorder contributes to both physical and mental health issues, as well as high healthcare costs. In recent years, various internet-based psychosocial interventions have been developed for treating this condition. These interventions can be categorized into three main groups: self-help and educational programs, mobile applications and gamified interventions, and peer support with community-based platforms. Studies indicate that these internet-based psychosocial interventions could be an effective alternative for the treatment of cannabis use disorder. Their strengths include the potential to reduce the frequency and amount of cannabis use, their flexible and accessible nature, and the ability to reach a broad user base. However, limitations such as technological access and digital literacy issues, data security and privacy concerns, discrepancies in demographic and cultural diversity, and challenges in long-term follow-up and sustainability are evident, particularly in cases of severe psychological disorders or situations requiring immediate intervention. While the results of relevant research are promising, there have been a limited number of randomized controlled trials conducted. Keywords: Cannabis, Cannabis use disorder, Internet-based psychosocial interventions.

Analysis of the causes of Domestic Violence against men in Ecuador

The research aimed to analyze the causes of domestic violence against men in Ecuador, identifying aggressors' behavioral patterns and the social context contributing to this phenomenon. A bibliographic review of articles in English and Spanish published between 2018 and 2023 was employed, using databases such as PUBMED and DIALNET. The final selection included 27 relevant studies, of which 17 were used for analysis. The methodology focused on using the Pareto chart, which allowed for identifying and prioritizing the main causes of violence. These factors were distributed in a bar chart, showing that a small number of causes are responsible for most of the effects. The results indicated that violence against men is an underestimated and underreported problem due to social stigmas and gender expectations. Additionally, a lack of specific public policies and legal resources for male victims of violence was observed, perpetuating their invisibility and lack of adequate support. Men who suffer violence can develop severe psychological disorders, including depression and post-traumatic stress disorder. It was concluded that this problem must be addressed comprehensively by implementing awareness campaigns, psychological and legal support, and promoting cultural changes to recognize violence against men as a public health issue. The creation of specific public policies and early intervention programs was also recommended to mitigate this phenomenon and provide adequate support to victims.Keywords: male abuse, violent acts, psychological harm, preventive actions

Children after war: From moral development claims to welfare and agency rights

AbstractWithin a framework of rights that protects children's interests and seek to balance their developing interests in welfare and agency, I consider how contexts of war impact children's lives to argue that such contexts provide opportunities to advance or set back both the development of moral powers, namely capacities for a sense of justice and a conception of the good, and capacities for autonomy. Besides an interest in satisfying their basic needs and protection, children have an interest in developing their moral powers and growing into autonomous agents. Evidence shows great variation in children's responses to traumatic circumstances, from severe psychological disorders to enhanced resiliency and moral reasoning. As moral powers and autonomy ground the permissibility for paternalistic treatment and the exclusion of children from certain rights, I argue that once the war is over children are entitled to an adequate assessment of how their interests and capacities have changed. For children whose development was set back, states should grant opportunities for recovery and further development, which suggests strengthening welfare and protection rights; while for children whose development was advanced, states should recognize such advancement and grant opportunities for the exercise of their newfound capacities, which suggests granting certain agency rights alongside welfare and protection.

Musculoskeletal disorders in hemodialysis patients: prevalence, clinical symptoms, and associated factors

Introduction: One of the major public health problems is end-stage renal disease (ESRD). ESRD is commonly associated with musculoskeletal disorders (MSDs). Objectives: Due to the importance of MSDs in hemodialysis patients and the absence of sufficient studies in Iran, this study aims to investigate MSDs in hemodialysis patients. Patients and Methods: This cross-sectional study was conducted on 75 patients with ESRD, who were under hemodialysis at the special diseases center of Birjand university of medical sciences, south Khorasan, Iran. Inclusion criteria were history of at least 2 years of hemodialysis, and age more than 18 years. All patients with previous neurological disorders, previous rheumatic diseases, previous arthroplasty of the limbs, and severe psychological disorders were excluded from the study. Baseline characteristics and laboratory data collected. MSDs examined based on the Nordic Musculoskeletal Screening Questionnaire (NMQ). Data were described using central tendency, CHI-SQUARE test, and Fisher’s exact test were used. The significance level in this study was P<0.05. Results: Seventy-five patients participated (Mean and standard deviation (SD) of age: 62.13±1.73 years, male to female ratio: 1.14). Sixty-three patients (84.0%) had MSDs. There was no significant difference based on age, dialysis vintage, gender, laboratory tests, and comorbidities (P>0.05). Dialysis etiology, knee osteoarthritis, shins pain, knee pain and knee range of motion had significantly difference between groups (respectively, P=0.047, P=0.003, P=0.012, P=0.001, P=0.002). Conclusion: The frequency of MSDs in these patients was 84.0%. There was a significant association between MSDs with the cause of hemodialysis, lower limb pain, and knee osteoarthritis.

The improvement effect of food additive analysis in patients with anorexia nervosa

BackgroundAnorexia nervosa is a severe psychological disorder, and current treatment of anorexia nervosa relies on psychotherapy and medical nutritional support. The study applied food additives to the relevant treatment, aiming to help improve the patients’ diet.Subjects and MethodsPatients who met the diagnostic criteria of anorexia nervosa were randomly selected and divided into experimental and control groups, with 25 patients in each group. The experimental group received food additive-assisted treatment, while the control group received only conventional treatment. Before and after treatment, the patients’ body mass index (BMI) and height were measured, and eating disorders were assessed using the EDE-Q. The resultant data were analyzed using SPSS22.0.ResultsAfter treatment, the BMI of the experimental group was significantly higher than that before treatment (F=18.42, P<0.05), while the BMI of the control group did not change significantly (F=9.71, P>0.05). In the EDE-Q scale assessment, the experimental group scored lower than the control group in terms of frequency of binge eating, frequency of emesis, and restriction of eating factor, and the difference was statistically significant (P<0.05).ConclusionsAfter treatment, patients in the experimental group showed a significant increase in BMI, and the frequency of binge eating, frequency of emetic, and restriction of eating factor scores were lower than those of the control group. This suggests that food additives may have potential efficacy in alleviating the symptoms of anorexia nervosa.

Impact of Psychological and Social Determinants on Health

The World Health Organization defines the Social Determinants of Health (SDH) as "the conditions under which people are born, grow, work, live, and age, as well as the broader set of forces and systems influencing the conditions of daily life". Psychosocial variables and social determinants both have an important role in determining a person's health and well-being. The psychological, social, and cultural dimensions of these issues can have an impact on a person's behavior and health. Stress, education, poverty, social exclusion, discrimination, and violence are a few examples of these psychosocial determinants. These elements can be protective or, on the other hand, raise the risk of physical and mental illness and lower people's quality of life. Social determinants of health are a combination of social, economic, and physical factors. They play a role in determining the patterns of illness, disease, and health that are observed in a population. They establish the circumstances in which people are conceived, develop, live, work, and age. Health and medical care, economic security, social and communal context, local geography and built environment, and education are all examples of social determinants of health. The connection between individuals and their social and physical environments frequently worsens poor health outcomes. Low socioeconomic position, unemployment, strained family ties, and hazardous neighborhoods have been shown in studies to have a significant negative impact on mental health. Additionally, those who suffer from severe psychological disorders are more probable to experience social segregation, poverty, food insecurity and housing uncertainty all of which can decrease quality of life and hamper rehabilitation. Pakistan experienced the largest gain among the SAARC nations between 2013 and 2018, increasing its happiness score by 26 points, and is expected to rank among the top 20 gainers globally in 2020 [2]. However, it lowers to 4.934from 2018-2020 and is ranked 105 out of 149 happiest countries. There could be a number of causes for this downward tendency. The need of the hour is to pinpoint the causes of Pakistan's declining happiness level. These findings would help policymakers get rid of or manage the factors contributing to people's lower levels of happiness. It is improbable to understate the importance of social and psychological factors in determining health. Healthcare systems and politicians may create initiatives that successfully promote well-being, lessen health inequities, and enhance overall health outcomes by understanding and addressing these variables. A healthier and more equal society must be built via comprehensive strategies that incorporate socioeconomic inequities and mental health care. In order to promote a more inclusive and sustainable society, the international community is making great progress towards reaching many Sustainable Development Goals (SDGs). We are covering several SDGs described by United Nations which include: SDG 1, “No Poverty”; SDG 2, "Zero Hunger"; SDG 3, "Good Health and Well-being"; SDG 4, "Quality Education"; SDG 5, "Gender Equality"; SDG 8, "Decent Work and Economic Growth" and SDG 10, "Reduced Inequalities". The elimination of poverty, hunger, and inequality, as well as the promotion of sustainable economic growth, are the top priorities behind these objectives. By achieving these objectives, we can collectively work towards a more sustainable and equitable future in which no one is left behind.

Feasibility study on using house-tree-person drawings for automatic analysis of depression

Major depression is a severe psychological disorder typically diagnosed using scale tests and through the subjective assessment of medical professionals. Along with the continuous development of machine learning techniques, computer technology has been increasingly employed to identify depression in recent years. Traditional methods of automatic depression recognition rely on using the patient’s physiological data, such as facial expressions, voice, electroencephalography (EEG), and magnetic resonance imaging (MRI) as input. However, the acquisition cost of these data is relatively high, making it unsuitable for large-scale depression screening. Thus, we explore the possibility of utilizing a house-tree-person (HTP) drawing to automatically detect major depression without requiring the patient’s physiological data. The dataset we used for this study consisted of 309 drawings depicting individuals at risk of major depression and 290 drawings depicting individuals without depression risk. We classified the eight features extracted from HTP sketches using four machine-learning models and used multiple cross-validations to calculate recognition rates. The best classification accuracy rate among these models reached 97.2%. Additionally, we conducted ablation experiments to analyze the association between features and information on depression pathology. The results of Wilcoxon rank-sum tests showed that seven of the eight features significantly differed between the major depression group and the regular group. We demonstrated significant differences in HTP drawings between patients with severe depression and everyday individuals, and using HTP sketches to identify depression automatically is feasible, providing a new approach for automatic identification and large-scale screening of depression.

Exploring the Relationship between Disordered Sleep and Mood in Male Anorexia Nervosa: An Actigraphy Study

Eating disorders (EDs), including anorexia nervosa (AN), are severe psychological disorders that affect individuals’ eating behaviours and body perception. Previous research has shown that people with EDs often report poorer sleep. Some literature has suggested that it is mood dysregulation that mediates the link between EDs and sleep. However, the majority of previous studies only focused on females, while male ED patients have been overlooked. Therefore, the present study aimed to investigate the relationships between EDs, mood, and sleep among male ED patients. Using a mixture of actigraphy recordings and self-reported questionnaires, the current study analysed a total 33 adult male participants diagnosed with AN. The participants first wore an actigraphy device for seven continuous days, following which their ED severity and mood were assessed by the Eating Disorder Examination Questionnaire (EDE-Q) and Depression Anxiety Stress Scale (DASS), respectively. The descriptive actigraphy results suggested that, similar to females, males with AN also showed disturbed sleep, including insomnia, sleep fragmentation, low sleep efficiency, and increased napping sessions. However, when ED severity was correlated against actigraphy data and mood, no significant relationships were found between them. Thus, it was suggested that future studies may investigate discrete ED symptoms instead of global ED severity interacting with sleep and mood. Overall, this study represents an initial step in the investigation of EDs and sleep and mood dysregulation among an under-represented sample.

Orthorexia and Eating Attitudes in Health Sciences Students

ABSTRACT Background: The prevalence of eating disorders and orthorexia nervosa has steadily increased and this situation may lead to severe physical, psychological, and social disorders. Aim: The aim of this study was to investigate the prevalence of disordered eating attitudes and orthorexia tendencies among university students studying in various Health Sciences departments in Turkey. Subjects and Methods: The study subjects were selected from Health Sciences Faculty students. Among the students who accepted the study, 639 people were reached by simple random sampling method. The EAT-40 and ORTO-15 which are validated instruments for the screening of abnormal eating behaviors and orthorexia nervosa respectively, were used as measurement tools. Results: The majority of the students who participated in the study were found to exhibit orthorexic tendencies, and male students had a higher orthorexic tendency in comparison to female students (p = 0.022). More specifically, the students studying in the Department of Nutrition and Dietetics had lower orthorexic tendencies compared with the students from other departments. There was no significant relationship between BMI values and the mean ORTO-15 scores, whereas the mean EAT-40 score was found to increase statistically significantly with increased BMI (p = 0.038). There was a statistically significant difference between the departments and classes in terms of mean EAT-40 scores, whereas no difference was found regarding gender. Conclusion: Orthorexia nervosa is a common problem for university students studying in health-related departments. Interestingly, the orthorexic tendencies of girls and students studying in the Nutrition and Dietetics department were found to be lower in this study. It was determined that all students except the Nutrition and Dietetics department had orthorexia tendencies. More comprehensive studies are needed to better understand orthorexia nervosa and healthy lifestyle interaction.

Clinical сase of disorder of sex development with karyotype 47XYY

Disorder of sex development (DSD) is a term used to refer to congenital disorders that led to atypical structure of the genitals. The cause of DSD is a disorder of the embryonic development of the reproductive system due to chromosomal, genetic pathology or other adverse effects on pregnancy. DSD entails difficulties with social adaptation of the family, leads to severe psychological disorders in the child and his relatives. Sex of a child with DSD should be established only after a full examination and consultation of specialists in this field. A clinical case is presented to illustrate the complexity of differential diagnosis and choice of passport sex in a child with one of the rare forms of DSD.

Sevoflurane Preconditioning Alleviates Posttraumatic Stress Disorder—Induced Apoptosis in the Hippocampus via the EZH2-Regulated Akt/mTOR Axis and Improves Synaptic Plasticity

Posttraumatic stress disorder (PTSD) is a persistent and severe psychological and mental disorder resulting from experiences of serious trauma or stress and is suffered by many individuals. Previous studies have shown that pretreatment with sevoflurane is efficient in reducing the incidence of PTSD. However, we require a more comprehensive understanding of the specific mechanisms by which sevoflurane works. Enhancer of zeste homolog 2 (EZH2) has been reported to be regulated by sevoflurane, and to improve patient cognition. In this study, we aimed to explore the mechanisms of sevoflurane and the role of EZH2 in PTSD cases. We explored the effects of sevoflurane and EPZ-6438 (inhibitor of EZH2) on rat behavior, followed by an investigation of EZH2 mRNA and protein expression. The effects of sevoflurane and EZH2 on neuronal survival were assessed by western blotting and TUNEL staining, while western blotting was used to examine the expression of PSD95 and the AKT/mTOR proteins. Sevoflurane preconditioning restored EZH2 expression and significantly inhibited apoptosis by regulating phosphorylation of the AKT/mTOR pathway. Synaptic plasticity was also significantly improved. These results suggest that pretreatment with sevoflurane could play an important role in PTSD prevention by regulating EZH2 expression.

Scalable interventions for refugees.

Refugees experience a greater rate of common mental disorders relative to most other populations, and there remains a need to address these needs. However, most refugees are hosted in low-and-middle-income countries, where there is a lack of resources and mental health providers who can deliver mainstream mental health services. This situation has led to the emergence of scalable mental health interventions that can deliver evidence-based programs to refugees in need. Many countries hosting refugees have implemented programs that train local lay providers in interventions that can be delivered at scale. This review provides a narrative overview of these scalable interventions and critiques the evidence for their efficacy. It is noted that there are limitations to currently available scalable interventions, and there is a need for greater attention to determining the longer-term benefits of interventions, addressing the mental health needs of refugees who do not respond to these interventions, assisting refugees with more severe psychological disorders, and understanding the specific mechanisms that underpin observed benefits of these interventions.

The GluA1-Related BDNF Pathway Is Involved in PTSD-Induced Cognitive Flexibility Deficit in Attentional Set-Shifting Tasks of Rats.

Background: Post-Traumatic Stress Disorder (PTSD) is a severe psychological disorder characterized by intrusive thoughts, heightened arousal, avoidance, and flashbacks. Cognitive flexibility dysfunction has been linked with the emergence of PTSD, including response inhibition deficits and impaired attentional switching, which results in difficulties for PTSD patients when disengaging attention from trauma-related stimuli. However, the molecular mechanisms of cognitive flexibility deficits remain unclear. Methods: The animals were exposed to a single prolonged stress and electric foot shock (SPS&S) procedure to induce PTSD-like features. Once the model was established, the changes in cognitive flexibility were assessed using an attentional set-shifting task (ASST) in order to investigate the effects of traumatic stress on cognitive flexibility. Additionally, the molecular alterations of certain proteins (AMPA Receptor 1 (GluA1), brain-derived neurotrophic factor (BDNF), and Postsynaptic density protein 95 (PSD95) in the medial prefrontal cortex (mPFC) were measured using Western blot and immunofluorescence. Results: The SPS&S model exhibited PTSD-like behaviors and induced reversal learning and set-shifting ability deficit in the ASST. These behavioral changes are accompanied by decreased GluA1, BDNF, and PSD95 protein expression in the mPFC. Further analysis showed a correlative relationship between the behavioral and molecular alterations. Conclusions: The SPS&S model induced cognitive flexibility deficits, and the potential underlying mechanism could be mediated by GluA1-related BDNF signaling in the mPFC.

Long-term complications after gastric bypass and sleeve gastrectomy: What information to give to patients and practitioners, and why?

Bariatric surgery is now recognized as the most effective treatment of morbid obesity, leading to durable weight loss and resolution of associated co-morbidities. Roux-en-Y gastric bypass and sleeve gastrectomy are the two most widely used operations today. However, potentially serious medical, surgical, and/or psychiatric complications can occur that raise questions regarding the benefits of this type of surgery. These complications can lead to surgical re-operations, iterative hospitalizations, severe nutritional deficiencies and psychological disorders. Indeed, death from suicide is said to be three times higher than in non-operated obese patients. These results are of concern, all the more because of the high prevalence of patients lost to follow-up (for various and multifactorial reasons) after bariatric surgery. However, better knowledge of post-surgical sequelae could improve the information provided to patients, the preoperative evaluation of the benefit/risk ratio, and, for patients undergoing surgery, the completeness and quality of follow-up as well as the detection and management of complications. The development of new strategies for postoperative follow-up such as telemedicine but also the mobilization of all the actors along the healthcare pathway can make inroads and warrant further study.