Medicine and Health Sciences Commons^™

Relationships Of Academic Expectation Stress & Self-Efficacy, Efficacy For Self-Regulated Learning With Academic Performance During Covid Pandemic, Muath A Alammar, Dushad Ram, Hamad Ali Alwarthan, Fouad A. Alshubayshiri, Abdullah Mohammed Alobaidi

International Journal of Health and Allied Sciences

Background: Academic expectation stress & self-efficacy and efficacy for self-regulated learning may affect academic performance. The Covid pandemic has affected the physical and psychological well-being of all, including students. However, there is a paucity of studies examining these variables in college students in Saudi Arabia. Objectives: This study was conducted to explore the levels and relationships of academic expectation stress & self-efficacy, self-regulated learning, and its relationships with academic performance in college students of ---- University during the Covid pandemic. Material and Methods: A total of 302 students were recruited in this cross-sectional study. They were assessed with sociodemographic and …

Multilingualism And Memory: Investigating Possible Differences In The Abilities Of Monolingual And Multilingual College Students, Clara E. Barned

Honors Projects

This study investigated whether there is a difference in the memories of monolingual and multilingual undergraduate students using simple memorization tasks. There were 46 participants, 30 of which were monolingual (only knew one language) and 16 of which were multilingual (knew two or more languages). There was found to be no significant difference between the performance of the two groups, with the data generating a p-value of 0.557. This study further suggests related avenues of research and ways in which the study could be improved in the future.

Investigating The Income Academic Achievement Gap: An Exploration Of The Roles Of Mindfulness And Self-Concept Clarity In Low-Income College Students., Natalie Burke

Electronic Theses and Dissertations

The purpose of the current study was to examine whether linguistic patterns previously associated with trait mindfulness and self-concept clarity in low-income college students’ application essays are associated with academic performance and psychosocial variables. The aims of the study were as follows: 1) Explore relations between linguistic markers that have been previously associated with higher mindfulness/self-concept clarity and GPA and 2) Explore relations between linguistic markers that have been previously associated with higher mindfulness/self-concept clarity and anxiety/depression. Participants were 54 undergraduate students in the Cardinal Covenant program (a scholarship program for students from low-income families) who began college in the …

Hiv And Early Life Stress On Neuroimaging And Risky Behavior, Paola Garcia Egan

Dissertations

This study examined the interactive effects of early life stress (ELS) and HIV on brain morphometry, diffusion-basis-spectrum-imaging (DBSI), risky decision-making, and sex-risk behavior. 122 people with HIV (PWH) and 113 people without HIV (PWoH), free of major psychiatric illness and neurological confounds, were stratified into high (≥ 3 events) vs. low (< 3 events) ELS [PWoH/low ELS (n = 57), PWoH/high ELS (n =56), PWH/low ELS (n = 43), PWH/high ELS (n = 79)] and underwent structural magnetic resonance imaging, DBSI, neuropsychological, and risky-behavior assessment; all PWH were virologically controlled. Compared to PWoH, PWH had smaller orbitofrontal cortex (OFC), parietal lobes, insula, caudate and anterior cingulate. No ELS effects were detected in volumetric measures. Significant interactions were found between HIV serostatus and ELS on the OFC and on cellularity of the inferior fronto-occipital fasciculus after multiple comparisons adjustment. Specifically, PWH/high ELS exhibited significantly smaller OFC and PWoH/high ELS show significantly larger OFC than the other groups. PWoH/high ELS exhibited higher DBSI cellularity (neuroinflammation proxy) of the inferior-occipital-fasciculus compared to PWoH/high ELS. Regardless of HIV status, executive function moderated the relationship between the OFC and sex-risk behavior such that individuals within the sample who performed above average on a measure of executive function and had a larger OFC reported fewer sex partners in past six months than individuals with smaller volumes. No interaction was found between HIV serostatus and ELS on risky behavior measures. Clustering analyses defined ELS subgroups in PWH that were determined by demographic characteristics, duration of infection, recent CD4+ T-cell count, nadir CD4+ T-cell count and high/low ELS.Even in PWH that are virologically controlled, without major current psychiatric comorbidities, there is evidence of a synergistic impact of ELS and HIV on OFC volumes. Higher volumes in the OFC were detrimental when associated with lower executive function scores or advantageous when associated with higher executive function. Findings suggest that ELS is associated with different brain signatures among PWoH and virally suppressed PWH. However, ELS was not directly associated with risky behaviors, and subgroups in PWH were characterized by demographic variables, past substance use and HIV clinical variables.

Educational Intervention To Increase Confidence And Knowledge Of Pediatric Nurses Caring For Pediatric Mental Health Patients, Alexa M. Wroblewski, Allyson Neal, Janie R. Holmes

Graduate Publications and Other Selected Works - Doctor of Nursing Practice (DNP)

Background: Given the rise in the mental health crisis, there is an increase of non-psychiatric nurses caring for pediatric mental health patients. This crisis leads nurses to experience feelings of doubt, hopelessness, stress, and insecurities in caring for this population. These feelings, combined with a lack of support and training, create a powerlessness loop of care. Local problem: In a Pediatric ICU, there is a lack of training and resources available to the nurses caring for pediatric mental health patients. Despite the lack of training, 35% of total admissions in 2020 were pediatric patients experiencing an acute mental health crisis. …

Early Life Exposure To Unpredictable Parental Sensory Signals Shapes Cognitive Development Across Three Species, Elyssia Poggi Davis, Kari Mccormack, Hina Arora, Desiree Sharpe, Annabel K. Short, Jocelyne Bachevalier, Laura M. Glynn, Curt A. Sandman, Hal S. Stern, Mar Sanchez, Tallie Z. Baram

Psychology Faculty Articles and Research

Exposure to early life adversity has long term consequences on cognitive function. Most research has focused on understanding components of early life adversities that contribute to later risk, including poverty, trauma, maltreatment, and neglect. Whereas these factors, in the aggregate, explain a significant proportion of emotional and cognitive problems, there are serious gaps in our ability to identify potential mechanisms by which early life adversities might promote vulnerability or resilience. Here we discuss early life exposure to unpredictable signals from the caretaker as an understudied type of adversity that is amenable to prevention and intervention. We employ a translational approach …

Improving Patient Outcomes In Substance Use Disorder Through Behavioral Therapy In Depression Development And Impacts Of Social Determinants Of Health During And After Substance Use Treatment, Jerry Ryan Armstrong, Chyanne Napp

Doctoral Projects

Substance Use Disorder (SUD) is a growing problem in the United States (U.S.) and worldwide and relapse is a common occurrence among those facing SUD. Limited scholarly research has been published addressing evidence-based treatment improvement strategies. This study focused on improving SUD treatment through the incorporation of depression tracking from admission to and discharge from inpatient treatment, as well as the incorporation of social determinants of health education during treatment, with an evaluation of relapse rates 30-days after inpatient treatment discharge. Results indicated a significant improvement in depression scores from admission to discharge. Results also revealed improved knowledge regarding social …

The Social Determinants Of Ideal Cardiovascular Health: A Global Systematic Review, Farah Qureshi, Kelb Bousquet-Santos, Sakurako S. Okuzono, Elaine Tsao, Scott Delaney, Anne-Josie Guimond, Julia K. Boehm, Laura D. Kubzansky

Psychology Faculty Articles and Research

This systematic review synthesizes research published from January 2010-July 2022 on the social determinants of ideal cardiovascular health (CVH) carried out around the world and compares trends in high-income countries (HICs) to those in low- and middle-income countries (LMICs). 41 studies met inclusion criteria (n = 28 HICs, n = 13 LMICs). Most were from the United States (n = 22) and cross-sectional (n = 33), and nearly all evaluated associations among adults. Among studies conducted in LMICs, nearly all were from middle-income countries and only one was carried out in low-income country. Education (n = …

Prevalence And Outcomes Of The Use Of Telemedicine For Psychiatry Patients In The Outpatient Setting, Amberly Ray, Madison Dew, Udema Millsaps, Adeolu Funso Oladunjoye, Anna Fuchs, Danielle Hovington, Alexa Primavera, Aakash Padodara, Maria Yee, Eduardo Espiridion

Transformative Medicine (T-Med)

OBJECTIVE: With the recent surge in telepsychiatry utilization, it is important to study the effectiveness of this virtual modality. METHODS: To determine if telemedicine visits were effective in keeping psychiatric patients stable, a retrospective study was performed in an outpatient behavioral health setting using the OQ®45.2/Y-OQ® 30.2 assessment tool, which assesses patient reported outcomes across areas of functioning. To qualify for this study, patients needed at least two OQ scores with one being prior to the onset of telepsychiatry care and one being after returning to in-person care. RESULTS: 51.1% of adults (n=176) improved or remained the same, whereas 48.8% …

Introducing A Physical Therapist-Led Acceptance And Commitment Therapy Training For Pain: A Clinical Perspective, Joseph Tatta

Internet Journal of Allied Health Sciences and Practice

Purpose: Mounting evidence supports the use of cognitive and behavioral techniques as part of physical therapist practice. These methods are used within a physical therapist’s multimodal treatment approach for the management of pain and to facilitate health behavior change. There is a multitude of evidence-based cognitive behavioral techniques to choose from including newer approaches based on Acceptance and Commitment Therapy. Yet few studies have examined physical therapists’ perceptions to learning and implementing ACT into clinical practice. The purpose of this manuscript is to present a clinical perspective of physical therapists learning about and incorporating Acceptance and Commitment Therapy in clinical …

Transformative, Noetic, And Transpersonal Experiences During Personal Development Workshops, Helané Wahbeh, Cassandra Vieten, Garret Young, Agnes Cartry-Jacobsen, Dean Radin, Arnaud Delorme

International Journal of Transpersonal Studies Advance Publication Archive

The global personal development market was valued at $38.28 billion in 2019 and is expected to grow an additional 5% from 2020 to 2027. Many of these workshops promise to be transformational. This secondary analysis study examined transformative, transpersonal, and noetic aspects of personal development workshops. We found that 74% of post-survey records endorsed that participants experienced a moment of clarity or profound insight during their workshop. In addition, 66% endorsed that participants had experienced at least one noetic experience, and 84% endorsed at least one transpersonal experience. These analyses provide preliminary evidence for the transformational potential of personal development …

The Impossible Situation? Impasse As Psychotherapeutic Paralysis, Possibility, And Progress, Leo Cancelmo

Dissertations, Theses, and Capstone Projects

Psychotherapeutic impasse has long been understood in the clinical literature as treatment stagnation and even failure, both from one-person and two-person psychodynamic perspectives. However, there is a dearth of empirical research that delves deeper to understand this complex and rich phenomenon. Using semi-structured interviews with nine psychodynamic therapists speaking about individual adult patients, this study examined experiences of impasse to better understand treatments that become embroiled in a kind of paralysis. Qualitative analyses revealed dyads where patients were conceptualized as struggling chronically with negative feelings about themselves and others, and who experienced traumatic personal histories. Impasse in and of itself …

Macrodosing To Microdosing With Psychedelics: Clinical, Social, And Cultural Perspectives, Ayse Ceren Kaypak, Amir Raz

Psychology Faculty Articles and Research

To date, the clinical and scientific literature has best documented the effects of classical psychedelics, such as lysergic acid diethylamide (LSD), psilocybin, and dimethyltryptamine (DMT), in typical quantities most often associated with macrodosing. More recently, however, microdosing with psychedelics has emerged as a social trend and nascent therapeutic intervention. This variation in psychedelic practice refers to repeat, intermittent ingestion of less-than-macrodose amounts that do not cause the effects associated with full-blown “trips”. Microdosing paves the road to incorporating psychedelic drugs into a daily routine while maintaining, or even improving, cognitive and mental function. Unlike macrodosing with psychedelics, the influence of …

Explicit And Implicit Emotion Processing In The Cerebellum: A Meta‑Analysis And Systematic Review, Jordan E. Pierce, Marine Thomasson, Philippe Voruz, Garance Selosse, Julie Péron

Center for Brain, Biology, and Behavior: Faculty and Staff Publications

The cerebellum’s role in affective processing is increasingly recognized in the literature, but remains poorly understood, despite abundant clinical evidence for affective disruptions following cerebellar damage. To improve the characterization of emotion processing and investigate how attention allocation impacts this processing, we conducted a meta-analysis on task activation foci using GingerALE software. Eighty human neuroimaging studies of emotion including 2761 participants identified through Web of Science and ProQuest databases were analyzed collectively and then divided into two categories based on the focus of attention during the task: explicit or implicit emotion processing. The results examining the explicit emotion tasks identified …

The Effect Of Propionic Acid On The Habituation To Social And Non-Social Odour Cues In Adult Male Rats, Cashmeira-Dove P. Tyson

Electronic Thesis and Dissertation Repository

The enteric bacterial metabolite, propionic acid (PPA), elicits physiological and behavioural changes in rodents reminiscent of autism spectrum disorder (ASD). This includes abnormal sensory processing and social behaviour. ASD may contribute to social deficits through impaired habituation; therefore, the present study examined the effects of intraperitoneal PPA on the habituation to social and non-social odours. Adult male rats were injected daily with PPA or the vehicle control, and for 3 days, habituated to a conspecific odour or vanilla extract for 10 minutes. On day 4, rats were exposed to a novel conspecific odour or almond extract for 10 minutes to …

The Purple Heart And Suicidal Behaviors In Post-9/11 U.S. Army Combat Veterans With A Traumatic Brain Injury: A Mixed Methods Study, Jayna Moceri-Brooks

Electronic Theses and Dissertations

Military suicide rates remain high, despite years of targeted efforts to prevent suicide. Specifically, Army Combat Veterans who sustained a traumatic brain injury (TBI) while deployed in support of the Global War on Terrorism are at the highest risk for suicide. This dissertation highlights possible causes for suicidal behaviors within this unique group and provides specific military suicide prevention recommendations. The dissertation is organized into three publishable manuscripts: The first manuscript (Chapter 1) is a mixed-methods dissertation research proposal written according to the National Institute of Health proposal guidelines. The second manuscript (Chapter 2) is an integrative review of the …

Emergency Care For Youth Who Experience Suicidality And Identify As Lesbian Gay Bisexual Transgender Queer/Questioning (Lgbtq+): An Interpretive Phenomenology, Theresa Schultz

Electronic Theses and Dissertations

Purpose: Suicide is a leading cause of death in children; youth who identify as LGBTQ+ are at an exponentially higher risk of suicide. The purpose of this study was to explore the lived experiences of young adults who identify as LGBTQ+ and sought emergency care for suicidality when they were adolescents.

Methods: Heideggerian hermeneutics phenomenology is the research method used in this study. Youth, ages 18-25 years, who identify as LGBTQ+ and sought emergency treatment for suicidality when they were adolescents (13-17 years) were recruited to participate;fifteen youth enrolled. Individuals ranged in age from 20 to 25 years. Participants described …

Reducing The No-Show Rate At A Community Mental Health Organization., Philip E. Pippen

Doctor of Nursing Practice Papers

Relative to other outpatient healthcare specialties, appointment nonattendance (no-shows) is most prevalent in psychiatric settings. Upon meeting with a community-based mental health organization in Louisville, KY (LCMHO), referral no-shows for intake appointments were identified as a significant issue. LCMHO’s intake appointment no-show rate, estimated at 25 – 40%, exceeded nonattendance trends in the literature. The purpose of this evidence-based practice (EBP) project was to develop and implement a referral engagement reminder intervention for improving intake appointment attendance. A systematic approach guided by the Model for Improvement was applied to foster this evidence-supported practice change. The project’s findings included a 16% …

Evaluating The Student Training Equity Project: An Upstream Recruitment Approach To Diversifying Clinical Psychology Graduate Programs, Hannah L. Joseph, Mary Fernandes, Meghan Goyer, M. Alejandra Arce, Ciera Lewis, Claudia A. Delbasso, Suzann Lawry, Corey A. Walker, Omolade Amole, Mikael Sampson, Erin Tone

Georgia Educational Researcher

The U.S. psychology workforce is considerably less diverse than the population that it serves. While several recruitment and admission practices are effective for diversifying psychology training programs, upstream recruitment of underrepresented candidates is particularly promising. Aiming to diversify the clinical psychology graduate program applicant pool, the Student Training Equity Project (STEP) was developed to promote and evaluate upstream recruitment of undergraduate students of color interested in psychology graduate studies. This study used a mixed-method design to evaluate immediate outcomes for three STEP programmatic strategies. Survey results suggest that STEP networking events were associated with undergraduate research and mentorship opportunities. Findings …

Supporting Post-Secondary Implementation Of Recovery-Oriented Practice In A Stepped Care Model, Janis Campbell

The Dissertation in Practice at Western University

Student mental health has been a growing concern for higher education communities for many years. Campuses have been struggling to keep up with the increasing demand for services which has been complicated further by the COVID-19 pandemic. A Stepped Care model (SCM) developed at a Canadian university has been offering new ways of organizing mental health resources based on open access, student choice, and recovery principles. There are diverse definitions of recovery in the literature and are usually based on values such as empowerment, respect, and self-determination. SCMs have been shown to increase access to resources and reduce or eliminate …

Increasing Naloxone Co-Prescribing Among At-Risk Individuals: Evaluation Of A Quality Improvement Project In A Large Health System, Sarah Hemphill Ba, Kristen Silvia Md, Marc D. Kimball Md

Journal of Maine Medical Center

Background: Naloxone availability and early administration is key in preventing death following opioid overdose. The CDC advises that naloxone should be made available to all at-risk individuals. In 2017, providers at Maine Medical Center noted that only 6% of at-risk patients had naloxone prescriptions

Methods: Included in this study were all patients of MaineHealth, a health system comprising 9 hospitals and 30 primary care practices, serving approximately 1.1 million patients. Between 2017 and 2020, we implemented several system-wide quality improvement interventions to increase rates of naloxone co-prescribing among at-risk individuals. Risk factors included prescribed opioids ≥50 morphine milligram equivalents, concurrent …

Contribution Of Early-Life Unpredictability To Neuropsychiatric Symptom Patterns In Adulthood, Andrea D. Spadoni, Meghan Vinograd, Bruna Cuccurazzu, Katy Torres, Laura M. Glynn, Elysia P. Davis, Tallie Z. Baram, Dewleen G. Baker, Caroline M. Nievergelt, Victoria B. Risbrough

Psychology Faculty Articles and Research

Background

Recent studies in both human and experimental animals have identified fragmented and unpredictable parental and environmental signals as a novel source of early-life adversity. Early-life unpredictability may be a fundamental developmental factor that impacts brain development, including reward and emotional memory circuits, affecting the risk for psychopathology later in life. Here, we tested the hypothesis that self-reported early-life unpredictability is associated with psychiatric symptoms in adult clinical populations.

Methods

Using the newly validated Questionnaire of Unpredictability in Childhood, we assessed early-life unpredictability in 156 trauma-exposed adults, of which 65% sought treatment for mood, anxiety, and/or posttraumatic stress disorder (PTSD) …

A Survey Of The Mental Health Of Uk Olympic And Paralympic Sport Athletes., Sandra D. Leyland Dr, Alan Currie Prof, Elizabeth Board Dr, Amit D. Mistry Dr, Rod Jaques Dr, Craig Ranson Dr

Journal of Athlete Development and Experience

Abstract

This study examined the prevalence of psychological distress and well-being amongst elite athletes in the UK.

An online survey was emailed to 753 athletes within the English Institute of Sport. Response rate 52.3%. 371 participants (median age 25) completed measures of psychological distress and subjective well-being alongside demographics and sport-related variables.

High or very high psychological distress was reported by 23.7%. Poor subjective well-being was reported by 18.8%. Of those reporting psychological distress, 9% also reported good subjective well-being. The odds of psychological distress and poor well-being increased if the athlete was female (OR 2.03, distress; OR 2.00, poor …

Mothers’ Reflections On Cat Ownership For A Child With Autism Spectrum Disorder During Covid-19, Saskia Keville, Sophia De Vita, Amanda K. Ludlow

People and Animals: The International Journal of Research and Practice

Animal- assisted interventions are increasingly used as a complementary therapy in clinical practice to support people with autism spectrum disorder (ASD), with promising outcomes compared to traditional therapies. Less is understood about the therapeutic benefits of more accessible and affordable small pet ownership for families with a child with ASD, alongside the pets’ welfare living in these homes. This study explored the experiences of cat ownership for young people with ASD from the perspective of their mothers during a time of transition generated by COVID-19. Semi-structured interviews were conducted with six mothers and transcripts analyzed using reflexive thematic analysis. Three …

‘Mapping’ Moral Engagement In The Solution-Focused Approach Through Macintyre’S Model Of Practice, Brian K. Jennings

Journal of Solution Focused Practices

I attempt to answer Trish Walsh’s two questions about the ‘maps’ that might exist for moral engagement in the ‘helping’ professions and how these might relate to the Solution-Focused Approach (Walsh, 2010). I seek to do this by exploring the narrative of the emergence of the Solution Focused Approach from the perspective of Alasdair MacIntyre’s concept of a ‘practice’ (MacIntyre, 1985) with the aim of providing the basis for ‘map’ for moral engagement by Solution-Focused Practitioners. To this end I attempt to interpret the Solution Focused Approach as a MacIntyreian ‘practice’ in which virtues (as ‘human qualities’) emerge out of …

Through The Cracks: The Disposition Of Patients With Schizophrenia Spectrum Disorders In The Post-Asylum Era, Briana Tillman, Erin Smith, Alicia Cho, Colt Kennington, Alexandra Kreis

HCA Healthcare Journal of Medicine

This paper aims to explore current disposition options for patients with psychosis in light of shifts toward community care and changes in mental healthcare funding in the post-asylum era and to propose systemic-level improvements based upon local successes. It evaluates critiques of long-term psychiatric care programs, claims of transinstitutionalization to incarceration, shelters, and emergency rooms, and programs initiated to address deinstitutionalization. The authors conclude that while Assertive Community Treatment, Partial Hospitalization Programs, intermediate-level care, and housing interventions can improve outcomes for many persons with psychotic illness, a significant portion of these patients would still be best served in long-term psychiatric …

Psychological Well-Being In Childhood And Cardiometabolic Risk In Middle Adulthood: Findings From The 1958 British Birth Cohort, Julia K. Boehm, Farah Qureshi, Laura D. Kubzansky

Psychology Faculty Articles and Research

Childhood adversity is linked to poor cardiometabolic outcomes, but less is known about positive childhood factors. Using data from 4,007 members of the 1958 British Birth Cohort, we investigated whether children with greater psychological well-being had lower adulthood cardiometabolic risk. At age 11, participants wrote essays about their future. Two judges rated each essay for nine psychological well-being items (Finn’s r = .82–.91), which were combined into a standardized overall score (Cronbach’s α = .91). When participants reached age 45, nurses assessed their blood pressure, heart rate, lipids, glycosylated hemoglobin, fibrinogen, and C-reactive protein, which were standardized and summed for …

Individual Differences In The Criminogenic Effects Of Discrimination: An Exploration Of The Role Of Impulse Control And Callous-Unemotional Traits, Toni Walker

LSU Doctoral Dissertations

The association between perceived discrimination and engagement in criminal offending has been well studied, especially in samples of minority (predominantly Black, Hispanic, and Latinx) adolescents. Several theories have been developed (Social Schematic Theory) and adapted (General Strain Theory) in an attempt to explain how harmful, discriminatory experiences may have an effect on an individual’s behavior. There may be variability in how an individual responds to perceived discrimination, however, but the moderating role of personality characteristics has not been explored. Impulse control and callous-unemotional (CU) traits are both established predictors of offending and may also relate to the mechanisms that theories …

Utility Of The Motivation To Change Lifestyle And Health Behaviors For Dementia Risk Reduction Scale (Mclhb-Drr) Based On A North American Sample, Angelina E. Witbeck

Dissertations

As the population ages, the prevalence rates of dementia continue to increase. Without a cure or promising treatment for dementia, the best course of lowering the prevalence rates of dementia is through preventative measures. Through an electronic survey, the study utilized the MCLHB-DRR scale to determine whether (1) gender, age, educational background, and socioeconomic status will impact the motivational factors to change lifestyle and health behaviors to reduce the risk of developing dementia and (2) direct experiences with individuals that have a dementia diagnosis are likely to impact one's motivational factors to change lifestyle and health behaviors to reduce the …

The Life Story Analysis Of Those Suffering From Autoimmune Thyroiditis, Azalea Di Nardi

Dissertations

The purpose of this study was to understand the pervasive impacts of autoimmune thyroiditis, specifically Hashimoto’s and Graves’ disease. To accomplish this, the life story methodology was utilized to gather individual experiences from 11 participants diagnosed with Hashimoto’s or Graves’ disease. The participants completed a background and general health questionnaire and 45- to-100-minute virtual interview disclosing their journey from the onset of symptoms, through diagnosis, to their most recent state. Themes were compiled from the interviews, which allowed identification of the largest areas of impact, needs, and future implications for practitioners and providers. Major themes identified were decreased quality of …