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2023

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Full-Text Articles in Social and Behavioral Sciences

Student Perceptions Of The Effectiveness Of Collegiate Recovery Programs And Collegiate Recovery Communities, Michael Anthony Herold Dec 2023

Student Perceptions Of The Effectiveness Of Collegiate Recovery Programs And Collegiate Recovery Communities, Michael Anthony Herold

Theses and Dissertations

Research on the objective effectiveness of Collegiate Recovery Programs and Collegiate Recovery Communities (CRPs / CRCs) has shown success in maintaining recovery and improving academic outcomes for college students in recovery, but research on the experiences of this population is starting to emerge. This study used a mixed-method design to investigate the perceptions of members of CRPs / CRCs regarding the impact of participation on their recovery from substance abuse and their overall quality of life. Thirty-one participants completed the Drug Avoidance Self-Efficacy Scale (DASES) and the Quality of Life Index – Generic Version iii (QLI). Paired samples t-tests were …


Does What Doesn’T Kill You Make You Stronger? Examining The Effects Of Resilience And Functional Outcomes On Post-Traumatic Growth In Adults With Acquired Disability, Dominique Renee Ghirardi M.S. Dec 2023

Does What Doesn’T Kill You Make You Stronger? Examining The Effects Of Resilience And Functional Outcomes On Post-Traumatic Growth In Adults With Acquired Disability, Dominique Renee Ghirardi M.S.

Theses and Dissertations

Disabilities acquired in adulthood are often unexpected and disruptive because a loss of functioning can affect one’s ability to maintain employment, pursue their interests, and participate in social activity without assistance or accommodation. This is especially true for those who experience a life-altering injury or develop a chronic health condition between the ages of 18 and 64, as they likely have not planned for the financial and social adjustments that life with a disability involves. However, factors such as post-traumatic growth can reveal the extent to which someone experiences personal growth and improvement in the wake of a traumatic and …


Social Media And Mental Health: The Public Health Impact And Future Policy Directives, Renae A. Merrill Dec 2023

Social Media And Mental Health: The Public Health Impact And Future Policy Directives, Renae A. Merrill

Graduate Theses and Dissertations

The relationship between social media use among young people and the increasing concerns of mental health problems in the U.S. and globally is on systemic agendas. Furthermore, research on social media use and mental health indicate reasons to suspect a causal relationship, but more work needs to be done. Therefore, this three-article dissertation seeks to explore (1) associations between social media use, personality, and depression; (2) associations between social media emotional support, anxiety, and personality; and (3) the relationship between social media use and mental health using Deborah Stone’s causal stories framework. Findings from this study provide an improved understanding …


A Case Study Of The Political Determinant Of Health On The Public Health Crisis Of Malaria In Nigeria, Bisola M. Olumegbon Dec 2023

A Case Study Of The Political Determinant Of Health On The Public Health Crisis Of Malaria In Nigeria, Bisola M. Olumegbon

Electronic Theses and Dissertations

Abstract

Globally, there were about 229 million cases of malaria in 2022. The sub-Saharan African region accounted for 92% of the reported cases and 94% of deaths. Nigeria had the highest number of malaria cases and deaths, representing 27% of global cases. This scholarly project was a case study guided by the political determinants of health. Triangulation of data using thematic analysis was used to identify the political determinants of malaria in Nigeria and to understand how the concept of interaction contributes to the persistence of the disease. The analysis involved a deductive and inductive approach based on the literature …


Exploration Of The Implementation Of An Integrated Electronic Laboratory Information Management System On Quality Diagnostics Service Indicators At A County Level Public Hospital In Western Kenya., Kelly Allen Nov 2023

Exploration Of The Implementation Of An Integrated Electronic Laboratory Information Management System On Quality Diagnostics Service Indicators At A County Level Public Hospital In Western Kenya., Kelly Allen

Capstone Collection

Underinvestment in pathology and laboratory capacity caused by low visibility in research and in prioritization by public health leaders results in limited effective healthcare coverage and an estimated 1.1 million premature deaths annually in Low-and-Middle-Income Countries. Kenya’s public health laboratories provide a median 41% of the Essential Diagnostic List to their patients and in Kisumu County, as much as 44.2% of the population has little to no access to essential diagnostics. The government of Kisumu implemented the county Health Laboratory Strategic Plan 2018-2022 to address this public health challenge. Little information exists on the effectiveness of these initiatives and the …


Crossing Schools, Language, And Migration Borders: The Experiences Of Latinx And Caribbean Emergent Multilingual Mothers In K-12 Public Schools, Michelle Angelo-Rocha Nov 2023

Crossing Schools, Language, And Migration Borders: The Experiences Of Latinx And Caribbean Emergent Multilingual Mothers In K-12 Public Schools, Michelle Angelo-Rocha

USF Tampa Graduate Theses and Dissertations

Anti-immigrant sentiment and "English-only" ideologies have a significant impact on educational policies, practices, and processes. This includes parental engagement, the quality of education and life opportunities offered to immigrant children, and families’ well-being. The purpose of this study was to examine how Latinx and Caribbean mothers in Florida with various immigration statuses (i.e., undocumented, asylum seekers, refugees, international students, and mixed-status) and often with limited financial resources attempt to steward their children through the U.S. educational system. The research question was: How did emergent multilingual immigrant mothers experience the K-12 education system in Florida? The sub-question was: How did schools …


Characterizing How Food Advertising And Genetic Obesity Risk Factors Affect Neural Reward Reactivity And Eating In The Absence Of Hunger In Children, Dabin Yeum Nov 2023

Characterizing How Food Advertising And Genetic Obesity Risk Factors Affect Neural Reward Reactivity And Eating In The Absence Of Hunger In Children, Dabin Yeum

Dartmouth College Ph.D Dissertations

The complex and multifactorial etiology of obesity involves the interaction of numerous risk factors. Assessing the gene-environment interaction of pediatric obesity can provide valuable insights for the characterization of key factors contributing to obesity and identification of potential points of intervention. The data used in this thesis comes from a single sample of young children recruited from the communities surrounding Dartmouth College. The primary objective of this thesis is to assess the impacts of complicated gene-environment interaction on pediatric obesity. First, we assessed the dynamic and static advertising of food cues to examine they lead to differential neural reward responsivity. …


Experiences Of Indigenous Women With Maternal Nutrition In Climate Change (Cold Weather) In Rural Bajaur, Khyber Pakhtunkhwa, Pakistan: Implications For Maternal-Infant Health, Ihsan Ullah Nov 2023

Experiences Of Indigenous Women With Maternal Nutrition In Climate Change (Cold Weather) In Rural Bajaur, Khyber Pakhtunkhwa, Pakistan: Implications For Maternal-Infant Health, Ihsan Ullah

Theses & Dissertations

Background: Pakistan is one of the countries that is most susceptible to the effects of climate change. The country’s Northern regions have experienced several extreme cold weather events, including floods, heavy snowfall, and heavy rains, in recent years, significantly impacting maternal and infant health. Indigenous child-bearing age women in the northern rural areas are the most vulnerable populations experiencing food insecurity, disruptive food systems, increasing food prices, and disrupting food production due to climate change exacerbation.
Aim of the study: The study aimed to explore the experiences of indigenous women with maternal nutrition in harsh winter caused by climate change …


Sun Protection Behaviors And Skin Cancer Risk Among Children Of Color, Williana Magloire Nov 2023

Sun Protection Behaviors And Skin Cancer Risk Among Children Of Color, Williana Magloire

Theses and Dissertations

Sun protection is beneficial for children of color as it decreases the risk for sunburns, hyperpigmentation, and most importantly, skin cancer. Invasive melanoma is commonly seen in children of color due to inadequate sun protection. Parental and caregiver modeling of sun protection behaviors may decrease the likelihood of skin cancer among children of color. The American Academy of Pediatrics (AAP, 2011) has suggested that pediatricians adopt the role of informing parents about the benefits of using sun protection products for their young children. They recommended that providers discuss sun protection behaviors with both the parent/child beginning at the age of …


The Relationship Between Parental Trauma History And Perceptions Regarding Their Child’S Healthcare And Utilization Of Healthcare Services, Krishna Patel Nov 2023

The Relationship Between Parental Trauma History And Perceptions Regarding Their Child’S Healthcare And Utilization Of Healthcare Services, Krishna Patel

Theses and Dissertations

Abstract

TITLE: The Relationship Between Parental Trauma History and Perceptions Regarding Their Child’s Healthcare and Utilization of Healthcare Services

Adverse child events (ACEs) have been associated with a number of physical and mental health problems and have also been linked to increased health care utilization. While parents who have an ACE history may tend to seek healthcare services for themselves, limited studies have examined the impact of their trauma history on seeking healthcare services for their child. Healthcare utilization may also depend on the parents’ level of health anxiety, as well as their anxiety about their child’s health status. This …


Clinically Applied Anthropology: A Syndemic Intervention., Jason W. Wilson Oct 2023

Clinically Applied Anthropology: A Syndemic Intervention., Jason W. Wilson

USF Tampa Graduate Theses and Dissertations

This dissertation demonstrates that a critical, clinically applied anthropology is possible by testing a hypothesis that a syndemic intervention, and use of a structural vulnerability assessment tool, can achieve improved healthcare outcomes. A critical, clinically applied anthropology integrates social scientists into healthcare delivery, alongside biomedical providers, through the co-creation of new diagnostic and patient care pathways that utilize anthropological methods (ethnographically informed care, syndemics, thematic/mixed methods data analysis) and advance anthropological theory (biomedicine and culture, structural violence, structural competency/vulnerability, ontology, assemblage theory, and entanglements) to decrease healthcare inequities.

Medical anthropology has previously engaged biomedicine and other attempts at a clinical …


Incremental Validity Of The Mmpi-A-Rf And Maci In A Clinical Outpatient Setting, Madison Smart-Mccarthy Oct 2023

Incremental Validity Of The Mmpi-A-Rf And Maci In A Clinical Outpatient Setting, Madison Smart-Mccarthy

Psychology Theses & Dissertations

With the persistent rise of depression and suicide in adolescents, it is imperative that clinicians select empirically supported measures that accurately assess these conditions (Van Orman, 2022; Sellbom & Suhr, 2020). One empirical method used to evaluate measures is incremental validity. Incremental validity examines the level of improvement in predicting a phenomenon when adding a test or procedure to a combination of other instruments (APA, 2020). Experts regard the Minnesota Multiphasic Personality Inventory—Adolescent Version—Restructured Form (MMPI-A-RF; Archer et al., 2016) and the Millon Adolescent Clinical Inventory (MACI; Millon et al., 1993) as psychometrically sound measures often used in clinical practice. …


Inviting The Outside In: Nature's Contribution To Counselor Wellness, Naomi Medina Oct 2023

Inviting The Outside In: Nature's Contribution To Counselor Wellness, Naomi Medina

Dissertations

The positive influence of nature on client wellness and psychological health (BonhamCorcoran et al., 2022) is well reflected in the emergence of nature-based counseling interventions such as wilderness therapy, walk talk therapy, and horticulture therapy, among other counseling modalities that involve aspects of the natural world (Lewis et al., 2022). This suggests that the inclusion of nature within the counseling session could also contribute to the wellness of the counselor. The purpose of this research was to determine the extent to which presence of nature contributes to counselor wellness and which of the five senses may play a greater role …


Seminarians In The Person-Of-The-Therapist (Pott) Training : A Phenomenological Study, Tomichan Moonnanappillil Oct 2023

Seminarians In The Person-Of-The-Therapist (Pott) Training : A Phenomenological Study, Tomichan Moonnanappillil

Dissertations

This dissertation presented a transcendental phenomenological study conducted among eight seminarians in one of the theological schools in Southern Texas, who attended the personof-the- therapist (POTT) training program during the fall semester of 2019. This study aimed to examine seminarian participants' experiences in POTT training, their influence on their selfawareness, and their impact on their emotional maturity and the ability to make responsible life choices. The study was guided by an existential-humanistic philosophical orientation as an overarching theoretical orientation with the subjective epistemological worldview and socialconstructionism paradigm. Findings indicated POTT training positively impacted seminarian participants' human formation, which was foundational …


Crisis Narratives In Crisis? A Comparative Investigation Into National Covid-19 Narratives, Mouse D. Bennett Oct 2023

Crisis Narratives In Crisis? A Comparative Investigation Into National Covid-19 Narratives, Mouse D. Bennett

Graduate Program in International Studies Theses & Dissertations

On January 31, 2020, the World Health Organization (WHO) declared a public health emergency for only the sixth time in its history. On March 11, 2020, it was stated that COVID-19 constituted a pandemic. How did countries respond? This dissertation traces the evolution of national crisis narratives in four states and assesses their relative success. The findings of this study are that pandemic crisis narratives are not generalizable to all crisis situations but require a high level of compliance to be effective in stopping the crisis. There is no formula for government success, there are no decisive variables determining outcomes. …


The Influence Of Attachment Styles And Mental Health Symptoms On Marital Satisfaction Among Deployed Us Army Soldiers, Leo Mora Oct 2023

The Influence Of Attachment Styles And Mental Health Symptoms On Marital Satisfaction Among Deployed Us Army Soldiers, Leo Mora

Dissertations

Since 2002, changes in the frequency, duration, and nature of military campaigns overseas have piqued efforts to understand the effects of deployment on the mental health of DoD service members, especially married Army soldiers. However, few studies have examined the influence of attachment styles on the emotional health of combat veterans and the wartime impact they have also imparted to their spouses. Thus, in the context of military deployments, this study examines how secure/insecure attachment styles, posttraumatic stress (PTS), and depressive symptoms significantly influence married soldiers and their perceptions of marital satisfaction. In addition, this study also examines pre-existent, internalized, …


Experiences Of Counselors Who Assist Women In Midlife Who Display Depressive Symptoms: A Transcendental Phenomenological Study, Carla Pestana Oct 2023

Experiences Of Counselors Who Assist Women In Midlife Who Display Depressive Symptoms: A Transcendental Phenomenological Study, Carla Pestana

Dissertations

In this dissertation, I present a transcendental phenomenological study conducted with 12 counselors who worked with women in midlife who displayed depressive symptoms. The purpose of this study was to understand the lived experiences, clinical and personal, of licensed professional counselors (LPCs) who worked with women in midlife who displayed depressive symptoms. Through the study, I sought to recognize the essence and themes that emerged from these LPCs who worked with this population. Moreover, this study was designed to obtain a better understanding of how these LPCs managed their feelings and thoughts, how they helped when working with these women, …


Internet Pornography Use, Loneliness, And Adult Attachment Patterns Among Asian Indian Young Adults: An Explanatory Sequential Mixed Methods Design, Anish Baby Oct 2023

Internet Pornography Use, Loneliness, And Adult Attachment Patterns Among Asian Indian Young Adults: An Explanatory Sequential Mixed Methods Design, Anish Baby

Dissertations

Internet pornography consumption among Asian Indian Americans, an ethnic minority group, is largely underrepresented in current scholarly literature despite their growing population in the United States. The purpose of this research was threefold: (a) to measure the prevalence of internet pornography use among Asian Indian American young adults and adults; (b) to explore the relationship between internet pornography use, loneliness, and attachment patterns; and (c) to describe the lived experience of problematic porn consumers. Using an explanatory sequential mixed methods design, I conducted this study in two distinct phases: quantitative followed by qualitative. In the quantitative phase, I employed an …


Lived Experiences Of School Counselors Working In Conjoint Roles In A Multisystem Framework To Address The Mental Health Needs Of Students, Angela Sampson Oct 2023

Lived Experiences Of School Counselors Working In Conjoint Roles In A Multisystem Framework To Address The Mental Health Needs Of Students, Angela Sampson

Dissertations

The purpose of this phenomenological qualitative study was to explore the lived experiences of school counselors working in conjoint roles as social–emotional leaders and mental health professionals (MHPs) to address the mental health needs of students through multisystem collaboratives (MSCs) and school-based systems of mental health care (SBSMHC).

The role of the school counselor has expanded into becoming a social–emotional leader and school MHP advocating for comprehensive social–emotional learning and the “school-linked” movement that coalesced their exclusive professional proficiency with both school-based and community resources working to enhance initiatives for student psychosocial development in ways that would increase student assets …


Analyzing African American College Student Willingness To Participate In Clinical Trials, Caitlin B. Ulmer Oct 2023

Analyzing African American College Student Willingness To Participate In Clinical Trials, Caitlin B. Ulmer

Senior Theses

Previous studies regarding African American participation in clinical trials have found that African Americans participate at a significantly lower rate than other ethnic/racial groups. Scholars argue that this lack of participation in clinical trials is a direct result of historical trauma linked to unethical experiments and African American distrust in the healthcare system. However, there is a gap in the literature because these studies focus on African American individuals above the age of 30. This study aimed to fill the gap by examining clinical trial participation among African American college students within the ages 18 to 23. This study also …


Nightmares And Self-Injury Among High-Risk Adolescents: Examining The Role Of Emotion Regulation, Kinjal K. Patel Oct 2023

Nightmares And Self-Injury Among High-Risk Adolescents: Examining The Role Of Emotion Regulation, Kinjal K. Patel

Psychology Theses & Dissertations

Self-injurious thoughts and behaviors (SITBs) are a public health concern among youth. SITB rates rise drastically during adolescence -- a critical and sensitive developmental period characterized by dramatic changes in biological and social systems. Prior research has identified distal risk factors which tell us who is at risk for SITBs. Emerging research suggests proximal risk factors may be useful to identify when an individual may be at risk for SITBs. One promising proximal risk factor for SITBs is sleep problems. Although the relation between sleep problems and SITBs has been widely documented, little is known about the short-term, proximal links …


The Prevalence Of Burnout In Saudi Arabia Dental Hygienists, Nouf Hamad Aldayel Oct 2023

The Prevalence Of Burnout In Saudi Arabia Dental Hygienists, Nouf Hamad Aldayel

Dental Hygiene Theses & Dissertations

Purpose: The purpose of this pilot study was to assess the prevalence of burnout in Saudi Arabian dental hygienists and identify risk factors associated with burnout. Methods: A descriptive survey design using the Copenhagen Burnout Inventory (CBI) assessed burnout among a convenience sample of n=123 Saudi dental hygienists. The survey was disseminated electronically to 1,000 Saudi Arabian dental hygienists. The CBI measures three subscales: personal, work-related, and client/patient-related burnout on a five-point Likert-type scale. The survey also included six demographic questions, two Likert-type, one “yes/no,” and one openended question, related to burnout. Descriptive statistics, one-way between subject’s ANOVA, independent samples …


The Impact Of Mandatory Substance Abuse Counselor Reporting Requirements On Child Maltreatment Reporting Outcomes, Bilgé Özgé Yilmaz Oct 2023

The Impact Of Mandatory Substance Abuse Counselor Reporting Requirements On Child Maltreatment Reporting Outcomes, Bilgé Özgé Yilmaz

Psychology Theses & Dissertations

The present study sought to examine how state-level mandatory reporting policies are associated with child maltreatment reporting through analysis of the National Data Archive on Child Abuse and Neglect (NDACAN, 2021). This study aimed: 1) to examine how the implementation of substance abuse counselor reporting requirements is associated with the reporting process, including the disposition of reports and the presence of substance abuse; and 2) to examine differences in the above outcomes based on associations between non-specific reporting requirements and specific requirements that mention substance use counselors. A quasi-experimental approach with repeated cross-sectional data was utilized, as it is a …


Cheiloscopy Examination And Classification Of Lip Prints With And Without Parafunctional Oral Habits: A Cross-Sectional Observation Study, Emily Smith Regan Oct 2023

Cheiloscopy Examination And Classification Of Lip Prints With And Without Parafunctional Oral Habits: A Cross-Sectional Observation Study, Emily Smith Regan

Dental Hygiene Theses & Dissertations

Problem: Lip prints are unique and have potential for use as a human identifier. The purpose of this study was to observe possible cheiloscopy differences of individuals with and without parafunctional oral habits. Additionally, inter-rater reliability (IRR) of lip print examiners was observed. Methods: This IRB approved blinded cross-sectional observational study collected lip prints from sixty-six individuals using lipstick and adhesive tape to transfer lip prints to white bond paper for viewing purposes. Each set of included lip prints was divided into quadrants and dichotomized as those with or without an oral parafunctional habit. Each quadrant sample was manually analyzed …


Making Mindfulness More Accessible: A Practical Guide To Trauma-Informed Mindfulness, Leslie Formby Sep 2023

Making Mindfulness More Accessible: A Practical Guide To Trauma-Informed Mindfulness, Leslie Formby

Mindfulness Studies Theses

Mindfulness is currently embedded in a growing understanding of how trauma permeates and adversely impacts peoples’ physical and psychological well-being. Increased awareness of the prevalence of trauma and its harmful effects has led to renewed interest in mindfulness to help manage the challenges generated by the detrimental effects of trauma.

These effects may draw people to mindfulness and, in turn, may make the benefits of mindfulness out of reach. Mindfulness methods and practice adaptations have been found to help trauma survivors experience the benefits of what the Buddha taught. As a support for those engaging in mindfulness and meditation, this …


Expressive Arts Therapy To Support Positive Experiences Of Embodiment Among Rural Lgbtq+ Adults: A Literature Review, Ann Stromgren Sep 2023

Expressive Arts Therapy To Support Positive Experiences Of Embodiment Among Rural Lgbtq+ Adults: A Literature Review, Ann Stromgren

Expressive Therapies Capstone Theses

This paper investigates the use of expressive arts therapy to support LGBTQ+ adult clients in rural communities. Caring professionals in rural areas often lack training on how to work with LGBTQ+ clients, and best practices for clinical mental health counseling with rural LGBTQ+ clients have yet to be defined. Some evidence suggests that using “metronormative” best practices with rural clients may be irrelevant or cause harm (Giano et al., 2020). Although some recommendations exist for using expressive therapies with LGBTQ+ clients, they are rarely evidence-based, as very few empirical studies exist evaluating the effectiveness of expressive therapy interventions with LGBTQ+ …


Overcoming The Inner Critic: The Therapeutic Use Of Self-Portraits With Older Adults, Brenda Echeverry Sep 2023

Overcoming The Inner Critic: The Therapeutic Use Of Self-Portraits With Older Adults, Brenda Echeverry

Expressive Therapies Capstone Theses

Older adults are a growing and vulnerable population who experience discriminatory practices that impact their access to equitable housing, employment, and healthcare which was made even more obvious during the Coronavirus pandemic in the United States. A community engagement project was developed and facilitated by the writer to support older adults with the psychological effects of surviving the pandemic. This project also helped to increase accessibility to expressive arts therapy in the writer’s local community. Expressive arts therapy is an effective and accessible method to support mental health and wellness for people of all ages. Engagement with the arts helps …


Overcoming The Inner Critic: The Therapeutic Use Of Self-Portraits With Older Adults, Brenda Echeverry Sep 2023

Overcoming The Inner Critic: The Therapeutic Use Of Self-Portraits With Older Adults, Brenda Echeverry

Expressive Therapies Capstone Theses

Older adults are a growing and vulnerable population who experience discriminatory practices that impact their access to equitable housing, employment, and healthcare which was made even more obvious during the Coronavirus pandemic in the United States. A community engagement project was developed and facilitated by the writer to support older adults with the psychological effects of surviving the pandemic. This project also helped to increase accessibility to expressive arts therapy in the writer’s local community. Expressive arts therapy is an effective and accessible method to support mental health and wellness for people of all ages. Engagement with the arts helps …


Recursive Functional Learning In Nonfluent Aphasia, Gerald C. Imaezue Sep 2023

Recursive Functional Learning In Nonfluent Aphasia, Gerald C. Imaezue

Dissertations, Theses, and Capstone Projects

People with nonfluent aphasia (PWNA) require feedback from an external agent as well self-feedback to facilitate performance of language production tasks. The extent to which PWNA can use self-feedback alone to improve their task performance is unknown. In addition, it is argued that self-feedback may reinforce or minimize performance errors over time. To test whether either is the case, we introduce an original learning mechanism, recursive functional learning, which uses self-feedback loops to optimize recursively multiple subsystems (cognitive and linguistic subsystems) that PWNA engage during task performance. We used this mechanism to underpin a novel automated procedure we developed, recursive …


Apoe Risk Disclosure: A Review Of Positive And Negative Outcome, Stacey Rowcliffe Sep 2023

Apoe Risk Disclosure: A Review Of Positive And Negative Outcome, Stacey Rowcliffe

Dissertations

Two of this century’s most significant healthcare challenges are Alzheimer’s disease and mild cognitive impairment, with 40 million people suffering from the diseases. In fact, a conservative estimate projects that both conditions will double every 20 years until 2050. Alzheimer’s disease involves memory impairment, disorientation, confusion, and various problematic behaviors. Presently, no prevention method or cure has been discovered for Alzheimer’s. Mild cognitive impairment typically includes problems with memory, language, thinking, and judgment beyond those typical of one’s age. Usually, these symptoms do not interfere with daily activities but do not improve and have been linked with a risk of …