Open Access. Powered by Scholars. Published by Universities.®

Medicine and Health Sciences Commons

Open Access. Powered by Scholars. Published by Universities.®

Graduate Theses and Dissertations

Discipline
Institution
Keyword
Publication Year

Articles 1 - 30 of 1133

Full-Text Articles in Medicine and Health Sciences

Perceived Discrimination And Cardiovascular Outcomes In Blacks: A Secondary Data Analysis Of The Heart Score Study, Marilyn Aluoch Nov 2019

Perceived Discrimination And Cardiovascular Outcomes In Blacks: A Secondary Data Analysis Of The Heart Score Study, Marilyn Aluoch

Graduate Theses and Dissertations

Despite the consistent reduction in morbidity and mortality associated with cardiovascular disease (CVD) over the last four decades, CVD remains the leading cause of death globally. In the United States, Blacks are disproportionately affected by CVD compared to Whites. Blacks are also more likely to report incidence of perceived discrimination. Perceived discrimination has been linked to cardiovascular risk factors such as smoking, hypertension (HTN), hyperlipidemia, and obesity. However, the relationship between perceived discrimination and cardiovascular outcomes such as stroke, myocardial infarction, acute ischemic syndrome, coronary revascularization, and cardiac death remains unclear. The primary goal of this study was to examine ...


Introducing A Mobile Health Care Platform In An Underserved Rural Population: Reducing Assimilations Gaps On Adoption And Use Via Nudges, Joseph Hodges Nov 2019

Introducing A Mobile Health Care Platform In An Underserved Rural Population: Reducing Assimilations Gaps On Adoption And Use Via Nudges, Joseph Hodges

Graduate Theses and Dissertations

Rural communities are often overlooked when it comes to offering cutting edge consumer healthcare technologies. Mobile applications usually exclude populations in rural demographics due to the infrastructure requirements and available technology in the region. The population studied is a low income rural health plan in southwest Georgia. They are uniquely considered as they have the highest healthcare costs in the U.S. and are compared to healthcare costs among higher income populations like Vail, Colorado. Innovations, such as mobile healthcare applications, have the capacity to offset some of these costs, but even if adoption occurs, this does not guarantee use ...


Health-Promoting Behaviors And Subjective Well-Being Among High School Students, Nicholas David W. Smith Nov 2019

Health-Promoting Behaviors And Subjective Well-Being Among High School Students, Nicholas David W. Smith

Graduate Theses and Dissertations

In positive psychology, a greater emphasis is placed on the presence of indicators of both physical and mental health. This study examined the relationship between 12 health-promoting behaviors and subjective well-being (SWB; e.g., happiness) in a sample of 450 high school aged youth from five high schools in two states. Participants reported on their dietary habits, physical activity, abstinence from tobacco products, abstinence from alcohol, and sleep hygiene (i.e., 8 unique components) as well as a multidimensional assessment of SWB (i.e., life satisfaction, positive affect, and negative affect). It was hypothesized that increased engagement in each of ...


A Comparison Of Different Modeling Techniques To Establish Token Reinforcers In Classroom Settings, Spencer B. Gauert Nov 2019

A Comparison Of Different Modeling Techniques To Establish Token Reinforcers In Classroom Settings, Spencer B. Gauert

Graduate Theses and Dissertations

Prior research has supported the use of reinforcer-based methods in school settings. Video based modeling methods for establishing conditioned reinforcers without the need for explicit pairing with primary reinforcers can help to extend the use of these resources into new contexts. The use of video based conditioning has potential applications in school settings to increase academic skills without the use of more costly-to-implement reinforcer systems. However, conditioning of this kind might be restricted by the need to individually condition stimuli with different participants. The current study evaluated effects of video based conditioning on relative rate of sight word reading across ...


Epidemiological Analysis Of Malaria Decrease In El Salvador From 1955 Until 2017, Tatiana I. Gardellini Guevara Nov 2019

Epidemiological Analysis Of Malaria Decrease In El Salvador From 1955 Until 2017, Tatiana I. Gardellini Guevara

Graduate Theses and Dissertations

The disease of malaria is complex, with clinical presentation that ranges from severe and complicated to mild and uncomplicated or even to asymptomatic malaria. A recent effort made by several world organizations has shown important advances in the effort to control and eradicate malaria. Following the general ordinance established by the trans-border organizations, each country has tried to define, according to their local geopolitical scenario, individual ¨road maps¨ to succeed in reducing the morbidity and mortality caused by malaria. Moreover, it is now accepted universally that these road maps need to be revised and appropriated in order to correct actions ...


Isokinetic Sampling Efficiency Differences For Blunt Edge Vs Sharp Edge Sampling Probes, Cory A. Treloar Oct 2019

Isokinetic Sampling Efficiency Differences For Blunt Edge Vs Sharp Edge Sampling Probes, Cory A. Treloar

Graduate Theses and Dissertations

This project aims to determine if sampling efficiency differences are present between a sharp edge probe and a blunt edge probe during isokinetic sampling. To answer this question, isokinetic sampling was performed inside a wind tunnel. Sampling was performed with the sharp edge probe and compared to data previously obtained using the blunt edge probe. Two different particle sizes were used, 0.50 m and 2.00 m, at air velocities of 0.5 m/s, 1.0 m/s and 2.0 m/s in the wind tunnel. Results showed that there is a difference in sampling efficiency between ...


Autonomy, Suffering, And The Practice Of Medicine: A Relational Approach, Michael A. Stanfield Oct 2019

Autonomy, Suffering, And The Practice Of Medicine: A Relational Approach, Michael A. Stanfield

Graduate Theses and Dissertations

In this project, I argue that the conventional view of personal autonomy that is operational in contemporary American culture, bioethics and medical practice places undue emphasis on individualism and a limited range of personal qualities and attributes (such as self-sufficiency). Instead, I argue in favor of a relational approach to autonomy which recognizes that each person that exists has certain minimal connections or relations to others, and these connections/relations are identity-forming. Unfortunately, current medical practices have tended to overemphasize individuality and choice (consistent with the conventional view) while minimizing or excluding these relational aspects. As a result, informed consent ...


Associations Between Mental Health, Academic Success, And Perceived Stress Among High School Freshman In Accelerated Coursework, Andrew S. Jenkins Oct 2019

Associations Between Mental Health, Academic Success, And Perceived Stress Among High School Freshman In Accelerated Coursework, Andrew S. Jenkins

Graduate Theses and Dissertations

Youth in accelerated curricula programs are an understudied population in relation to groups who struggle academically. To date, few studies have been conducted examining relationships between psychopathology symptomology, life satisfaction, academic achievement, and perceived stress. To address this, the current study completed a secondary analysis of an archival dataset in order to expand upon previous research into the predictive relationships between mental health (psychopathology and life satisfaction; beginning of year) and students’ subsequent academic achievement and perceived stress (assessed mid-year). Furthermore, the current study investigated the predictive effects of mid-year academic achievement (course grades) and perceived stress on students’ subsequent ...


The Relationship Between Continuous Glucose Monitor (Cgm) Derived Metrics And Indices Of Glycemic Control, Ryan Bailey Oct 2019

The Relationship Between Continuous Glucose Monitor (Cgm) Derived Metrics And Indices Of Glycemic Control, Ryan Bailey

Graduate Theses and Dissertations

Introduction: Both hypoglycemia (low blood glucose) and hyperglycemia (high blood glucose) are common among individuals with type 1 diabetes and are associated with severe medical complications, therefore it is essential that health care providers are able to accurately measure glycemic control. Measures derived from continuous glucose monitoring (CGM) may provide more accurate measurements of glycemia than the commonly used HbA1c blood test.

Methods: Data from the Juvenile Diabetes Research Foundation (JDRF) clinical trial to assess the efficacy of continuous glucose monitoring was used to estimate the ability of CGM composite scores to predict time in range, time in hyperglycemia and ...


Hybrid Fusion Protein For Inhibition Of Multiple Proteases For Chronic Wound Healing, Graham L. Strauss Jul 2019

Hybrid Fusion Protein For Inhibition Of Multiple Proteases For Chronic Wound Healing, Graham L. Strauss

Graduate Theses and Dissertations

Many diseases display a multitude of relevant factors that contribute to the persistence of the disease and difficulty treating it. The multifactorial characteristics of some diseases lead to the requirement of combination of treatments in order to restore health. The latter may necessitate the mixing of treatments, medications, and therapeutics to first halt the disease, then assist the human body in returning itself to a state of normality. For example, chronic wounds exhibit this multifactor characteristic in which there exist many factors that lead to the body’s inability to properly heal in a timely manner. This presents a further ...


Mitigating Barriers To Chronic Disease Risk Factor Prevention And Management In Disadvantaged Communities, Krys M. Johnson Jul 2019

Mitigating Barriers To Chronic Disease Risk Factor Prevention And Management In Disadvantaged Communities, Krys M. Johnson

Graduate Theses and Dissertations

Background: The incidence and prevalence of chronic disease (CD) has increased in recent decades due to the advent of CD management and life-extending technologies. To address this burden on the population and healthcare system, evidence-based CD prevention programs have been developed to reduce the incidence and therefore the prevalence of these diseases. Despite the development and dissemination of effective interventions, African-Americans and Hispanics have disproportionately higher prevalence of CD and associated risk factors and disproportionately lower participation in CD prevention programs. Overweight/obesity and CDs may have intergenerational effects, with overweight adults being more likely to have overweight children who ...


Mapping Reward Values To Cues, Locations, And Objects: The Influence Of Reward Associations On Visual Attention, Constanza De Dios Jul 2019

Mapping Reward Values To Cues, Locations, And Objects: The Influence Of Reward Associations On Visual Attention, Constanza De Dios

Graduate Theses and Dissertations

Previous work has attempted to fit reward-driven attentional selection as being exogenous (stimulus-driven) or endogenous (goal-driven). However, recent work suggests that reward’s effects on attention depend on the type of stimulus feature that the motivational information is imparted during learning (incentive salience). If true, then reward should not be limited to solely impacting early perceptual or late categorization processes attention. The current study used event-related potentials (ERPs) to test the idea that reward’s effects on attention depend on the process that the reward information is embedded – early perceptual or late categorization. Results demonstrated reward-driven effects on perceptual representation ...


Widow Narratives On Film And In Memoirs: Exploring Formula Stories Of Grief And Loss Of Older Women After The Death Of A Spouse, Jennifer R. Bender Jul 2019

Widow Narratives On Film And In Memoirs: Exploring Formula Stories Of Grief And Loss Of Older Women After The Death Of A Spouse, Jennifer R. Bender

Graduate Theses and Dissertations

This dissertation analyzes narratives (written and mediated) about widows’ post-loss experiences—specifically the ways in which these women embody and adjust/adhere to their post-loss widow identities—and whether or not the canonical/formula stories about widows reflect current experiences of widowhood. I look at older widowed women—both those in well-read widow memoirs and also in media portrayals of widows on film. The canonical view of widows as not attractive, not useful, and not interesting needs to be reexamined in light of changing ideas about gender roles and increased longevity. Surely older women have experiences, desires, and goals that ...


The Left Behind Generation: Instructional Practices To Increase The Technological Literacy Of Older Adults, Daphne Pace Phillips Jul 2019

The Left Behind Generation: Instructional Practices To Increase The Technological Literacy Of Older Adults, Daphne Pace Phillips

Graduate Theses and Dissertations

This study sought to explore the utilization and perception of best practices by community-based technology training programs when instructing older adults to become technologically literate. The target population included adults age 55 years and older of the Baby Boomer generational cohort who ranged academically from possessing a high school diploma or General Education Diploma (GED) through a college degree and had enrolled in a local technology training program to improve their technological skill level with the goal of obtaining employment and/or to remain functionally independent. This study was conducted at three community technology training centers located in the southeast ...


Home-Based Cognitive Monitoring: The Role Of Personality And Predictors Of Adherence And Satisfaction, Nasreen A. Sadeq Jul 2019

Home-Based Cognitive Monitoring: The Role Of Personality And Predictors Of Adherence And Satisfaction, Nasreen A. Sadeq

Graduate Theses and Dissertations

Over the last several decades, a growing awareness of the benefits of regular screening for common health conditions, such as cancer and cardiovascular diseases, has paved the way for preventative screenings to become routine in medical settings. Given that cognitive impairment is frequently reported as the number one worry of older adults, home-based cognitive monitoring may be an innovative solution that allows middle aged and older adults to take an active role in monitoring an important aspect of their health. Although several home-based cognitive monitoring programs have been validated for use in clinical and home-based settings, the Cogstate Brief Battery ...


Supporting Persons With Dementia In Communicating Their Care Preferences, Vanessa L. Burshnic Jul 2019

Supporting Persons With Dementia In Communicating Their Care Preferences, Vanessa L. Burshnic

Graduate Theses and Dissertations

Person-centered care is important to the quality of life of nursing home residents with dementia. Preference assessments enable person-centered care by documenting residents’ preferred activities. Residents with severe dementia are less likely to have a role in preference assessment due to communication challenges associated with the disease. External supports (visual and text cues) are effective in improving the communication of residents with dementia, but these cues are often not used in practice. Standard assessment (verbal questioning) places greater demands on short-term memory and attention, which are known deficits in dementia.

Applying a within-subjects design, this study evaluated two conditions (standard ...


Script Training For Adults Who Stutter, Courtney M. Rankin Jun 2019

Script Training For Adults Who Stutter, Courtney M. Rankin

Graduate Theses and Dissertations

Treatment for adulthood stuttering traditionally focuses on some combination of stuttering management and fluency management and may also target emotional and cognitive reactions to stuttering. However, long-term gains are often limited, and there is a need for continued development of approaches for mitigating impacts of stuttering. We know of no evidence-based therapy approaches designed to target functional communication in adults who stutter (AWS), despite widespread interest in improving functional communication in members of this speaker group. Script training is an intervention approach designed to improve accuracy and automaticity in functional communication. Script training was originally designed for use with adults ...


The Relationship Between Hand And Wrist Musculoskeletal Disorders And Hand Activity And Posture, Warren M. Henry Jun 2019

The Relationship Between Hand And Wrist Musculoskeletal Disorders And Hand Activity And Posture, Warren M. Henry

Graduate Theses and Dissertations

Musculoskeletal disorders are common in many industries such as automotive, manufacturing and line assembly. Risk factors include high frequency or hand repetition, long duration of work activities with short rest periods, unsustainable postures which put strain on the body and muscles, and activities that require significant force to fulfill duties. The current ACGIH TLV for hand activity uses hand activity level (HAL) and normalized peak force (NPF) to assess an individual’s risk of developing an MSD. The purpose of this study is to propose the use of Posture as an alternative to NPF and couple it with HAL to ...


The Effect Of Narrative Language Intervention On The Language Skills Of Children With Hearing Loss, Stephanie M. Raymond Jun 2019

The Effect Of Narrative Language Intervention On The Language Skills Of Children With Hearing Loss, Stephanie M. Raymond

Graduate Theses and Dissertations

Children with hearing loss have limited auditory access to their native language and struggle to develop appropriate language skills. These children consistently demonstrate less complex oral language output, smaller vocabulary inventories, and delays in overall communicative proficiency. With the extensive implications hearing loss has on language development, a child with hearing loss requires immediate access to appropriate and effective intervention to address deficits and curb long-term language delays. However, there is a paucity of research investigating the effects of various language intervention programs with children with hearing loss. Much of the existing research focuses on the consequences of a selected ...


Evolutionary Dynamics Of Influenza Type B In The Presence Of Vaccination: An Ecological Study, Lindsey J. Fiedler Jun 2019

Evolutionary Dynamics Of Influenza Type B In The Presence Of Vaccination: An Ecological Study, Lindsey J. Fiedler

Graduate Theses and Dissertations

Understanding the evolutionary dynamics of influenza type B in human hosts is a public health concern as we strive to minimize the disease burden in seasonal epidemics. Vaccination is considered the best defense against contracting influenza, and everyone over the age of 6 months is advised to get vaccinated before each season. The effect that vaccine-acquired immunity has on the evolution of influenza B remains unclear. In the U.S., vaccine-uptake is irregular across the states, and the differing coverages present an opportunity to study how vaccination influences viral evolution. This thesis analyzes the evolutionary patterns of influenza B in ...


Using Predicted Heat Strain To Evaluate Sustainable Exposures, Samantha L. Thacker Jun 2019

Using Predicted Heat Strain To Evaluate Sustainable Exposures, Samantha L. Thacker

Graduate Theses and Dissertations

The most commonly used exposure assessment for heat stress is based on Wet Bulb Globe Temperature (WBGT), and the limits are based on empirical relationships that demonstrate a sustainable exposure. The ISO 7933 (2017) describes Predicted Heat Strain (PHS), which is a rational model for heat stress assessment that is used to assess time-limited exposures. Investigators have examined PHS validity under a variety of time-limited conditions. The purpose of this paper is to evaluate if PHS can predict sustainable exposures.

The data used for this study were from two previous heat stress studies using a progressive heat stress protocol. The ...


Neuro-Correlates Of Word Processing Among Four-And-Five-Year-Old Children From Homes Varying In Socio-Economic Status, Wendy Olsen Jun 2019

Neuro-Correlates Of Word Processing Among Four-And-Five-Year-Old Children From Homes Varying In Socio-Economic Status, Wendy Olsen

Graduate Theses and Dissertations

A large body of research relates families’ socioeconomic status (SES) to child language development (Hoff & Tian, 2005). Results from these studies indicate preschoolers from low SES backgrounds may have underdeveloped linguistic foundations required for future academic success (Sirin, 2005; Lacouri & Tissington, 2011). These differences have been said to create a 30 million word-gap between the language experiences of low and middle to high SES children by the age of 3 years. Thus, children who come from lower SES backgrounds often lack the vocabulary knowledge used in school and in textbooks (Hart & Risley, 1995). One index of SES is parental level of education, specifically maternal education (Hoff & Tien, 2005). The current study compared the language processes related to word knowledge of 17 preschoolers who live ...


Localization Of Five Target Proteins In Tachyzoites Of Toxoplasma Gondii, Abigail M. Kaiser May 2019

Localization Of Five Target Proteins In Tachyzoites Of Toxoplasma Gondii, Abigail M. Kaiser

Graduate Theses and Dissertations

Five target genes were selected in Toxoplasma gondii tachyzoites for localization studies. These five genes, detected through proteomics studies, included TgME49_227450, TgME49_223080, TgME49_262390, TgME49_230940, and TgME49_269620. Localization of these five target proteins is a first step to confirm their interaction with TgCrk2 and understand their function and role in TgCrk2 regulation of the tachyzoite cell cycle. Gene models for the targets were analyzed using ToxoDB and ApE analysis tools. Endogenous tagging constructs were created for each target. Transgenic parasites were created. Finally, localization analysis of the target proteins in tachyzoites was completed using immunofluorescent microscopy following. One protein was found ...


Contribution Of Retrotransposons To Breast Cancer Malignancy, Isaac D. Raplee Apr 2019

Contribution Of Retrotransposons To Breast Cancer Malignancy, Isaac D. Raplee

Graduate Theses and Dissertations

The components contributing to cancer progression, especially the transition from early to invasive are unknown. Consequently, the biological reasons are unclear as to why some patients diagnosed with atypia and ductal carcinoma in situ (DCIS) never progress into invasive breast cancer. The “one gene at a time” approach does not sufficiently predict progression. To elucidate the early stage progression to invasive ductal cancer, expression signature of transcripts and transposable elements in micropunched samples of formalin-fixed, paraffin embedded (FFPE) tissue was conducted. A bioinformatics pipeline to analyze poor quality, short reads (>36 nts) from RNA-Seq data was created to compare the ...


A Retrospective Study Of The Opioid Epidemic And Fentanyl Related Overdose Fatality Cases In A Florida West Coast Medical Examiner District Population, Anne Terese Powell Apr 2019

A Retrospective Study Of The Opioid Epidemic And Fentanyl Related Overdose Fatality Cases In A Florida West Coast Medical Examiner District Population, Anne Terese Powell

Graduate Theses and Dissertations

Opioids are scheduled by the propensity for misuse and abuse with a high rate of dependency and risk of fatal overdose. Opioids can be divided into different classes, including, natural, synthetic, and semi-synthetic. Opiates are naturally occurring and come directly from the opium poppy plant; whereas the semi synthetics opioids are chemical modifications of the poppy plant. Synthetic opioids attach to the opioid receptor but contain no part of the poppy plant. The increased variety and frequency in opioid prescriptions contributed to an opioid epidemic in the United States which is still on going.

According to the CDC, the opioid ...


Respiratory Infections And Risk For Development Of Narcolepsy: Analysis Of The Truven Health Marketscan Database (2008 To 2010) With Additional Assessment Of Incidence And Prevalence, Darren Scheer Mar 2019

Respiratory Infections And Risk For Development Of Narcolepsy: Analysis Of The Truven Health Marketscan Database (2008 To 2010) With Additional Assessment Of Incidence And Prevalence, Darren Scheer

Graduate Theses and Dissertations

Background and Significance: Narcolepsy is a chronic neurological disorder. These patients experience various psychiatric and physical comorbid diseases and mortality at an increased rate compared to the general population. Additionally, patients with narcolepsy experience approximately a doubling of various annual healthcare related facility visits, transactions, and costs comparatively. Narcolepsy with cataplexy is generally believed to be more prevalent than narcolepsy without cataplexy. However, incidence and prevalence estimates of narcolepsy (with or without cataplexy) vary widely with few large epidemiological studies conducted worldwide and none in the U.S evaluating these proportions in both children and adults utilizing a large health ...


Genomics And Transcriptomics Approaches To Understanding Drug Resistance Mechanisms In The Malaria Parasite Plasmodium Falciparum, Justin Allan Gibbons Mar 2019

Genomics And Transcriptomics Approaches To Understanding Drug Resistance Mechanisms In The Malaria Parasite Plasmodium Falciparum, Justin Allan Gibbons

Graduate Theses and Dissertations

The malaria parasite Plasmodium falciparum is responsible for about 500,000 deaths a year and is evolving resistance to the front-line treatment of artemisinin-based combination therapy. Resistance is currently confined to South East Asia, however millions of lives will be at risk if resistance spreads to Africa. Understanding the mechanism of resistance to artemisinins would aid containment strategies to prevent the spread of artemisinin resistance. There is also an urgent need to accelerate drug discovery since drug resistance has already been documented to all existing antimalarials. Here, I report on our efforts to understand the function of the gene k13 ...


Effects Of External Memory Aid Assessment And Treatment On Everyday Task Performance Of Individuals With Mild Neurocognitive Disorder, Alyssa M. Lanzi Mar 2019

Effects Of External Memory Aid Assessment And Treatment On Everyday Task Performance Of Individuals With Mild Neurocognitive Disorder, Alyssa M. Lanzi

Graduate Theses and Dissertations

Individuals with mild neurocognitive disorder complete many activities of daily living independently; however, they may require the use of compensatory strategies while performing everyday tasks. Compensatory strategies, such as external memory aids, incorporate a strengths-based approach to enhance the functional needs of individuals. Although external memory aids have a strong evidence-base, limited assessment tools and interventions are available to facilitate the development of individualized treatment plans that promote sustained strategy use. To better support the everyday needs of individuals with mild neurocognitive disorder and to inform clinicians who are developing interventions, the current dissertation includes four paper that examine a ...


Medical Decision Making Among Individuals With A Variant Of Uncertain Significance In A Hereditary Cancer Gene And Those With A Chek2 Pathogenic Variant, Deanna J. Almanza Mar 2019

Medical Decision Making Among Individuals With A Variant Of Uncertain Significance In A Hereditary Cancer Gene And Those With A Chek2 Pathogenic Variant, Deanna J. Almanza

Graduate Theses and Dissertations

Despite national guidelines, women with a BRCA VUS or CHEK2 pathogenic variant are choosing to have risk-reducing surgeries such as bilateral mastectomies which are not aligned with their level of cancer risk based on genetic test results alone. Semi-structured telephone interviews were conducted with 6 women with a BRCA VUS and 12 with a CHEK2 pathogenic variant exploring the factors influencing their decision-making process when considering medical management options. Patients from a cancer registry agreed to a recorded telephone interview. Coding was performed using the main constructs from the Ottawa Patient Decision Guide including: knowledge, uncertainty, values, and support. Iterative ...


Effects Of An Academic Enrichment Program On Elementary-Aged Students' Performance, Lauren E. Nieder Mar 2019

Effects Of An Academic Enrichment Program On Elementary-Aged Students' Performance, Lauren E. Nieder

Graduate Theses and Dissertations

The goal of this research was to develop a greater understanding of the effectiveness of enrichment programs outside of the school setting. This study was also intended to contribute to the broader understanding of the mechanism of student school-related stress, reported by parents, as it relates to student academic performance, specifically in a population which primarily consists of students and parents who are of Asian-Indian-American descent. With rising standards and intensifying pressure on students to be academically successful, it is necessary to examine the stress students experience due to their academics, as well as its effects on their academic performance ...