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From Awareness To Action: The Group Processes Course As Design Laboratory, Kimberly B. Rogers Oct 2026

From Awareness To Action: The Group Processes Course As Design Laboratory, Kimberly B. Rogers

Feminist Pedagogy

In this article, I describe several pedagogical tools used in my group processes course to help students understand how group processes contribute to inequality and how to effectively intervene on these processes. I pair experimental research with work in natural settings to help students trace the development of theories across levels of application and understand their usefulness outside the laboratory. I incorporate reading reflections and simulation exercises that encourage students to apply course material to their own group experiences and make abstract group processes and their consequences more visible for analysis and action. I use complex instruction to promote more …


Showing Students Their Power: Demonstrating How Status Is Afforded In Interactions, Christianne Corbett Oct 2026

Showing Students Their Power: Demonstrating How Status Is Afforded In Interactions, Christianne Corbett

Feminist Pedagogy

The Showing Students their Power original teaching activity conveys to students in a visceral, embodied – and therefore hopefully memorable - way the concept of status, how it is afforded by others, and how quickly and accurately individuals perceive the status with which others view them. Students are informed that characteristics like gender, race, class, sexual orientation are status characteristics and that people who are viewed as lower status tend to be treated less respectfully. By identifying the existence of status, how it is conveyed from person to person, and the power we all have to influence other people, students …


The Adapted Socratic Circle As A Tool For Learning Sociological Social Psychology, Justin Huft Oct 2026

The Adapted Socratic Circle As A Tool For Learning Sociological Social Psychology, Justin Huft

Feminist Pedagogy

This paper presents an adapted Socratic Circle as a feminist pedagogical strategy for teaching sociological social psychology. Unlike traditional Socratic methods that often privilege rapid recall, professorial authority, and dominant communication styles, this approach reimagines the circle as a collective practice of creating and applying knowledge. Students alternate between inner and outer groups, engaging both as discussants and evaluators, while formal assessment is distributed equally across professor, peers, and self-evaluations. This multi-source structure decentralizes authority, resists meritocratic norms, and affirms students as co-creators of knowledge. The feminist commitments of the activity are threefold. First, it centers process over product by …


Psychological Therapy In The Management Of Temporomandibular Disorders: A Systematic Review, Pragatheeswari R, Kavitha M, Sarumathi T, Niveditha B, Barkavi Panchatcharam, Pavithra D, Samu Fathima A I, Vigneshwaran J Oct 2026

Psychological Therapy In The Management Of Temporomandibular Disorders: A Systematic Review, Pragatheeswari R, Kavitha M, Sarumathi T, Niveditha B, Barkavi Panchatcharam, Pavithra D, Samu Fathima A I, Vigneshwaran J

International Arab Journal of Dentistry

Aim: To evaluate the effectiveness of psychological therapy in the management of temperomandibular disorders compared to other treatment modalities.

Methodology: Studies were selected according to PICO criteria, considering the RDC/TMD as a reference, improvement of pain and psychological parameters were the primary outcomes. Data search was mainly carried out through electronic search in several renowned databases: PubMed, Embase, Scopus, Web of Science and Google scholar. The publications collected were published between 2010 and 2024. Randomized clinical trials that compared the efficacy of psychological treatment modality with other conservative treatment modalities were screened and evaluated. A total of 5 …


“All The World Is A (Debate) Stage”: College Debates As A Form Of Civic Engagement, Sara S. Whipple, Valentina Dimitrova-Grajzl, Kim Connolly Oct 2026

“All The World Is A (Debate) Stage”: College Debates As A Form Of Civic Engagement, Sara S. Whipple, Valentina Dimitrova-Grajzl, Kim Connolly

eJournal of Public Affairs

Political division and self-censorship in the United States have risen considerably in recent years. One means of countering such divides and siloed dialogue is through civil discourse that exposes people to diverse viewpoints. In an effort to bridge partisan divides, the Braver Angels Organization developed a debate format centered on these principles. Virginia Military Institute is one college campus that has adopted such debates as a form of civic engagement. In this paper we describe the development of the VMI College Debates and Discourse Program which has become a leading community of practice in civil discourse and engagement across college …


Persuasive Strategies To Increase Student Voting: A Communication-Based Framework For Civic Engagement At The Higher Education Institutions, Daniel Sherrick Apambila Oct 2026

Persuasive Strategies To Increase Student Voting: A Communication-Based Framework For Civic Engagement At The Higher Education Institutions, Daniel Sherrick Apambila

eJournal of Public Affairs

The decline in civic engagement among college students poses a significant threat to democratic society, with youth electoral participation dropping from 50% in 2020 to 42% in 2024. This study presents a comprehensive communication-based framework designed to increase student voting participation at Illinois State University through theoretically grounded persuasive strategies. Drawing from established persuasion theories including Cialdini’s Principles of Persuasion, the Theory of Planned Behavior, the Elaboration Likelihood Model, and repetitive frequency effects, this research addresses structural, informational, and motivational barriers that prevent student electoral participation.

The proposed strategic framework encompasses three interconnected approaches: (1) behavioral positioning and target segmentation …


Meet Phoenix, Feng Jiang Oct 2026

Meet Phoenix, Feng Jiang

Persimmon Creek

One act play


Law Enforcement Perceptions Of An Integrated Co-Responder Model: A Qualitative Case Study At The Jefferson County Sheriff’S Office, Austin D. Schwent Oct 2026

Law Enforcement Perceptions Of An Integrated Co-Responder Model: A Qualitative Case Study At The Jefferson County Sheriff’S Office, Austin D. Schwent

Doctoral Dissertations and Projects

Law enforcement personnel often serve as first responders to behavioral health crises, yet limited research has examined agency-based co-responder models staffed by embedded mental health professionals. This descriptive, non-evaluative, site-specific generic qualitative case study examined commissioned personnel’s descriptions of the benefits and challenges of the Jefferson County Sheriff’s Office Crisis Response and Mitigation Unit (CRMU) and perceived operational differences from external partnership models. The anonymous PowerDMS questionnaire served as the primary participant-derived source and produced 91 routing-item responses and 528 nonblank narrative response units; three organizational artifacts supplied procedural, historical, and structural evidence concerning the bounded case. The researcher manually …


Cisgender Women With Autism And Their Experiences In Psychotherapy: A Phenomenological Study, Lillian Katherine Gray Oct 2026

Cisgender Women With Autism And Their Experiences In Psychotherapy: A Phenomenological Study, Lillian Katherine Gray

Doctoral Dissertations and Projects

Research has underrepresented cisgender women with autism, and there are limited and inadequate resources and services. Cisgender women with autism experience unique challenges which connect to mental health challenges. The purpose of this qualitative phenomenological study was to understand the lived experiences of cisgender women with level one autism; specifically, their experiences related to camouflaging, reasons for seeking psychotherapy, and the therapeutic relationship with their mental health care provider. Participant criteria included being a cisgender woman diagnosed with level one autism, who camouflage, and attended psychotherapy as an adult. Procedures included an online screening survey and semi-structured interviews. I used …


Examining Emotion Regulation And The Link Between Childhood Adversity And Secondary Trauma In First Responders, Maci Lenora Harmon Oct 2026

Examining Emotion Regulation And The Link Between Childhood Adversity And Secondary Trauma In First Responders, Maci Lenora Harmon

Doctoral Dissertations and Projects

First responders are routinely exposed to traumatic events in the course of their professional duties, placing them at increased risk for secondary traumatic stress (STS). However, psychological responses to occupational trauma exposure vary considerably across individuals. Developmental research suggests that adverse childhood experiences (ACEs) may contribute to long-term alterations in emotional functioning and stress responsivity, potentially increasing vulnerability to later trauma-related symptoms. Emotion regulation (ER) has been identified as a transdiagnostic process associated with trauma-related stress. Furthermore, ER may function as a pathway linking early adversity to occupational stress outcomes. The purpose of this quantitative, cross-sectional correlational mediation study was …


Equipping Church Leaders As Mediators: Implementing And Evaluating Conflict Mediation Training In A Multicultural Church, Komie T. Bumpers Oct 2026

Equipping Church Leaders As Mediators: Implementing And Evaluating Conflict Mediation Training In A Multicultural Church, Komie T. Bumpers

Doctoral Dissertations and Projects

The social, political, ideological, and racial divides that lead to conflict and shape today's culture are the same issues that plague American evangelical churches. While faith traditions can bring people together, cultural issues can divide them. Despite the centrality of conflict in congregational life, many theological seminaries do not provide comprehensive conflict mediation training as a core component of pastoral and leadership formation, resulting in a deficit in preparedness. The purpose of this research was to develop, implement, and evaluate a comprehensive conflict mediation training program for multicultural church leaders that equips them to effectively navigate ongoing interpersonal, doctrinal, political, …


Examining The Barriers Of Youth Homelessness And Its Impact On The Utilization Of Mental Health Care Services, Layla A. Martin Oct 2026

Examining The Barriers Of Youth Homelessness And Its Impact On The Utilization Of Mental Health Care Services, Layla A. Martin

Doctoral Dissertations and Projects

This paper examines the barriers of youth homelessness and its impact on the utilization of mental health services for this demographic. Youth experiencing homelessness encounter many barriers including but not limited to mental health concerns, social obstacles, and street victimization. Understanding how homelessness impacts the access and utilization of mental health services among youth experiencing homelessness is important. Overall, the literature discusses significant findings, gaps in research, and suggestions for future research. Increased knowledge of how homeless youth access mental health care services and the barriers will help to increase awareness to help decrease barriers. The purpose of this quantitative …


The Impact Of Active Killer Defense Training Preparations And The Church, Michael Edward Howell Oct 2026

The Impact Of Active Killer Defense Training Preparations And The Church, Michael Edward Howell

Doctoral Dissertations and Projects

The purpose of this grounded theory (GT) study was to develop and understand the training and prevention tactics used in defending the church against active killer violence. Exploring the Routine Activity Theory (RAT) developed by Cohen and Felson (1979) in relation to active killer violence aimed to contribute significantly to building a more robust understanding of related problems associated with active killer violence in the world today in terms of a motivated offender, suitable target, and a lack of a capable guardian. The central phenomenon of this GT study focused on the understanding of the lethal threat from active killer …


The Correlational And Predictive Effect Of Evangelical Adolescent Church Volunteering And Mental Health Flourishing, Todd Reiff Lesher Oct 2026

The Correlational And Predictive Effect Of Evangelical Adolescent Church Volunteering And Mental Health Flourishing, Todd Reiff Lesher

Doctoral Dissertations and Projects

Adolescence is a time of significant development, often characterized by pubertal changes, identity exploration, and shifts in interpersonal relationships from parents to peers, all of which are necessary for the transition from childhood to adulthood. In addition to these aspects of adolescent development, personal and contextual changes can contribute to internalizing vulnerabilities throughout adolescence that can jeopardize their mental health. The focus of this study concentrates on religious volunteering, to better understand how variables related to volunteering contribute to adolescent mental health. The purpose of this study is to understand how Evangelical church volunteering impacts mental health flourishing in adolescents. …


Decoding Officer Wellness: A Qualitative Descriptive Study Of The Decision-Making Processes In Law Enforcement Administrations And Government Partnerships, Erik Lee Peffer Oct 2026

Decoding Officer Wellness: A Qualitative Descriptive Study Of The Decision-Making Processes In Law Enforcement Administrations And Government Partnerships, Erik Lee Peffer

Doctoral Dissertations and Projects

The purpose of this qualitative descriptive study was to describe how law enforcement administrators in Orange County, California, in collaboration with the governments they serve, make decisions regarding the development, implementation, and evaluation of officer wellness programs. Lewin's Change Theory guided the study and framed the movement from unfreezing to changing to refreezing. Ten administrators participated in semi-structured interviews. Each administrator had at least five years of experience and held decision-making authority over officer wellness initiatives. The data were analyzed using Braun and Clarke's thematic analysis. Screening and demographic questionnaires, field notes, and member checking were also used to support …


Unlocking Flow: Revealing The Blueprint For Peak Experiences Among Surgeons, Maximilian H. Pollack Oct 2026

Unlocking Flow: Revealing The Blueprint For Peak Experiences Among Surgeons, Maximilian H. Pollack

Doctoral Dissertations and Projects

Flow supports optimal performance and well-being, yet surgical research has treated it as a static, intrapersonal state, leaving its interpersonal and organizational conditions poorly understood. The purpose of this descriptive phenomenological study was to explore how surgeons experience flow in the operating room and to identify the conditions and strategies participants described as supporting flow access. Guided by Csikszentmihalyi’s (1990) flow theory, McQueen et al.’s (2025) multifaceted framework, and self-determination theory (Deci & Ryan, 1985), purposive and snowball sampling recruited 20 surgeons across nine specialties (12–49 years, M = 33.95) for semi-structured interviews. Analysis followed Englander and Morley’s (2023) five-step …


Minority Domestic Violence Victims And The Criminal Justice System, Jasmine Nicle Shelton Oct 2026

Minority Domestic Violence Victims And The Criminal Justice System, Jasmine Nicle Shelton

Doctoral Dissertations and Projects

This phenomenological study used a qualitative approach to develop an understanding of lived experiences of minority domestic violence victims. The six open-ended questions were designed for the participants to describe their experiences when interacting with law enforcement, the court system, and victim support services. African American and Hispanic participants between the ages of 18 and 55 were recruited from domestic abuse treatment or support facilities and social media outreach. Potential participants completed an eligibility screening to determine whether they met the inclusion criteria. Interviews were conducted with 13 African American and Hispanic participants until data saturation was reached, indicating that …


Adult Children Of Alcoholics: How Growing Up With An Alcoholic Influences Parenting Practices And The Parent-Child Dynamic, Taylor Sayre Bart Oct 2026

Adult Children Of Alcoholics: How Growing Up With An Alcoholic Influences Parenting Practices And The Parent-Child Dynamic, Taylor Sayre Bart

Doctoral Dissertations and Projects

The purpose of this transcendental phenomenological study was to understand how the influence of growing up with an alcoholic parent influenced one’s parenting practices and the parent-child dynamic. This study explored the lived experiences of adult children of alcoholics (ACOAs) as it related to their alcoholic parents’ parenting practices and styles. This study also explored how the participants’ childhood experience affected their relationship with their children and subsequently influenced their own parenting practices and styles. Bowlby’s attachment theory and Bowen’s family systems theory guided this study. Attachment theory was used as it is a key factor in building relationships between …


The Human Side Of Healing: A Qualitative Study Of The Holistic Benefits When Integrating Dog Training Into Posttraumatic Stress Disorder Recovery, Michelle J. Nordstrom Oct 2026

The Human Side Of Healing: A Qualitative Study Of The Holistic Benefits When Integrating Dog Training Into Posttraumatic Stress Disorder Recovery, Michelle J. Nordstrom

Doctoral Dissertations and Projects

Introduction: Posttraumatic stress and posttraumatic stress disorder (PTSD) are highly prevalent among Servicemembers and veterans. Many of those with PTSD also struggle with moral injury and co-occurring health complications. This combination results in poor outcomes with current evidence-based practices. However, a series of recent studies examined the efficacy of a service dog training program (SDTP) which demonstrated improvements in symptoms.

Methods: A privatized archival dataset of redacted transcripts was used. The interviews were collected during a broader mixed methods study and maintained for a phenomenological, thematic analysis. There were 119 transcripts from 84 of the original 117 participants who engaged …


A Phenomenological Study: Life During The Pandemic As An Adolescent In Hidalgo County, Texas, And Life Today, Melissa Guevara-Pérez Oct 2026

A Phenomenological Study: Life During The Pandemic As An Adolescent In Hidalgo County, Texas, And Life Today, Melissa Guevara-Pérez

Doctoral Dissertations and Projects

The COVID-19 pandemic disrupted the lives of adolescents during a critical part of social, emotional, and identity development. Although previous research has noted the immediate effects of the pandemic on adolescents, limited research has examined the long-term impact on individuals who experienced the pandemic during adolescence and are now transitioning into adulthood. The purpose of this qualitative phenomenological study was to explore the lived experiences of Hispanic young adults who experienced the COVID-19 pandemic as adolescents and to understand how those experiences influenced their social and personal development as they transitioned into adulthood. Participants included 10 Hispanic young adults who …


Paying The Success Tax: A Phenomenological Study Of Black Women Navigating Workplace Microaggressions, Santisha Taylor Oct 2026

Paying The Success Tax: A Phenomenological Study Of Black Women Navigating Workplace Microaggressions, Santisha Taylor

Doctoral Dissertations and Projects

The purpose of this phenomenological study was to investigate the lived experiences of professional Black women as they relate to microaggressions experienced in professional spaces. Professional, for this study, refers to Black women in professional positions that require a degree, advanced degree, professional licensure, and those with current/past military service in the enlisted rank of E-7 and above or commissioned officers in the rank of O3 and above. The theory that guided this study was the phenomenological variant of ecological systems theory (PVEST), which emphasizes how people develop, considering the unique intersectionality of multiple social identities (Spencer et al., 1997). …


Funding And Quality In Metropolitan Vs. Non-Metropolitan Head Start Programs, Kelly Smith Oct 2026

Funding And Quality In Metropolitan Vs. Non-Metropolitan Head Start Programs, Kelly Smith

Doctoral Dissertations and Projects

This quantitative survey study examined how Head Start program location and perceived funding levels were associated with perceived classroom quality and perceived teacher-child interactions. The study addressed three research questions: how funding distribution between metropolitan and non-metropolitan programs related to perceived classroom quality; how perceived funding levels related to teacher-child interactions; and whether perceived funding, classroom quality, and teacher-child interactions were significantly related across program settings. Head Start programs support children from low-income families through federal, local, and community resources. Because resources may vary by location, this study compared perceived funding, classroom quality, and teacher-child interactions across metropolitan and non-metropolitan …


A Qualitative Content Analysis Of The Personal Branding Practices Of Forbes 30 Under 30 Honorees, Hannah Naylor Regitz Oct 2026

A Qualitative Content Analysis Of The Personal Branding Practices Of Forbes 30 Under 30 Honorees, Hannah Naylor Regitz

Doctoral Dissertations and Projects

This qualitative study examines the personal branding practices of 10 honorees from the Forbes 2025 North American 30 Under 30 list. Through a thematic content analysis of Instagram, the honorees’ posts, captions, and the conversation climate of their comments from October 2025 were analyzed to determine patterns and similarities in their personal branding practices. Grounded in cultivation theory, this study explored how repeated exposure to curated content of these high-achieving young professionals shapes their personal brand perception. Additionally, it explored their interaction with commenters and the types of comments they engaged with. The analysis revealed seven themes that were present …


The Literacy Link: Connecting Parents Who Are Incarcerated With Their Young Children Through Reading Aloud, Mary Campbell Wood, Heidi Ungrodt, Pamela Wedig-Kirsch, Ronda Davis, Jacqueline Buck, Lindsay A Weymouth Oct 2026

The Literacy Link: Connecting Parents Who Are Incarcerated With Their Young Children Through Reading Aloud, Mary Campbell Wood, Heidi Ungrodt, Pamela Wedig-Kirsch, Ronda Davis, Jacqueline Buck, Lindsay A Weymouth

Journal of Extension

Parental incarceration is consequential for children. Outreach strategies can maintain parent–child relationships during incarceration. The Literacy Link connects parents in jail and prison with their children through two strategies: a dialogic reading workshop and a recorded book reading program. Over 3 years, we implemented these strategies with parents in jails and prisons located in 12 counties. We surveyed parents and the caregivers with whom children live during their parents' incarceration. Parents reported improvements in attitudes and confidence related to reading aloud. Most parents and caregivers reported that these strategies provided a connection between parents and children during incarceration.


Pandemic-Driven Mediatization Of The Seventh-Day Adventist Church In Jamaica, Gervon Garcia Marsh Oct 2026

Pandemic-Driven Mediatization Of The Seventh-Day Adventist Church In Jamaica, Gervon Garcia Marsh

Doctoral Dissertations and Projects

The Seventh-day Adventist Church in Jamaica experienced a radical shift in its relationship with information and communication technology (ICT) due to the COVID-19 mandatory lockdowns imposed by the Government of Jamaica. Prior to the pandemic, ICT use was less pronounced in the life and ministry of the Church, suggesting limited susceptibility to mediatization. This shift accelerated the mediatization of the Church, leading to a heavy reliance on ICT that has become entrenched in its life and ministry post-pandemic. This qualitative exploratory case study examined how pandemic-driven mediatization shaped the collective agency of the Seventh-day Adventist Church in Jamaica through ICT, …


Exploring Potential Psychological, Behavioral, And Physiological Predictors Of Human Flourishing In Division 1 Athletes: Toward A More Comprehensive Mental Health Screening, Derek Aaron Wheeler Oct 2026

Exploring Potential Psychological, Behavioral, And Physiological Predictors Of Human Flourishing In Division 1 Athletes: Toward A More Comprehensive Mental Health Screening, Derek Aaron Wheeler

Doctoral Dissertations and Projects

The National Collegiate Athletic Association (NCAA) has created numerous task forces and guidelines to address the rise in mental health challenges faced by student-athletes. However, these efforts have largely focused on identifying psychopathology rather than promoting flourishing. The purpose of this study was to examine the predictive utility of self-report and objective measures of human flourishing among NCAA Division I student-athletes at initial screening (i.e., preparticipation exam). This retrospective, cross-sectional, correlational study analyzed archival data from 92 student-athletes from 13 different sports. Measures included the Secure Flourishing Index (SFI), Patient Health Questionnaire-9 (PHQ-9), Athlete Sleep Behavior Questionnaire (ASBQ), and Power …


How Veterans With Ptsd Experience Symptom Improvement From Social Support, Patti "Lori" Beisner Oct 2026

How Veterans With Ptsd Experience Symptom Improvement From Social Support, Patti "Lori" Beisner

Doctoral Dissertations and Projects

Social support is a concept that is simple to grasp, yet subjective in nature and difficult to describe. Current research abounds reporting the positive impact of social support upon veterans with posttraumatic stress disorder (PTSD). However, few studies describe the phenomenon of social support for combat veterans, which they attribute to PTSD symptom improvement. The purpose of this study was to address this gap in research by exploring the lived experiences of veterans who have improved symptoms that they attribute to support they have received. Semi-structured interviews were conducted with eight combat veterans who self-reported PTSD symptom improvement due to …


Closing The Gap Between Pastoral Responsibility And Mental Health Preparedness, Robert Lee Lytle Jr Oct 2026

Closing The Gap Between Pastoral Responsibility And Mental Health Preparedness, Robert Lee Lytle Jr

Masters Theses

Faith communities increasingly encounter significant mental health needs among congregants, yet many pastors and ministry leaders remain underprepared to respond effectively within their pastoral scope. This Dissertation-in-Praxis addressed the persistent gap between the growing prevalence of mental health challenges in faith-based contexts and the limited leadership preparedness required to provide informed, ethical, and integrated pastoral care. This researcher defined the theological, organizational, and contextual dimensions of the problem, identifying stigma, insufficient pastoral training, and fragmented referral practices as primary contributors to the divide between responsibility and preparedness. Grounded in interdisciplinary scholarship at the intersection of spirituality, leadership, and mental health, …


A Multiple Case Study: Servant Leadership And Ethical Practices In Ethically Complex Organizational Environments, Gregory Antoine Davis Oct 2026

A Multiple Case Study: Servant Leadership And Ethical Practices In Ethically Complex Organizational Environments, Gregory Antoine Davis

Doctoral Dissertations and Projects

The purpose of this qualitative multiple case study was to explore how organizational leaders applied servant leadership to inform ethical practices within ethically complex organizational environments. Guided by a constructivist paradigm and Greenleaf’s servant leadership theory, the study examined leaders’ experiences navigating ethical challenges while balancing organizational demands with ethical responsibility. Data were collected through semi-structured interviews with organizational participants and document analysis across three organizational cases. Methodological triangulation, member checking, reflexive journaling, and an audit trail enhanced the credibility, dependability, confirmability, and transferability of the findings. Analysis revealed six interconnected themes: servant leadership, ethical leadership, organizational culture, leader development, …


Examining How The Frequency Of Artificial Intelligence Use In The Workplace Relates To Employee Self-Efficacy And Job Satisfaction, Dalton R. Vail Oct 2026

Examining How The Frequency Of Artificial Intelligence Use In The Workplace Relates To Employee Self-Efficacy And Job Satisfaction, Dalton R. Vail

Doctoral Dissertations and Projects

Artificial intelligence is a prominent topic in society. Its adoption in the healthcare sector has occurred rapidly. Nonetheless, much existing research focuses on clinical healthcare professionals, thereby overlooking those in non-clinical roles. Non-clinical roles make up a small portion of the healthcare industry, but they account for a large share of burnout in the field. This quantitative study aimed to explore the relationships among artificial intelligence, job satisfaction, and self-efficacy. It posited that these variables are interconnected concerning artificial intelligence in a non-clinical context. Furthermore, the study sought to determine whether job satisfaction and self-efficacy are influenced by how often …