A Caring Program for Health Promotion among Women Who Have Experienced Trauma: A QuasiExperimental Pilot Study

Purpose@#Women are more vulnerable to post-traumatic stress (PTS) than men, causing several health problems. Nurses should understand and work with women who have experienced trauma and provide interventions to promote their physical, social, and mental health. @*Methods@#This quasi-experimental pilot study used a one-group pre-test/post-test design. Data were collected from 14 women recruited between December 2019 and May 2020 from a self-sufficiency support center in South Korea for sexually-exploited women who had experienced trauma. The program consisted of six one-on-one intervention sessions per week for six weeks. Each session averaged 60~120 minutes. Participants were assessed at pre-test, post-test, and one-month follow-up. Changes in outcome variables over time were analyzed using the Wilcoxon signed-rank and Friedman tests. @*Results@#The caring program for health promotion was divided into six sessions: understanding the self, sharing traumatic events and negative emotions, reframing the meaning of traumatic events, identifying thoughts and physical and emotional responses, developing health promotion activities, and maintaining a positive attitude during the process of change. As a result of the caring program, PTS (F = 36.33, p < .001), depression (F = 24.45, p < .001), health-promoting behaviors (F = 7.06, p = .004), and self-esteem (F = 19.74, p < .001) among the participants differed significantly at pre-test, post-test, and follow-up. @*Conclusion@#This study provides foundational information for the implementation of a theory-driven program by nurses in clinical and community settings to provide comprehensive care for women who have experienced trauma.

A Survey on the Perception of Psychiatric Hospital Nurses on Patient Safety / 정신간호학회지

Purpose@#The purpose of this study is to investigate the patient safety status and patient safety education contents and methods perceived by nurses working in psychiatric hospitals. @*Methods@#Data were collected using a semi-structured questionnaire for psychiatric hospital nurses who had worked for more than one year. A total of 157 questionnaires were filled and were used for analysis using descriptive statistics. Open-ended questions about the contents and methods of patient safety education were classified by each researcher and a reclassification was conducted by consensus through discussions. @*Results@#Overall, 142 nurses (90.4%) experienced patient safety accident during the previous 1 month. Among those who experienced a patient safety accident, profanity, violence, and aggression-related accident counted for the highest percentage (82.8%). The demand for education on workplace stress management and education on psychiatric medication were the highest. Required education methods included case-by-case education on patient safety accidents, regular and continuous education, and small-scale face-to-face education. @*Conclusion@#In the future, it is necessary to actively utilize the results of this study as basic data for in-depth research on the causes of patient safety accidents, accident prevention, and the workload of nursing personnel.

A Systematic Review of the Effect of Web-based Trauma-Education Programs for Mental-Health Professionals / 정신간호학회지

Purpose@#This study was conducted to review the web-based trauma-education programs for mental-health professionals reported in English and Korean. @*Methods@#A systematic literature search was conducted using the PubMed, CINALH, EMBASE, Cochrane Library, PsycINFO, Web of Science, RISS, KISS, NDSL, US National Library of Medicine, Clinical Research Information Service, and Virginia Henderson International Nursing Library. The database search identified 11,852 articles. The selection of articles involved a three-phase process, in which duplications were identified and, titles and abstracts of retrieved articles were determined according to inclusion criteria, followed by full-text reading of articles identified. Finally, a total of three studies were included in this review, which published in the United States in 2011, 2014, and 2019. One was a pilot randomized controlled trial and two were pre- and post- studies. Only one included nurses as participants. Selected studies were rated for quality assessment using the Risk of Bias tool of Cochrane’s collaboration. @*Results@#Although the specific content of the programs was unknown, they improved mental health professionals' knowledge level, performance confidence, satisfaction, and education-completion rate. @*Conclusion@#More well-designed studies are needed of the optimal content for web-based education programs in mediating trauma for a broad spectrum of mental-health professionals.

Relationships among Suicide Traumatic Experiences, Attitudes toward Suicide, Depression, Self-efficacy, and Social Support in General Adults / 정신간호학회지

Purpose@#The amis of this study were to examine the suicide traumatic experiences and attitudes toward suicide and examine their associations with depression, self-efficacy, and social support in general adults. @*Methods@#In this descriptive cross-sectional study, data were collected through a web-based survey (N=500). We analyzed 441 respondents considering missing data. A structured questionnaire included Attitude Toward Suicide (ATTS), experiences and characteristics related to suicide, depression, self-efficacy, and social support. The data were analyzed using descriptive statistics, one-way ANOVA with Scheffé tests, Fisher’s exact tests, and Pearson’s correlation coefficients with SPSS/WIN 23. @*Results@#Among study participants, 34.9% reported suicide traumatic experiences. When they had more acceptability’ and ‘understandability’ in the attitudes toward suicide, they were younger, more depressive, and at the lower level of self-efficacy. There were somewhat differences of associations of ‘understandability’ in the attitudes toward suicide with depression, suicide attempt, suicide thought, and experience counseling between the suicide trauma and non-trauma groups. There were positive correlations for ‘acceptability’, ‘understandability’, ‘tabooing’, and depression and negative correlations for ‘acceptability’, self-efficacy, and social support. @*Conclusion@#Our study findings suggest that educational programs need to improve nurse’s ability in suicide-related practices considering psychological factors and development of comprehensive nursing interventions.

Nurse Staffing and Health Outcomes of Psychiatric Inpatients: A Secondary Analysis of National Health Insurance Claims Data

Purpose@#The present study investigated the association between nurse staffing and health outcomes among psychiatric inpatients in Koreaby assessing National Health Insurance claims data. @*Methods@#The dataset included 70,136 patients aged 19 years who were inpatientsin psychiatric wards for at least two days in 2016 and treated for mental and behavioral disorders due to use of alcohol; schizophrenia,schizotypal and delusional disorders; and mood disorders across 453 hospitals. Nurse staffing levels were measured in three ways: registerednurse-to-inpatient ratio, registered nurse-to-adjusted inpatient ratio, and nursing staff-to-adjusted inpatient ratio. Patient outcomesincluded length of stay, readmission within 30 days, psychiatric emergency treatment, use of injected psycholeptics for chemical restraint,and hypnotics use. Relationships between nurse staffing levels and patient outcomes were analyzed considering both patient and systemcharacteristics using multilevel modeling. @*Results@#Multilevel analyses revealed that more inpatients per registered nurse, adjusted inpatientsper registered nurse, and adjusted inpatients per nursing staff were associated with longer lengths of stay as well as a higher risk of readmission.More adjusted inpatients per registered nurse and adjusted inpatients per nursing staff were also associated with increased hypnoticsuse but a lower risk of psychiatric emergency treatment. Nurse staffing levels were not significantly associated with the use of injectedpsycholeptics for chemical restraint. @*Conclusion@#Lower nurse staffing levels are associated with negative health outcomes of psychiatricinpatients. Policies for improving nurse staffing toward an optimal level should be enacted to facilitate better outcomes for psychiatricinpatients in Korea.

A Systematic Review of the Effect of Web-based Trauma-Education Programs for Mental-Health Professionals / 정신간호학회지

Purpose@#This study was conducted to review the web-based trauma-education programs for mental-health professionals reported in English and Korean. @*Methods@#A systematic literature search was conducted using the PubMed, CINALH, EMBASE, Cochrane Library, PsycINFO, Web of Science, RISS, KISS, NDSL, US National Library of Medicine, Clinical Research Information Service, and Virginia Henderson International Nursing Library. The database search identified 11,852 articles. The selection of articles involved a three-phase process, in which duplications were identified and, titles and abstracts of retrieved articles were determined according to inclusion criteria, followed by full-text reading of articles identified. Finally, a total of three studies were included in this review, which published in the United States in 2011, 2014, and 2019. One was a pilot randomized controlled trial and two were pre- and post- studies. Only one included nurses as participants. Selected studies were rated for quality assessment using the Risk of Bias tool of Cochrane’s collaboration. @*Results@#Although the specific content of the programs was unknown, they improved mental health professionals' knowledge level, performance confidence, satisfaction, and education-completion rate. @*Conclusion@#More well-designed studies are needed of the optimal content for web-based education programs in mediating trauma for a broad spectrum of mental-health professionals.

Validity and Reliability of the Attitudes Towards Suicide (ATTS) Scale for Korean Adults / 정신간호학회지

PURPOSE: The aims of this study was to verify the validity and reliability of the Attitudes Towards Suicide (ATTS) scale for Korean adults.METHODS: Participants were 441 adults in South Korea, who completed in a self-reported online survey of ATTS. A total of 37 items were used for conducting item analyses, exploratory factor analyses, and confirmatory factor analyses, as well as examining the internal consistency.RESULTS: Based on findings of item reduction and exploratory factor analyses, three factors were identified based on 16 items, such as ‘acceptability (7 items)‘, ‘understandability (5 items)‘, and ‘tabooing (4 items)‘. These factors accounted for 49.4% of the total variance of ATTS. Known-groups, item convergent, and item discriminant validity were confirmed; Fitness of the modified mode was acceptable (χ²=375.51, CFI=.84, TLI=.81, GFI=.90, AGFI=.87, RMSEA=.08). The Cronbach's α coefficient for the 16 items was .82.CONCLUSION: Three factors of the short version of ATTS may be useful to evaluate the suicidal attitudes of Korean adults effectively and accurately. Our study findings suggest that suicide attitude questionaries need to be constantly revised to consider socio-cultural environment.

An Integrative Review of Intervention for School-bullying Perpetrators / 정신간호학회지

PURPOSE: This study was intended to integrate the evidence of intervention for child and adolescent perpetrators of school violence through an integrative literature review. METHODS: Using combinations of the terms ‘bullying’, ‘school violence’, and ‘intervention’ as key words, the researchers searched eight electronic databases for relevant studies. Fifteen studies were selected through full-text screening of related research published in academic journals before June 2018. The framework was used to identify the selected studies' intervention patterns and classify the various intervention components. The extracted intervention components were grouped into potential themes to determine whether the researchers clearly showed the interventions in the studies. RESULTS: The intervention components of 15 selected studies were categorized into five themes: 1) Utilizing intervention techniques for voluntary participation, 2) Enhancing self-awareness, 3) Strategies to improve emotional intelligence, 4) Promoting interpersonal skills, and 5) Emphasis on responsibility through future vision experience. CONCLUSION: As a result of analyzing interventions for children and adolescent perpetrators of school violence, five components were derived. It is suggested that these components should be considered in the field, and intervention programs development and research using them are needed.

Relationships among Traumatic Experiences, Posttraumatic Stress Symptoms, and Mental Health-related Characteristics in Young Adults / 정신간호학회지

PURPOSE: The purpose of this study was to investigate the level of traumatic experiences, posttraumatic stress symptoms and mental health-related characteristics in young adults and identify relationships among the variables. METHODS: In this descriptive cross-sectional study, data were collected through a Web-based survey (N=568). Structured instruments included valid measures of traumatic experiences, posttraumatic stress symptoms, depression, somatization symptoms, insomnia, and alcohol use. Collected data were analyzed using descriptive statistics, t-tests, χ2 tests, ANOVA, and Pearson correlation coefficient with SPSS statistics 23. RESULTS: Among study participants, 76.8% reported traumatic experiences. The severity of trauma was associated with high levels of posttraumatic stress symptoms, depression, somatization symptoms, insomnia, and alcohol use. Women showed more severe posttraumatic stress and depressive symptoms than men. There were positive correlations for trauma experiences with posttraumatic stress symptoms, depression, somatization symptoms, and insomnia. CONCLUSION: Findings indicate the need to develop nursing intervention programs to relieve posttraumatic stress symptoms and improve mental health related characteristics targeting young adults, and to establish a national policy that addresses characteristics of trauma experienced in Korea.

Moral Sensitivity, Empathy and Perceived Ethical Climate of Psychiatric Nurses Working in the National Mental Hospitals / 정신간호학회지

PURPOSE: The purpose of this study was to identify the relationships between Moral Sensitivity, Empathy and Perceived Ethical Climate for nurses working in national mental hospitals and to provide basic data for the development of interventions that enhance Moral Sensitivity and help psychiatric hospital nurses in Ethical Decision-making. METHODS: This descriptive cross-sectional study was conducted with 182 psychiatric nurses working in the national mental hospitals. Data were collected through self-report questionnaires which included the Moral Sensitivity Questionnaire (MSQ), Interpersonal Reactivity Index (IRI), and Hospital Ethical Climate Survey (HECS). RESULTS: The mean score for MSQ was 5.19, for IRI, 2.49, and for HECS, 3.73. There was a significant positive correlation between moral sensitivity and empathy (r=.24, p=.001), between moral sensitivity and perceived ethical climate (r=.17, p= .025) and between empathy and perceived ethical climate (r=.17, p=.025). CONCLUSION: Findings indicate that moral sensitivity can be enhanced by improving empathy, a personal factor, and ethical climate, an organization factor. Further identification of the relationship between moral sensitivity and personal and organizational factors will be useful in the development of interventions to enhance moral sensitivity of nurses working in psychiatric wards.

Structural Equation Model for Caregiving Experience of Families Providing Care for Family Members with Mental Disorders

PURPOSE: This study was done to develop and test a structural model for caregiving experience including caregiving satisfaction and caregiving strain in families providing care for family members with a mental disorder. METHODS: The Stress-appraisal-coping model was used as the conceptual framework and the structural equation model to confirm the path that explains what and how variables affect caregiving experience in these families. In this hypothesis model, exogenous variables were optimism, severity of illness and uncertainty. The endogenous variables were self efficacy, social support, caregiving satisfaction and caregiving strain. Data were collected using structured questionnaires. RESULTS: Optimism and caregiving self-efficacy had significant direct and indirect effects on caregiving satisfaction. Optimism, severity of illness and uncertainty had significant direct and indirect effects on caregiving strain. The modified path model explained effects of optimism on caregiving self-efficacy with social support in the path structure as a mediator. Also, there were direct and indirect effects of optimism and uncertainty on caregiving satisfaction with social support and caregiving self-efficacy in the path structure as a mediators. CONCLUSION: Results suggest the need to improve caregiving self-efficacy of these families, establish support systems such as a mental health professional support programs for caregiving self-efficacy. Optimism, severity of illness and uncertainty perceived by families need to be considered in the development of support programs in order to increase their effectiveness.

Mediating Effect of Self-efficacy in the Relationship between Anger and Functional Health of Homeless Men

PURPOSE: The purpose of this study was to examine the mediation of self-efficacy in the relationship between anger and the functional health of homeless men in order to provide a basis for planning nursing interventions to improve the functional health of homeless persons. METHODS: The participants were 137 homeless men who lived in homeless shelters or visited one center serving free meals for homeless persons in Seoul. Data were collected using self-report questionnaires and analyzed with the SPSS-WIN 20.0 program. The instruments were the Functional Health Pattern Screening Assessment Tool (FHPAST), Self-efficacy Scale (SES), and State-trait Anger Expression Inventory-Korean version (STAXI-K). RESULTS: The mean score for functional health was 2.41. Overall self-efficacy was 70.82. state anger was 16.53, trait anger was 19.54, and anger expression was 25.31. There were signigicant correlations among the 3 variables, functional health, self-efficacy, and anger. Also, self-efficacy had a complete mediating effect in the relationship between anger and functional health. CONCLUSION: Based on the findings of this study, health management programs focusing on anger management and self-efficacy improvement are highly recommended to promote functional health in homeless persons.

Comparison between Users of Community Mental Health Services and Psychiatric Patients in Mental Health Related Facilities in Korea / 대한정신분열병학회지

OBJECTIVES: This study was conducted to compare the characteristics of psychiatric inpatients in mental health related facilities and community mental health services-utilizing patients by diverse factors in Korea. METHODS: Questionnaires were sent via mail to 140 standard mental health centers from October to December of 2008. 64 facilities responded and data of 461 mentally disabled who are registered at and utilize the services of these mental health centers were analyzed. T-test and cross-analysis were performed to determine the differences in the averages of the variables and the discrepancy in ratios, respectively. RESULTS: Differences between long-term psychiatric inpatients and community mental health services-utilizing patients were seen in characteristics such as gender, age, type of medical coverage, family support systems, diagnosis, age of onset, duration of hospitalization, community-dwelling period, and clinical symptoms and functions. It was significantly short in length of stay in facilities in users of community mental health services with comparison to institutionalized patients. CONCLUSION: The results of this study suggest that invigoration of community mental health services is an alternative that can help deter long-term hospitalization.

Military Stress, Stress Coping, and Mental Health Status among Soldiers who Need Intensive Care / 정신간호학회지

PURPOSE: The purpose of this study was to explore the level of military stress, stress coping, and mental health status and to identify the relationships among these variables in soldiers who need intensive care. METHODS: The participants were 113 perceived maladjusted soldiers who participated in Green-camp from one army base in Gyeong-gi Province. Data were collected using self-report questionnaires and analyzed with the SPSS-WIN 20.0 program. The instruments were the Military Stress Inventory, Ways of Coping Checklist, and Symptoms Checklist- 90-Revision (SCL-90-R). RESULTS: The level of stress was 3.6+/-0.70, overall stress coping was 1.1+/-0.41, and mental health status was 1.5+/-0.93. There were significant differences in stress, stress coping, and mental health status according religion, economic status of family, prospects for the future, persons with whom one could talk about troubles. The group with higher emotion focused coping had significantly higher scores on mental health status. There were significant positive correlations among major variables. Military stress was a significant predictor of mental health status (Adjusted R2 21.0%). CONCLUSION: Based on the findings of this study, stress management and intervention programs focusing on depression are highly recommended to manage maladaptive problems in soldiers.

Moral Distress, Moral Sensitivity and Ethical Climate of Nurses Working in Psychiatric Wards / 정신간호학회지

PURPOSE: The purpose of this study was to explore level of moral distress, moral sensitivity, and ethical climate of nurses working in psychiatric wards and identify factors that influence moral distress. Also this study was done to describe the content of moral distress. METHODS: Data were collected through self-report questionnaires and focus group interviews. A survey was conducted with 108 psychiatric nurses and 8 volunteers were interviewed. Instruments used in this study were the Moral Distress Scale for Psychiatric Nurses, Korean version of the Moral Sensitivity Questionnaire, and Ethical Climate Questionnaire. Data were analyzed using SPSS/WIN 20.0 program and content analysis. RESULTS: The mean score for moral distress was 3.74 and for moral sensitivity, 4.67. The significant factors influencing moral distress were clinical career in psychiatric wards, moral sensitivity, personal profit and friendship. As a result of content analysis, 3 domain of moral distress were found: moral distress situations, responses in moral distress situations, factors to overcome moral distress and resources that enable ethical nursing. CONCLUSION: The results suggest that in the development of interventions to decrease moral distress for nurses working in psychiatric wards, factors identified as influencing moral distress and content of moral distress should be considered.

Factors Affecting on Suicidal Ideation in Maladjusted Soldiers / 정신간호학회지

PURPOSE: The purpose of this study was to explore levels of depression, anxiety, suicidal ideation in maladjusted Korean soldiers and identify factors that influence suicidal ideation. METHODS: Instruments were the CES-D (Center for Epidemiologic Studies-Depression Scale), STAI (State Trait Anxiety Inventory), and SSI (Scale for Suicidal Ideation). The participants were 94 maladjusted soldiers from one army base in Gyeong-gi Province. Data were collected using self-report questionnaires, and analyzed with the SPSS/WIN 20.0 program. RESULTS: Mean scores were; for CES-D, 42.1+/-13.10, for STAI-I (state-anxiety) and STAI-II (trait-anxiety), 60.3+/-15.05 and 61.9+/-12.14 respectfully, and for SSI, 23.1+/-9.52. There were significant differences in suicidal ideation according the general characteristics of education, prospects for the future, and having someone to talk about troubles. Major variables showing significant correlations were prospects for the future, depression, trait anxiety, state anxiety, and suicidal ideation. Depression and prospect for future were significant predictors of suicidal ideation (Adjusted R2 65%). CONCLUSION: Based on the findings of this study, it is important to assess significant mental health problems at the clinical level and provide suicidal ideation prevention in maladjusted soldiers. Active input from experts such as nursing officers and intervention programs that focus on depression are needed.

Level and Correlation Factors of Uncertainty in Members of Families of a Patient with Mental Illness / 정신간호학회지

PURPOSE: The purpose of this study was to measure the level of uncertainty, credible authority, severity of illness and event familiarity in members of families where there is a patient with a mental illness and to examine the relationships among these variables. METHODS: Research data were collected from November 23 to December 7, 2010. Participants in the study were 96 family members who visited patients in a closed ward or out-patient department of one hospital in Goyang City. Self-report questionnaires were analyzed using the SPSS 18.0 Program. RESULTS: Mean scores were 79.8+/-11.23 for level of uncertainty in family members, 15.5+/-2.17 for credible authority, 13.3+/-2.02 for severity of illness, and 14.5+/-2.43 for event familiarity. Uncertainty in family members was significantly related to credible authority (r=-.52, p<.001), event familiarity (r=-.41, p<.001) and severity of illness (r=.22, p<.031). CONCLUSION: The results of the study indicate that credible authority, severity of the illness and event familiarity are major factors perceived uncertainty in members of families of these patients. This outcome suggests the need for a new trials in nursing interventions considering the effects of these variables.

Perceived Functional Health Patterns and Recovery in People with Schizophrenia Spectrum Disorders / 정신간호학회지

PURPOSE: The purpose of this study was to examine the relationship between perceived functional health patterns and recovery in people with schizophrenia spectrum disorders, to explore the magnitude of relationship between of these variables and influencing factors such as self-esteem, insight, therapeutic relationship, and social support. METHODS: Participants were 160 individuals from 16 Community Mental Health Centers in Gyeonggi Province. Data were collected from April 10 to June, 12, 2010. Analysis was done using descriptive data, Pearson's correlation coefficients, and canonical correlation coefficients with the SAS 9.1 program. RESULTS: The mean score for perceived functional health of participants was below the normal range and the mean for recovery was above the middle range. Functional health and recovery were positively correlated with all components. The magnitude of relationship between functional health pattern, recovery and influencing factors were high in order of self-esteem, social support, insight, and therapeutic relationship. CONCLUSION: Functional health is strongly associated with recovery and useful in promoting recovery. Development of recovery oriented training programs for professionals and interventions considering factors influencing recovery and functional health as identified in this study is recommended.

Communication abilities, Interpersonal Relationship, Anxiety, and Depression in Korean Soldiers / 정신간호학회지

PURPOSE: The purpose of this study was to explore status and level of communication ability, interpersonal relationships, anxiety, and depression in Korean soldiers and identify factors that influence depression. METHODS: A cross sectional study design was employed. The instruments were PCI (Primary Communication Inventory), RCS (Relationship Change Scale), STAI (State-Trait Anxiety Inventory), and CES-D (The Center for Epidemiologic Studies-Depression Scale). Data were collected from 961 soldiers from Gyeong-gi Province and analyzed using SPSS/WIN 17.0 program. RESULTS: The mean score for PCS, RCS were 87.0+/-11.43; and 98.8+/-14.17 respectfully and for STAI-I (state-anxiety), and STAI-II (trait-anxiety), 34.7+/-10.36; and 36.6+/-9.64 respectfully, and for CES-D, 11.2+/-7.0. Of the participants 22.2% were in the clinical group for depression. Major variables showing significant correlations were family intimacy, intimacy with friends or colleague, and inconvenience in not being able to use computer or internet. STAI-II, intimacy with friends or colleague, STAI-I accounted for 44.2double dagger of the variance in depression. CONCLUSION: The study results suggest that a systemic approach needed to relieve soldiers' anxiety and depression. Development of program for communication training, activities for leisure and interpersonal relationship during military life could contribute to lessening depression and anxiety in solder.

Analysis of Factors Influencing Risk-taking Behavior in Middle School Students / 정신간호학회지

PURPOSE: The purpose of this study was to explore the factors that influence risk-taking behavior in middle school students. METHODS: The participants in this study were 544 students from 4 middle schools in Seoul or Gyeonggi Province. From July 16, to September 9, 2008, data were collected using self-report questionnaires. Demographic, individual, socio-economic characteristics of risk-taking behavior were examined. Descriptive statistics, t-test, ANOVA, Pearson correlation coefficients, zero-inflated negative binomial regression as count model using SAS 9.1 and Stata 10.0 program were used for the analysis. RESULTS: The score for risk-taking behavior of the middle school students tended to be low with thrill-seeking behavior being the highest. Risk-taking behavior was higher for boys and for students not living with parents. Stress coping ability, family risk factors, family functioning, peer's risk-taking behavior, and harmful environment were correlated with risk-taking behavior. On zero-inflated negative binomial regression analysis, the factor significantly influencing risk-taking behavior were self-esteem and for increased risk-taking behavior, family functioning, and peer's risk-taking behavior. CONCLUSION: A risk-taking behavior approach that considers developmental needs is useful in understanding the behavior of early adolescents. Development of effective guidance and interventions considering factors influencing risk-taking behavior as identified in this study is recommended.