Correction to COVID‐19: A systems perspective on opportunities for better health outcomes (Geographical Research, (2022), 60, 4, (637-650), 10.1111/1745-5871.12561)

In Morgan (2022), the following errors were published on page 642. In Figure 2 caption, "north west (8 councils), north (9 councils)”, should read as "north west (9 councils), north (8 councils).” The corrected figure caption is shown below: FIGURE 2 Tasmanian regional and local government boundaries for the north west (9 councils), north (8 councils), and south (12 councils). Adapted from: "Map of Tasmanian Local Government Areas by Region” by Tasmanian Department of Premier and Cabinet (2019, p. 4) and MapSVG (2021). The authors apologize for the errors and any inconvenience they may have caused. © 2023 Institute of Australian Geographers.

Growth, income and wealth accumulation in rich countries

This paper discusses estimates of the distribution of national income and wealth produced by the World Inequality Lab in its World Inequality Report 2022. The methodology combines all existing microeconomic data on incomes (surveys, tax data) with macroeconomic data (the system of national accounts). While growth has slowed in rich countries, private wealth accumulation has continued to accelerate and public wealth continued to decline in an era of rising asset prices. The importance of «pre-distributive» policies for income inequality, and «popular wealth» for wealth inequality is emphasised, as well as the differing effects of the financial and Covid crises. In an age of big data it is time for countries to reconcile sources to provide official distributional estimates consistent with macroeconomic growth. © 2023,Ekonomiaz. All Rights Reserved.

Longitudinal Relations Between Emotion Regulation and Internalizing Symptoms in Emerging Adults During the Covid-19 Pandemic

Background Maladaptive and adaptive emotion regulation are putative risk and protective factors for depression and anxiety, but most prior research does not differentiate within-person effects from between-person individual differences. The current study does so during the early part of the Covid-19 pandemic when internalizing symptoms were high. Methods A sample of emerging adult undergraduate students (N = 154) completed online questionnaires bi-weekly on depression, anxiety, and emotion regulation across eight weeks during the early days of the Covid-19 pandemic (April 2nd to June 27th, 2020). Results Depression demonstrated significantly positive between-person correlations with overall maladaptive emotion regulation, catastrophizing, and self-blame, and negative correlations with overall adaptive emotion regulation and reappraisal. Anxiety demonstrated significantly positive between-person correlations with overall maladaptive emotion regulation, rumination, and catastrophizing, and a negative correlation with reappraisal. After controlling for these between-person associations, however, there were generally no within-person associations between emotion regulation and internalizing symptoms. Conclusions Emotion regulation and internalizing symptoms might be temporally stable individual differences that cooccur with one another as opposed to having a more dynamic relation. Alternatively, these dynamic mechanisms might operate over much shorter or longer periods compared to the two-week time lag in the current study. Supplementary Information The online version contains supplementary material available at 10.1007/s10608-023-10366-9.

Staff experience of a new approach to family safeguarding in Oxfordshire Children's Social Care Services

This paper presents the findings from a qualitative study that sought to understand the experiences of frontline staff working in Oxfordshire County Council (OCC) Children's Social Care Services and their views on a new family safeguarding model (Family Solutions Plus). Focus group interviews were conducted with 20 frontline staff and managers in different teams across OCC Children's Social Care Services using video conferencing software. Thematic analysis identified three overarching themes: Preparation for the implementation of Family Solutions Plus, staff views on the implemented model, and challenges to its implementation. Staff voiced strong support for the new model, which places a much greater emphasis than previous practice on supporting the whole family, developing parenting skills and keeping children safe with their families. The challenges associated with the transition to a new model were considerable in the short term, partly due to the COVID-19 pandemic, but there was optimism that the new model could be sustained and stabilized over time. © 2023 The Authors. Child & Family Social Work published by John Wiley & Sons Ltd.

Longitudinal Relations Between Emotion Regulation and Internalizing Symptoms in Emerging Adults During the Covid-19 Pandemic.

Background: Maladaptive and adaptive emotion regulation are putative risk and protective factors for depression and anxiety, but most prior research does not differentiate within-person effects from between-person individual differences. The current study does so during the early part of the Covid-19 pandemic when internalizing symptoms were high. Methods: A sample of emerging adult undergraduate students (N = 154) completed online questionnaires bi-weekly on depression, anxiety, and emotion regulation across eight weeks during the early days of the Covid-19 pandemic (April 2nd to June 27th, 2020). Results: Depression demonstrated significantly positive between-person correlations with overall maladaptive emotion regulation, catastrophizing, and self-blame, and negative correlations with overall adaptive emotion regulation and reappraisal. Anxiety demonstrated significantly positive between-person correlations with overall maladaptive emotion regulation, rumination, and catastrophizing, and a negative correlation with reappraisal. After controlling for these between-person associations, however, there were generally no within-person associations between emotion regulation and internalizing symptoms. Conclusions: Emotion regulation and internalizing symptoms might be temporally stable individual differences that cooccur with one another as opposed to having a more dynamic relation. Alternatively, these dynamic mechanisms might operate over much shorter or longer periods compared to the two-week time lag in the current study. Supplementary Information: The online version contains supplementary material available at 10.1007/s10608-023-10366-9.

Prenatal exposure to opioids and neurodevelopment in infancy and childhood: A systematic review.

Aim: This systematic review aims to estimate the relationship between prenatal exposure to opioids and neurodevelopmental outcomes and examines potential sources of heterogeneity between the studies. Methods: We searched four databases through May 21st, 2022: PubMed, Embase, PsycInfo and the Web of Science according to a specified search strings. Study inclusion criteria include: (1) cohort and case-control peer-reviewed studies published in English; (2) studies comparing neurodevelopmental outcomes among children with prenatal opioid-exposure (prescribed or used non-medically) vs. an unexposed group. Studies investigating fetal alcohol syndrome or a different primary prenatal exposure other than opioids were excluded. Two main performed data extraction using "Covidence" systematic review platform. This systematic review was conducted in accordance with PRISMA guidelines. The Newcastle-Ottawa-Scale was used for quality assessment of the studies. Studies were synthesized based on the type of neurodevelopmental outcome and the instrument used to assess neurodevelopment. Results: Data were extracted from 79 studies. We found significant heterogeneity between studies due to their use of different instruments to explore cognitive skills, motor, and behavioral outcomes among children of different ages. The other sources of heterogeneity included: procedures to assess prenatal exposure to opioids; period of pregnancy in which exposure was assessed; type of opioids assessed (non-medical, medication used for opioid use dis-order, prescribed by health professional), types of co-exposure; source of selection of prenatally exposed study participants and comparison groups; and methods to address lack of comparability between exposed and unexposed groups. Cognitive and motor skills as well as behavior were generally negatively affected by prenatal opioid exposure, but the significant heterogeneity precluded a meta-analysis. Conclusion: We explored sources of heterogeneity in the studies assessing the association between prenatal exposure to opioids and neurodevelopmental outcomes. Sources of heterogeneity included different approaches to participant recruitment as well as exposure and outcome ascertainment methods. Nonetheless, overall negative trends were observed between prenatal opioid exposure and neuro-developmental outcomes.

Detailed analysis of in-hospital transmission of SARS-CoV-2 using whole genome sequencing.

BACKGROUND: Hospital transmission of SARS-CoV-2 has proved difficult to control, with healthcare-associated infections troublesome throughout. AIM: To understand factors contributing to hospital transmission of infections, which is necessary for containing spread. METHODS: An outbreak of 56 staff and patient cases of COVID-19 over a 31-day period in a tertiary referral unit is presented, with at least a further 29 cases identified outside of the unit and the hospital by whole genome sequencing (WGS). FINDINGS: Transmission is documented from staff to staff, staff to patients, and patients to staff, showing disruption of a tertiary referral service, despite implementation of nationally recommended control measures, superior ventilation, and use of personal protective equipment. There was extensive spread from the index case, despite this patient spending only 10 h bed bound on the ward in strict cubicle isolation and with an initial single target low level (CT = 32) polymerase chain reaction test. CONCLUSION: This investigation highlights how effectively and rapidly SARS-CoV-2 can spread in certain circumstances. It raises questions about infection control measures in place at the time and calls into question the premise that transmissibility can be reliably detected by using lower sensitivity rapid antigen lateral flow tests. We also highlight the value of early intervention in reducing impact as well as the value of WGS in understanding outbreaks.

Differences in depression, anxiety, and coping in emerging adults prior to versus during the COVID-19 pandemic

Anxiety and depression symptoms were documented at high levels during the COVID-19 pandemic, especially for emerging adults. However, most of the research thus far has lacked prepandemic longitudinal or well-matched comparison samples, and cannot determine the extent to which the pandemic increased internalizing symptoms in this population. Additionally, more research is necessary to understand which types of emotion regulation (ER) strategies were used in the pandemic, as these strategies are tightly linked to psychopathology risk and resilience. The current study tested for differences in depression and anxiety symptoms and ER strategy use in emerging adults between a typical prepandemic college semester, and the beginning of the pandemic in the U.S. (April 2020). Results showed higher depression and anxiety symptoms, as well as significant changes in ER strategies, during the pandemic compared to prepandemic levels in well-matched independent samples (N = 324) and a longitudinal sample (n = 54). Planning, positive reappraisal, and self-blame decreased, while catastrophizing and other-blame increased during the pandemic across samples. These findings demonstrate significant increases in internalizing symptoms for emerging adults during the COVID-19 pandemic and provide important insights on how this population coped with the pandemic. The study was limited by examining levels at the beginning of the pandemic and cannot determine if such levels were maintained or fluctuated across the pandemic. (PsycInfo Database Record (c) 2023 APA, all rights reserved) Impact Statement What is the significance of this article for the general public?-The present study demonstrates increases in depression and anxiety symptoms among emerging adults along with changes in emotion regulation strategy use during the COVID-19 pandemic. These findings highlight potential coping profiles to target in counseling and interventions to minimize the negative impacts of salient, life-altering stressors. (PsycInfo Database Record (c) 2023 APA, all rights reserved)

LIFE LESSONS: THE EXPERIENCES OF OLDER ADULTS LIVING IN PUERTO RICO DURING COVID-19

What life lessons emerge from a group of older Puerto Ricans concerning their experiences with COVID-19. We will review study participants' reports of how they spent their time during the pandemic, what they found most difficult to cope with, and life lessons they learned as a result. We will use Erickson's life course theory of psychosocial development to frame their responses to these questions, including the crises (and strengths) of generativity versus stagnation (care) and ego integrity versus despair (wisdom). We will report evidence of care and wisdom as core ego strengths resulting from their lived experience. We will also review how isolation, sense of community, and key mental and physical health factors seemed to influence how their responses suggest coping strengths. We will discuss our findings in the context of social and cultural norms of current cohorts of older Puerto Ricans, highlighting the salience of community and family relations. (150 words)

DOES LOSS OF A LOVED ONE TO COVID-19 MODERATE THE ASSOCIATION OF LONELINESS AND MENTAL HEALTH AMONG OLDER PUERTO RICANS?

Loneliness is a well-established risk factor for poor mental health. During COVID-19, loneliness and mental health have been exacerbated by widespread disease-related mortality, suggesting that loss of a loved one may influence this relationship. Using data from 187 older adults in Puerto Rico, we assessed the association between loneliness and mental health and the potential moderating role of loss. Moderated multivariable linear regression results indicated that loneliness was significantly, positively associated with mental health (B = 1.58, p < .001). Although loss due to COVID-19 was not significantly associated with mental health (p = .473), it did moderate the relationship between mental health and loneliness (B = −1.00, p = .048). The lack of significant association of loss and mental health contrasts with previous research on COVID-19 and warrants further investigation. Nevertheless, the statistically significant interaction suggests that grief should be considered when assessing individual and community support during the pandemic.

National core competencies and dynamic capabilities in times of crisis: Adaptive regulation of new entrants in advanced technology markets

The extent to which domestic industrial capabilities are essential in contributing to a Nations' prosperity and national well-being is the topic of long-standing debate. On the one hand, globalization and the outsourcing of production can lead to greater productivity, lower product costs, and gains from trade. On the other hand, national capabilities have long been a source of competitiveness and security during times of war and other crises. We explore the importance of domestic industrial capabilities during crises through a comparative case study of two countries - Spain and Portugal - to the sudden spike in demand for the manufacture of mechanical ventilators brought on by the COVID-19 pandemic. Both countries had to work within the framework of EU regulations, but had very different internal competencies upon which to draw in doing so. In addition, mechanical ventilators serve as a particularly interesting context for study because they involve high risk (loss of patients' lives if incorrectly manufactured) and entering the market presents high entry barriers (including significant tacit knowledge in its production and use, and significant intellectual property embedded in proprietary software at large, established firms). To unpack the processes used by each country we leverage insights from 60 semi-structured interviews across experts from industry, healthcare workers, regulators, non-profit organizations, and research centers. We find that Spanish regulatory measures were more effective, resulting in 12 times more new products receiving regulatory approval to enter the market. Although neither country is known for their mechanical ventilator production, instrumental in informing the Spanish regulatory and industrial responses was their internal knowledge base due to domestic experts and existing capabilities in ventilator production. We conclude by proposing new theory for how nations might identify important core competencies to enhance their dynamic (regulatory) capabilities in areas likely to be critical to their social welfare.

Getting to the Heart of In-hospital Transmission of SARS-CoV-2 with the Help of Whole Genome Sequencing

We present an outbreak of 56 staff and patient cases of COVID-19 over a 31 day period in a tertiary referral unit, with at least a further 29 cases identified outside of the unit and the hospital by whole genome sequencing (WGS). We document transmission from staff-to-staff, staff-to-patients and patients-to-staff and show disruption of a tertiary referral service, despite implementation of nationally recommended control measures, superior ventilation and use of PPE. We demonstrate extensive spread from the index case, despite them spending only 10 hours bed bound on the ward in strict cubicle isolation and with an initial single target low level (CT=32) PCR test. This investigation highlights critical issues including how effectively and explosively SARS-CoV-2 can spread in certain circumstances. It raises questions about infection control measures in place at the time and calls into question the premise that transmissibility can be reliably detected using lower sensitivity rapid antigen lateral flow tests. We also highlight the value of early intervention in reducing impact as well as the value of WGS in understanding outbreaks.

WAS COVID A “BLESSING IN DISGUISE?” MAY-THURNER SYNDROME COMPLICATES COVID

CASE: A 30-year-old previously healthy male presented with three weeks of progressively worsening pain, erythema, swelling in his left thigh, inability to bear weight and associated fatigue, fever, and dyspnea on exertion. Four weeks prior, he experienced 1 week of anosmia, fatigue, and “even worse” dyspnea on exertion with a resting heart rate in excess of 110 bpm and felt he most likely had had COVID. He self-treated for symptoms, rested, isolated and felt he had improved from COVID. The pain and swelling in the left leg increased over the prior three weeks and he sought care. On exam the left thigh was warm to touch, erythematous, and painful. Ultrasound imaging revealed left lower extremity deep venous thrombosis (DVT) extending from his upper thigh to lower leg. Abdominal/thoracic CT w/ contrast noted diffuse pulmonary emboli and May-Thurner Syndrome (MTS). Treatment was started with IV heparin followed by thrombolytic therapy with higher dose heparin and alteplase for 3 days. Shortly after this therapy was initiated, he developed significant hypoxia and was transferred to the ICU. He was stabilized and on the final day of thrombolytic therapy, a left common iliac vein stent was placed and he was discharged two days later on Apixaban and aspirin. IMPACT/DISCUSSION: May-Thurner syndrome (MTS), is an anatomical variant that may lead to venous outflow obstruction due to extrinsic compression by the iliac arterial system against bony structures in the iliocaval venous territory. Most common in the left leg, MTS is present in about 20% of the population and is more commonly found in women. It can result in venous hypertension and venous thromboembolisms (VTE). In serious and untreated cases, these VTEs can progress to pulmonary embolisms with resultant serious injury, hospitalization, and death. In this case, a recent COVID infection unearthed an MTS anomaly. The activated proinflammatory state induced by COVID is known to result in blood clots in hospitalized patients and appears to be related to a cytokine storm. This inflammatory state induces endothelial damage, microvascular thrombosis, and possibly pro-thrombotic antiphospholipid antibodies. In hospitalized patients with more severe disease VTE is commonly diagnosed, however the risk of COVID related coagulopathy in the outpatient setting is unknown. It appears that when blood clots do develop in outpatients, 1/5 have had a recent COVID infection which indicates an association between inflammation from infection contributes to VTE. In this case, the COVID complication helped to uncover a May-Thurner anomaly. CONCLUSION: - Delayed presentation can exacerbate COVID-related complications, even after acute symptoms have diminished - more should be done to educate patients on the dangers of post COVID thromboembolic disease. - Despite its prevalence in females, May-Thurners Syndrome should be in the differential for males with DVT.

Psychological Considerations in the Intersection of Infectious Disease with Critical Care Medicine

This chapter discusses the intersection between infectious disease and critical care and how it has impacted the delivery of critical care medicine as well as the ability to provide rehabilitation and psychological intervention. It also considers the psychological implications for critical care staff, relationships at work and team dynamics, and the requirements for staff support. Specific issues encountered during worldwide pandemics are also reviewed, along with implications for future practice. The family of coronavirus illnesses are highlighted, including Middle East respiratory syndrome, severe acute respiratory syndrome, and coronavirus, which causes coronavirus disease (COVID-19). Similarities and differences between practices in the United Kingdom and United States are also discussed. © Oxford University Press 2022. All rights reserved.

Coping with COVID Stress: Maladaptive and Adaptive Response Styles Predicting College Student Internalizing Symptom Dimensions.

The COVID-19 pandemic significantly disrupted daily life for undergraduates and introduced new stressors (e.g., campus closures). How individuals respond to stressors can interact with stress to increase disorder risk in both unique and transdiagnostic ways. The current study examined how maladaptive and adaptive stress response styles moderated the perceived severity of COVID-related stressors effect on general and specific internalizing dimensions at the beginning of the COVID-19 pandemic in a combined undergraduate sample across two universities (N = 451) using latent bifactor modeling and LASSO modeling to identify optimal predictors. Results showed that perceived stress severity and maladaptive response styles (not adaptive response styles or interactions between stress and response styles) were associated with both common and specific internalizing dimensions. Results suggest additive associations of stress severity and maladaptive coping with internalizing symptoms during the pandemic's beginning, and provide important insights for screening, prevention, and intervention during future public health crises. Supplementary Information: The online version contains supplementary material available at 10.1007/s10862-022-09975-7.

Nationwide Trends in COVID-19 Cases and SARS-CoV-2 RNA Wastewater Concentrations in the United States.

Wastewater-based epidemiology has emerged as a promising technology for population-level surveillance of COVID-19. In this study, we present results of a large nationwide SARS-CoV-2 wastewater monitoring system in the United States. We profile 55 locations with at least six months of sampling from April 2020 to May 2021. These locations represent more than 12 million individuals across 19 states. Samples were collected approximately weekly by wastewater treatment utilities as part of a regular wastewater surveillance service and analyzed for SARS-CoV-2 RNA concentrations. SARS-CoV-2 RNA concentrations were normalized to pepper mild mottle virus, an indicator of fecal matter in wastewater. We show that wastewater data reflect temporal and geographic trends in clinical COVID-19 cases and investigate the impact of normalization on correlations with case data within and across locations. We also provide key lessons learned from our broad-scale implementation of wastewater-based epidemiology, which can be used to inform wastewater-based epidemiology approaches for future emerging diseases. This work demonstrates that wastewater surveillance is a feasible approach for nationwide population-level monitoring of COVID-19 disease. With an evolving epidemic and effective vaccines against SARS-CoV-2, wastewater-based epidemiology can serve as a passive surveillance approach for detecting changing dynamics or resurgences of the virus.

How has the COVID-19 pandemic influenced patient-centred care? Analysis of a qualitative collective case study by high-performing practice teams

Background and objective The COVID-19 pandemic has significantly affected primary healthcare systems throughout the world. The aim of this article is to present the analysis of the perspectives and experiences of patientcentred care (PCC) during the pandemic by high-functioning general practice teams in Australia. Methods A qualitative descriptive approach and collective case study method was employed. Participants, who undertook a semi-structured interview, were representatives of high-functioning general practice teams. Reflective thematic analysis was applied to all interview data (meta-synthesis) using a constant comparison approach. Results Five clinic representatives were interviewed. Six themes developed, highlighting that despite the pandemic creating new challenges to delivering PCC, general practice teams maintained a focus on PCC. General practice teams adapted to deliver PCC through strategies not used prior to the pandemic. Discussion This study identified new approaches to PCC that can guide other general practices and progress the health system towards policy-based PCC objectives.

Patterns of disease on admission to children's wards and changes during a COVID-19 outbreak in KwaZulu-Natal Province, South Africa.

BACKGROUND: Major causes of under-5 child deaths in South Africa (SA) are well recognised, and child mortality rates are falling. The focus of child health is therefore shifting from survival to disease prevention and thriving, but local data on the non-fatal disease burden are limited. Furthermore, COVID-19 has affected children's health and wellbeing, both directly and indirectly. OBJECTIVES: To describe the pattern of disease on admission of children at different levels of care, and assess whether this has been affected by COVID-19. METHODS: Retrospective reviews of children's admission and discharge registers were conducted for all general hospitals in iLembe and uMgungundlovu districts in KwaZulu-Natal Province, SA, from January 2018 to September 2020. The Global Burden of Disease framework was adapted to create a data capture sheet with four broad diagnostic categories and 37 specific cause categories. Monthly admission numbers were recorded per cause category, and basic descriptive analysis was completed in Microsoft Excel. RESULTS: Overall, 36 288 admissions were recorded across 18 hospital wards, 32.0% at district, 49.8% at regional and 18.2% at tertiary level. Communicable diseases, perinatal conditions and nutritional deficiencies (CPNs) accounted for 37.4% of admissions, non-communicable diseases (NCDs) for 43.5% and injuries for 17.1%. The distribution of broad diagnostic categories varied across levels of care, with CPNs being more common at district level and NCDs more common at regional and tertiary levels. Unintentional injuries represented the most common cause category (16.6%), ahead of lower respiratory tract infections (16.1%), neurological conditions (13.6%) and diarrhoeal disease (8.4%). The start of the local COVID-19 outbreak coincided with a 43.1% decline in the mean number of monthly admissions. Admissions due to neonatal conditions and intentional injuries remained constant during the COVID-19 outbreak, while those due to other disease groups (particularly respiratory infections) declined. CONCLUSIONS: Our study confirms previous concerns around a high burden of childhood injuries in our context. Continued efforts are needed to prevent and treat traditional neonatal and childhood illnesses. Concurrently, the management of NCDs should be prioritised, and evidence-based strategies are sorely needed to address the high injury burden in SA.

The Crucial Role of Black, Latinx, and Indigenous Leadership in Harm Reduction and Addiction Treatment

In 2020, accelerated by the COVID-19 pandemic, Black Americans and Native Americans died of substance overdoses at higher rates than White Americans, and Latinx overdose deaths increased at record rates.1,2 These deaths were closely linked to inequalities in employment, housing conditions, targeted law enforcement, and disproportionate exposure to unregulated illicit drug supplies3-5-making overdose prevention an urgent racial justice issue. In keeping with Chandra Ford's application of critical race theory to public health,6 we illustrate the unique contributions of Black and Latinx practitioners who (1) center the perspectives of racialized groups to inform harm reduction and substance use disorders (SUD) treatment initiatives;(2) use personal, experiential knowledge to relate and build trust with service users;and (3) inform research and practice with their own lived experiences as part of racialized populations. The impact of family members' roles in providing community members with food (P. G-Z.);growing up in communities where heroin use was rampant and witnessing drug-related deaths unfold in 1970s Brownsville Brooklyn, New York (J. T.);and being influenced by the political awakening of the civil rights movement and the response to the war in Vietnam (J. T.) propelled us into harm reduction and grassroots organizing work. The experiences of working under majority White leadership of a public clinic serving a predominantly Black and Latinx population who resisted engaging community leaders to improve services and did not act on innovative proposals (A. J.) and difficulties implementing evidenced-based interventions in Mexico (P. G-Z.)-where there is much stigma surrounding HIV and substance use-are examples of inadequate institutional support.

Latinx Undergraduates' Navigation in the Context of COVID-19 and Racial Injustice

Six self-identified, first-generation, Latinx, undergraduates from West Coast public institutions were recruited via social media to participate in individual, semi-structured, qualitative interviews about their experiences with COVID-19 and racial injustice during the summer and fall of 2020. Interviews explored challenges and meaning-making around what was happening in participants' lives during the COVID-19 pandemic and how they experienced and made sense of those events. Interpretative phenomenological analysis was used to identify emergent themes that fell into two main categories: (a) Adversities and (b) Ways of Overcoming. Several subthemes also emerged and are discussed for each category, including various ways of facing adversity, such as reliance on family and friends. Results highlight the need for expanded resources for first-generation Latinx undergraduate students. Limitations and future directions, as well as implications for counseling psychology researchers, educators, and practitioners are discussed.