Rural Young Adults Research Articles

Do healthy people migrate more? A 21-year follow-up of a rural cohort in Bangladesh

Demographers have long suspected that health influences whether a person migrates―a “healthy migrant effect” ―but this has rarely been tested for a longer period with high-quality, longitudinal data. This study aimed to assess which measures of health are associated with subsequent migrations among young adults from a rural community in Bangladesh, adjusted for socio-demographic characteristics, and how long these associations persist. The 1996 Matlab Health and Socioeconomic Survey (MHSS) characterized health (by self-reported chronic, and acute morbidity symptoms in the past 12 months and one month, respectively, and self-rated health status) of adults within the Matlab Health and Demographic Surveillance System (HDSS) cohort. Analyses included 3756 (M = 1,496, F = 2260) adults aged 18–34 years (the age when migration peaks) to study the effect of health on migration. Cox Proportional Hazards models were estimated to describe associations between health status and subsequent out-migration in 1996–2017, controlling for age, sex, education, religious affiliation, and household asset quintiles. Discrete-time logistic models were estimated to assess the sustained effects of health status measures on out-migrations. Results reveal that self-reported chronic morbidity, neither acute morbidity nor self-rated health status, inhibited subsequent migration. More reported chronic morbidity symptoms were associated with a lower migration (hazard ratio, HR = 0.82, CI = 0.74–0.92 for one symptom and HR = 0.73, CI = 0.63–0.84 for ≥2 symptoms relative to no symptoms). The differences diminished but persisted over time. Socio-demographic variables inhibiting migration were female sex, older age, and lower-level education. In conclusion, healthy young rural adults were more likely to migrate than their counterparts with symptoms of chronic morbidity, and the effect of chronic morbidity on subsequent migrations waned but not eliminated over time.

Hope mediates the relationship between childhood adversity and academic resilience among Appalachian young adults.

The impact of adverse childhood experiences (ACEs) on health and academic outcomes is well-supported in the research since Felitti, et al.’s (1998) research. Less is known about the interactions of positive supports that promote academic resilience (AR) among rural young adults who have experienced ACEs. This cross-sectional, moderated mediation study explored the factors that predict AR among young adults in rural Appalachia. We established the negative relationship between ACEs and AR, and we tested the degree to which hope and perceived social support (PSS) interact to influence that relationship. The study revealed the mediating role of hope but did not support the proposed role of PSS in moderating the relationship between ACEs and hope. We discuss this finding in the context of other research and provide recommendations for K12 educational leaders and for future research.

Whole-of-Rural-Community Approach to Supporting Education and Career Pathway Choice

Rural communities and partnerships are critical in career education, promoting pathways into work and further education and training. Families, teachers, and employers all may influence young people and adults who are considering pathway choices. This research aimed to equip these ‘key influencers’ with the knowledge and confidence to have supportive pathway conversations with rural young people and adults. The focus was not on those needing help with education/career choices, but rather those who influence their decisions. We used a Community Based Participatory Research (CBPR) approach in three communities to address the question: How can a whole of community approach best equip key influencers to inform and support rural student post school pathways? Community working parties were established to work alongside researchers to select, trial and evaluate of whole community, place-based, coordinated career education interventions, which targeted communities’ individual geographic, demographic and employment context. Communities were resourced with a local pathway broker and small budget for interventions. Individual interventions and the overall project approach were evaluated. Findings suggest that rural community-researcher partnerships can be effective in equipping key influencers with confidence and knowledge to inform and support education/career pathway choices. Community partnerships can take account of community assets and allow for interventions that address community contexts. Partnerships should foster community ownership to deliver education/career pathway information interventions that are flexible, accessible, sustainable, place-based, and authentic. This paper sets out a model for partnerships that effectively equips key influencers in rural communities to support education/career pathway choices.

Recruitment of Young Adults: Lessons Learned From Research on Rural E-Cigarette Use and Cessation.

Electronic nicotine delivery system (ENDS) use continues to grow in rural areas of the United States. In particular, young adults (18-24 years) in rural areas are a hard-to-reach population in regard to understanding the growing ENDS use trend. The purpose of this article was to describe recruitment strategies that were used for a series of ENDS-relevant projects for young adults in rural areas, report recruitment yields from these strategies, and provide methodological considerations to aid researchers in improving recruitment. We used descriptive statistical methods to characterize recruitment yields (responses to screening vs initial invites, and number of individuals who fully met eligibility criteria vs responses to screening) from 2 ENDS studies that focused on 3 main recruitment strategies, including student directories, leadership offices (eg, Student Affairs), and regional tobacco control support networks (eg, Area Health Education Centers) for reaching young adults in rural communities. The recruitment yield rates varied and ranged from 2% to 14% depending on strategy with leadership offices resulting in the highest recruitment yield. Methodological considerations by strategy are described in detail. Results of this study can be used to inform tailored recruitment strategies to increase the representation of rural young adults in ENDS or other tobacco research.

Short video social media use and subjective wellbeing among young adults in rural China: The mediating roles of upward social comparison and online social capital

This paper aims to describe how videos affect human behavior, especially teenagers and other major human beings. Given the large number of young adults who use short video social media (e.g., TikTok, Douyin, and Kuaishou) in rural China, understanding how the use of such platforms affects their subjective wellbeing is crucial. This study examines the mediating roles of online social capital and upward social comparison in the relationships between short video social media use (intensity, active vs. passive use) and subjective wellbeing using data gathered from a web-based survey of 412 young adults living in rural China. Structural equation modeling demonstrated that active short video use is associated with a greater level of online social capital, which in turn is related positively to subjective wellbeing. Passive short video use is negatively associated with online social capital. Active short video use is also associated with a greater level of upward social comparison, whereas passive short video use is negatively associated with upward social comparison. Nevertheless, the relationship between upward social comparison and subjective wellbeing is not statistically significant. Use intensity was associated with neither online social capital nor upward social comparison. The findings extend the understanding of the psychologically powerful nature of short video social media platforms and their effects on subjective wellbeing among Chinese rural young adults.

The journey of staying: A transitional and mobility perspective on the staying rural preferences of rural young adults

AbstractThis article presents insight into rural young adults’ reflections on their past, present and future staying rural preferences (transitional perspective) and how they relate to their experiences and connections outside the rural home area (mobility perspective). Using a biographical approach, we conducted 12 semi‐structured interviews with young employed adults living with their parents or alone in two rural areas in the Netherlands and Northern Ireland. Their transitional perspectives, which were agent‐centred, revealed that staying rural preferences do not evolve as a uniform process, fluctuating instead between ‘messy’ periods of stability and instability, entailing multiple alternations between deliberate and ‘just‐happened’ periods. In line with the ‘new mobilities paradigm’, the participants’ mobility perspectives confirmed the relevance of past residential experiences and current non‐residential mobility for analysing staying preferences. The article concludes that staying rural is a complex, (unstable) evolving, spatially relational and (only partly) conscious process.

Pathways to Adulthood in Rural America: A Latent Profile and Latent Transition Analysis of Adult Social Roles.

The transition to adulthood is characterized by the assumption of adult social roles, which are well documented in the literature; however, rural young adults remain understudied, especially using nationally representative samples. Therefore, this study analyzed a rural subsample of young adults from Add Health (N = 2562, 63.8% white, 34.2% Black, 50% female) using latent profile and latent transition analyses. Latent profiles at the average ages of 21-22 and 28-29 were identified highlighting transitions in education, work, and family formation. Two profiles previously unidentified in the literature emerged, high school graduates living with parents and prolonged transitioners, characterized by living with parents and limited transitions in romantic relationships and parenthood. Rural young people most likely to be in these profiles were male, Black, and from disadvantaged backgrounds. High school graduates living with parents and prolonged transitioners also had high probabilities of living in a rural area late in the transition to adulthood. Female and Black rural young adults had the highest probabilities of transitioning from the high school graduates living with parents profile to the prolonged transitioners profile. These empirically established role transitions and pathways to adulthood in rural communities can help inform investments, policies, and future research to support rural young adults following varying pathways during the transition to adulthood.

Spatial–Temporal Patterns and Coupling Characteristics of Rural Elderly Care Institutions in China: Sustainable Human Settlements Perspective

With rapid urbanization, more and more rural young adults are moving into towns and cities on a large scale, while the elderly are largely left behind in rural areas. The number of elderly people living alone, disabled and handicapped in rural areas is increasing, adding to the already weak rural elderly problem and increasing the pressure on the governance of rural elderly risks. The sustainable development of elderly care institutions is an important element in tackling the rural elderly problem and a key aspect of managing the rural elderly problem. The article uses data on rural aged-care institutions in 276 Chinese cities from 2010–2016 to construct comprehensive evaluation indicators for the development of rural aged-care institutions, and uses a combination of hierarchical analysis, composite score method, Theil index and coupling coordination model to reveal the spatial and temporal patterns and coupling characteristics of the development of rural aged-care institutions. The study concludes that: (1) From the time series change, the comprehensive score of rural elderly institutions shows a “fluctuating” change process, and there are significant differences in the development of each secondary indicator. (2) In terms of spatial and temporal patterns, the overall scores of rural elderly institutions, hard environment scores, soft environment scores and service recipients scores show a clear “gradient” in the east, middle and west. (3) In terms of regional differences, the Theil index for rural elderly care institutions is from high to low: Hard environment > service recipients > soft environment > overall score. From the decomposed Theil index, the intra-group differences of rural aged-care institutions are much larger than the inter-group differences, and the intra-group differences of the Theil index of the four major regions generally show a narrowing trend, with the intra-group differences of the eastern region being higher than those of the western region, those of the western region being higher than those of the central region, and those of the central region being higher than those of the northeastern region. (4) In terms of coupling coordination, the coupling degrees of the four major regions all exceed the low-level coupling stage index and are in the antagonistic stage or the grinding stage, and the coupling degrees of the four major regions are, in descending order, central region > eastern region > northeastern region > western region. The coupling coordination degree of the four major regions from high to low is: Eastern region > central region > northeastern region > western region. Based on the empirical analysis, the article proposes a model path for the sustainable development of rural elderly institutions in three aspects: Coordinated development, coupled development and sustainable development, in view of the unbalanced regional development of rural elderly institutions and the low degree of coupling and coordination between the soft and hard environments.

Childhood Adversity and Risky Behaviors among Chinese Rural Young Adults: The Mediation Effect of Perceived Stress and Moderation Effect of Social Support.

Research has documented that adverse childhood experiences (ACEs) significantly impact young people’s risky behaviors. Yet, few studies have explored if individuals’ perceived stress mediates the association between ACEs and risky behaviors; also if social support moderates the pathways from ACEs to risky behaviors through perceived stress. This study aimed to assess the mediation effect of perceived stress and the moderation effect of social support in the study of ACEs and risky behaviors. This study sample includes 1091 Chinese rural young people. A web-based survey was used to assess demographic information, ACEs, perceived stress, social support, and seven types of risky behaviors. Multivariate regression models were run to test associations between ACEs and different risky behaviors while controlling for confounding variables. The mediation model (Model 4) and the moderated mediation model (Model 58) were also performed using the PROCESS macro. Multivariate regression results showed that, with increasing ACEs values, there was an increased likelihood of all risky behaviors. The moderated mediation analysis confirmed that perceived stress mediated the linkage between ACEs and risky behaviors. However, no significant moderating effect of social support was found. The study findings indicate that ACEs, risky behaviors, and perceived stress are significant public health problems among rural Chinese young people. Culturally appropriate prevention and intervention programs and services need to be implemented to address these issues and promote rural Chinese young people’s wellbeing and development.

The appreciation of rural areas and their contribution to young adults’ staying expectations

Decisions to live in a certain place or region are partly prompted by material and symbolic factors of that place or region. This paper focuses on the importance of these factors for rural young adults based on a household survey in three rural areas in the Netherlands, Northern Ireland and Germany. It examines how rural young adults appreciate material and symbolic factors, and to what extent they play a role in their expectations to stay in the area. The results show that the environmental characteristics of rural areas and senses of belonging to rural areas, and not so much the social network in those areas, are highly appreciated and important for expectations to stay. Symbolic factors are slightly more important than material factors, but this differs for specific geographical contexts. Furthermore, while a relatively low share felt part of their local community, a sense of community still played a major role in expecting to stay. Overall, this paper shows that some factors that play a role in staying expectations are already highly appreciated, whereas factors that show lower appreciations do not always play a role in staying expectations, and thus may be of less concern for policy makers.

Urban-Rural Comparison of the Association between Unsupportive Relationships, Perceived Stress, Authentic Self-Presentation, and Loneliness among Young Adults in Taiwan.

This study examined and compared how unsupportive relationships, perceived stress, and authentic self-presentation influence loneliness and what differences exist between these relationships across urban and rural young adults in Taiwan. In total, 356 young adults (188 urban and 168 rural) were investigated, and partial least squares structural equation modelling was used in this study. The results indicated that authentic self-presentation directly and negatively affects loneliness in the urban group, but only indirectly affects loneliness in the rural group through unsupportive relationships and perceived stress. Unsupportive relationships and perceived stress in both the urban and rural groups positively affect their loneliness. In addition, multiple group analysis revealed that significant differences only existed between the effects of authentic self-presentation on unsupportive relationships between urban and rural young adults.

Vaccine hesitancy and COVID-19 immunization among rural young adults

Rural young adults may be more averse to receiving a COVID-19 immunization than urban young adults. We aimed to assess differences in COVID-19 vaccine hesitancy for rural, compared with urban, young adults and characterize modifiable factors.This cross-sectional online survey collected demographic data, vaccination attitudes, and COVID-19 impacts from 2937 young adults, ages 18–26 years, across the western U.S. from October 2020 to April 2021. Rurality was determined by participants’ zip code and classified using the rural and urban continuum codes (RUCC). Multivariable logistic regression described adjusted (age, gender, race and ethnicity, being a current student, and month of survey) odds of self-reported intent to receive the COVID-19 vaccination by rurality. Mediation analysis was used to decompose total effects into average direct effects and average causal mediation (indirect) effects.Rural participants had 40% lower odds than urban participants of intending to receive the COVID-19 vaccine after adjustments (adjusted odds ratio, 0.62 [95% CI, 0.50–0.76]). The direct effect remained (P < 0.001), but was mediated by both education (8.3%, P < 0.001) and month in which the survey was taken (23.5%, P < 0.001). We observed a divergence after December 2020 in vaccination intent between rural and urban young adults that widened over time.Hesitancy to receive the COVID-19 vaccine was greater among rural, compared with urban young adults, and grew disproportionally after December 2020. Mediation by whether one was a current student or not suggests differences in sources of information for vaccination decision-making, and highlights areas for addressing vaccine hesitancy.

The Association between the Consumption of Sugar-Sweetened Beverages and Metabolic Syndrome Components in Young Rural Adults in South Africa

Background: Metabolic syndrome (MetS) is the key risk factor for cardiovascular disease (CVD) development. However, lifestyle habits including high consumption of sugar-sweetened beverages (SSBs) contribute to its onset. The current study was aimed at investigating the association between SSBs consumption and MetS components among young adults aged 22 to 30 years. Methods: This was a cross-sectional study where a total of 596 young adults (307 females and 287 males) participated. Blood pressure, biochemical assessment, and anthropometric measurements were taken following protocols. A validated 24 h recall questionnaire and food manuals were used to collect SSBs data. Binary logistic regression was applied to determine the association between SSBs consumption and MetS components. Results: In males, high SSBs consumption increased the risk of high fasting blood glucose (FBG) (p &lt; 0.05). In females, high and low SSBs consumption decreased the risk of reduced high-density lipoprotein cholesterol (HDL-C), whereas only high SSBs consumption was associated with decreased risk of high triglycerides (TG) (p &lt; 0.05). In conclusion, high TG, reduced HDL-C and high FBG was significantly associated with high consumption of SSBs. Longitudinal studies are recommended to further investigate the extent to which SSBs influences components of MetS.

Investigating the Adoption of Precautionary Behaviors Among Young Rural Adults in South Iran During COVID-19.

COVID-19 is an unprecedented challenge for public health worldwide. Reducing the incidence of the disease requires protective measures to prevent virus transmission. Understanding those factors influencing preventive behavior is the first step in preventing the spread of the disease. This study investigates factors affecting youth intention and preventive behaviors in the face of COVID-19 through the health belief model by using a cross-sectional survey collected through an online questionnaire. The sample comprises 304 rural youth in South Iran who were selected through a random sampling technique. The results reveal that perceived severity, perceived benefits, public health beliefs, perceived self-efficacy, and the cue to act positively and significantly affect preventive behaviors. The model explains 59% of variance changes in rural youth preventive behaviors during COVID-19. Cue to action is the strongest and self-efficacy was the weakest determinant of youth's preventive behavior. This study confirms that the HBM framework has appropriate predictive power and is an effective tool for investigating preventive behaviors during COVID-19. These results provide important policy implications for the development of policies that aim to avoid the further spread of COVID-19 between young citizens.

Glycemic outcomes among rural patients in the type 1 diabetes T1D Exchange registry, January 2016–March 2018: a cross-sectional cohort study

IntroductionDoes rural status influence glycemic outcomes among participants in the type 1 diabetes T1D Exchange clinic registry?Research design and methodsData from the T1D Exchange clinic registry between January 2016 and...

Emerging Adulthood in the Time of Pandemic: The COVID-19 Crisis in the Lives of Rural Young Adults in Finland

This article discusses changes introduced into the everyday life and lifecourse dispositions of young adults in two sparsely populated regions in Finland during the COVID-19 lockdown period of spring 2020. By the age of 20, many of them had already spent some years living independently during their school years. Due to the pandemic, many had to move back to their rural home regions. This article shows that the sudden advent of the pandemic as a global risk and the restriction measures that followed affected these young, emerging adults in many ways, even though there were no infections in their immediate environments. Special attention is paid to their relationships with their remote home regions, which suddenly gained new, positive meanings in comparison to the global and national COVID-19 hotspots. The analysis is based on interviews conducted with 30 young adults in May 2020 and pre-existing longitudinal data from the same participants.

Body Roundness Index, A Body Shape Index, Conicity Index, and Their Association with Nutritional Status and Cardiovascular Risk Factors in South African Rural Young Adults.

Background: The study aimed to investigate the association of Body Roundness Index (BRI), A Body Shape Index (ABSI), and Conicity Index with nutritional status and cardiovascular risk factors in South African rural young adults. Methods: The study included a total of 624 young adults aged 21–30 years from the Ellisras rural area. Anthropometric indices, blood pressure (BP), and biochemical measurements were measured. Results: BRI was significantly correlated with insulin (0.252 males, females 0.255), homeostatic model assessment (HOMA)-β (0.250 males, females 0.245), and TG (0.310 males, females 0.216). Conicity Index was significantly associated with pulse rate (PR) (β 0.099, 95% confidence interval (CI) 0.017, 0.143, p < 0.013; β 0.081, 95% CI 0.000 0.130, p < 0.048), insulin (β 0.149, 95% CI 0.286 0.908, p < 0.001; β 0.110, 95% CI 0.123 0.757, p < 0.007). Conicity Index is associated with insulin resistance (IR) (odds ratio (OR) 7.761, 95% CI 5.783 96.442, p < 0.001; OR 4.646, 95% CI 2.792 74.331, p < 0.007), underweight (OR 0.023, 95% CI 0.251 0.433, p < 0.001; OR 0.031, 95% CI 0.411 0.612, p < 0.001), and obesity (OR 1.058, 95% CI 271.5 4.119, p < 0.001; OR 1.271, 95% CI 0.672 1.099, p < 0.001). Conclusion: Conicity Index was positively associated with insulin resistance, hypertension and dyslipidaemia. Further investigation of these indices and their association with nutritional status and cardiovascular diseases (CVDs) could assist in efforts to prevent CVD in the rural South African population.

Material deprivation and rates of all-terrain vehicle- and snowmobile-related injuries in Ontario from 2003 to 2018: a population-based study

ObjectivesSocio-economic status (SES) is a well-established predictor of health outcomes; however, there is a dearth of evidence on the relationship between SES and off-road vehicle (ORV) injuries. In Ontario, all-terrain vehicles (ATVs) and snowmobiles present a serious risk for preventable injury. This study assessed the association between area-level material deprivation and the risk of ATV- and snowmobile-related injuries in Ontario, as well as the impact of sex and age.MethodsA population-based, repeat cross-sectional study was conducted using administrative data of ATV- and snowmobile-related emergency room visits from 2003 to 2018. Material deprivation was measured using the Ontario Marginalization Index, which assigned a score and quintile of deprivation to each dissemination area in Ontario. Age-standardized incidence rates and relative index of inequality values were calculated, stratified by quintile of deprivation, sex, age group, vehicle type, and health region.ResultsWe found a significant, positive relationship between ORV-related injuries and quintile of material deprivation (RII = 1.28, 95% CI: 1.01–1.63). Rates of ATV- and snowmobile-related injuries remained stable over time. Across all age groups, sex, and rural categories, we found an inverse u-shaped relationship between rates of injuries and quintile material deprivation. Males, individuals living in rural areas, and adolescents and young adults experienced the highest rates of injuries.ConclusionDespite the positive relationship between ORV-related injuries and quintiles of deprivation, the inverse u-shaped relationship suggests that this increased risk of injury is likely related to exposure to ORVs. These results contribute to an understanding of the prevalence of the injury problem at a local level in Ontario. Stable rates of injury over time suggest that current public health programs are not sufficient in reducing these injuries, and further research should determine which factors amenable to intervention are contributing to increased risk of injury.

The Relationship between Binge Drinking and Metabolic Syndrome Components amongst Young Adults Aged 21 to 31 Years: Ellisras Longitudinal Study.

Background: Evidence is lacking on the effects of binge alcohol consumption on metabolic syndrome in the rural South African population. The purpose of this study was to investigate the association between binge drinking and components of metabolic syndrome (MetS) amongst Ellisras rural young adults aged 21 to 31 years who are part of the Ellisras Longitudinal Study. Methods: Logistic regression analysis was applied to a total of 624 participants (306 males and 318 females) aged 21 to 31 years who took part in the Ellisras Longitudinal Study (ELS). The model was adjusted for covariates, including smoking, age, and gender. Binge alcohol consumption was assessed using a standardised questionnaire that was validated for the Ellisras rural community. A standardised method of determining the components MetS was used after fasting blood samples were collected from all the participants. Results: Binge drinking remained significantly associated with low levels of high-density lipoprotein cholesterol (HDL-C) (OR = 2.64, 95% CI = 1.23–5.65), after being adjusted for smoking, age, and gender. Other MetS components were not predicted. Instead, gender remained significantly associated with all MetS components, except triglycerides, at multivariate analysis. Age retained significance at multivariate analysis with waist girth (OR = 2.13, 95% CI = 1.37–3.34), triglycerides (OR = 2.30, 95% CI = 1.05–5.02), and the MetS composite (OR = 1.65, 95% CI = 1.12–2.41). Conclusion: Binge drinking was significantly associated with lower levels of HDL-C. Future studies should investigate the relationship between alcohol abuse and the components of incident MetS in this population.

1622-P: Glycemic Outcomes among Rural Patients in the Type 1 Diabetes Exchange Registry, January 2016 to March 2018

Rural Americans with type 1 diabetes face health disparities that can contribute to diabetes-related complications. This study sought to examine glycemic outcomes among rural participants in the Type 1 Diabetes (T1D) Exchange clinic registry between January 1, 2016 and March 31, 2018. Data were identified by rural status as defined by the Centers for Medicaid and Medicare, and stratified by age range, and eventually multivariate regression modeling was performed to isolate glycemic differences based on hemoglobin A1c (HbA1c) levels. A full multivariate regression model including all significant (p&amp;lt;0.05 via two-sided testing) differential factors was determined with an additional indicator for rural status. Finally, the multivariate model was reduced using backwards elimination stepwise procedures until only significant (p&amp;lt;0.05 via two-sided testing) factors were included. Mean HbA1c levels for all rural participants (n=1837) were significantly higher (mean 8.71% [SD 1.66%]) compared to the non-rural group (mean 8.48% [SD 1.63%]), p&amp;lt;0.001. Rural children under age 13 (n=224) had a significantly higher average HbA1c (8.65% [1.17%]) compared to the non-rural group (8.45% [1.19%]), p=0.022. Rural adolescents between ages 13-18 (n=609) had a significantly higher average HbA1c (9.39% [1.73%]) than the non-rural group (9.14% [1.69%]), p&amp;lt;0.001. Rural young adults between ages 18-26 had a higher average HbA1c (9.07% [1.77%]) than the non-rural group (8.88% [1.78%]), p=0.042. The average HbA1c among rural adults (n=589) over age 26 was not significantly different (7.72% [1.21%] than those of non-rural adults (7.76% [1.15%]), p=0.503. There is a clear pattern in glycemic outcome disparities even after adjustment for characteristic differences between rural and non-rural participants in the T1D Exchange, most strikingly among youth. The full extent of this disparity and the contributing factors need to be more thoroughly studied to provide effective solutions. Disclosure A.K. Gill: None. M.D. Gothard: None. K. Briggs Early: None.