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Liu Y, Li S, Zhang X, Wang L, Li Z, Wu W, Qin X, Zhou J, Ma C, Meng W, Kuang X, Yin F, Xia Q, Jiang B, Yang Y. Corticotropin releasing factor neurons in the visual cortex mediate long-term changes in visual function induced by early adversity. Neurobiol Stress 2022; 21:100504. [DOI: 10.1016/j.ynstr.2022.100504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 11/22/2022] [Accepted: 11/24/2022] [Indexed: 12/03/2022] Open
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2
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Eckerle JK, Bresnahan MM, Kroupina M, Johnson DE, Howard CR. International Adoption: A Review and Update. Pediatr Rev 2021; 42:245-257. [PMID: 33931509 DOI: 10.1542/pir.2019-0120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Judith Kim Eckerle
- Department of Pediatrics, University of Minnesota, Minneapolis, MN.,MHealth Fairview University of Minnesota Masonic Children's Hospital, Minneapolis, MN
| | - Megan Marie Bresnahan
- MHealth Fairview University of Minnesota Masonic Children's Hospital, Minneapolis, MN
| | - Maria Kroupina
- Department of Pediatrics, University of Minnesota, Minneapolis, MN.,MHealth Fairview University of Minnesota Masonic Children's Hospital, Minneapolis, MN
| | - Dana Ernest Johnson
- Department of Pediatrics, University of Minnesota, Minneapolis, MN.,MHealth Fairview University of Minnesota Masonic Children's Hospital, Minneapolis, MN
| | - Cynthia Ruth Howard
- Department of Pediatrics, University of Minnesota, Minneapolis, MN.,MHealth Fairview University of Minnesota Masonic Children's Hospital, Minneapolis, MN
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3
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Liu Y, Wang Z, Zhang X, Li S, Wu W, Li X, Yang Y. A sex-dependent delayed maturation of visual plasticity induced by adverse experiences in early childhood. Neurobiol Stress 2020; 13:100256. [PMID: 33344711 PMCID: PMC7739182 DOI: 10.1016/j.ynstr.2020.100256] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 09/04/2020] [Accepted: 10/08/2020] [Indexed: 11/27/2022] Open
Abstract
Adverse experiences in early life have a long-term impact on the development of brain, which in turn increases the susceptibility to mental illness during adulthood, especially in female subjects. However, whether and how the visual cortex is affected by these adverse experiences as well as the mechanisms underlying the sex difference are largely unknown. Here, we established a new mouse model of early-life chronic mild stress (ECMS) without anxiety or depression-like behavior in adulthood. ECMS mice showed normal maturation of visual acuity and orientation/direction selectivity, whereas their visual cortical neurons preferred lower spatial frequency (SF) and higher temporal frequency (TF) than control mice. Meanwhile the development of ocular dominance (OD) plasticity was delayed. Specifically, compared with control mice, ECMS mice in the early stage of the critical period (CP) showed a reduction in GABA synthesis enzyme expression as well as lower OD plasticity which could be occluded by diazepam. In contrast, ECMS mice in the late stage of CP showed stronger OD plasticity, accompanied by higher expression of N-methyl-D-aspartate (NMDA) receptor NR2B subunit. Interestingly, only female ECMS mice at adulthood maintained juvenile-like OD plasticity as well as high NR2B expressions. Artificial increase in estradiol level in ECMS males via estradiol supplementary diminished this sex difference. Lastly, OD plasticity was abolished in adult ECMS females either performed with the bilateral ovariectomy in prepuberty, or directly infused with NR2B antagonist Ro 25–6981 into the visual cortex. Overall, our study demonstrates that early adverse experiences have a lasting effect on visual development of mice in a sex-dependent manner, which is mediated by the estradiol-NR2B pathway.
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Affiliation(s)
- Yueqin Liu
- Hefei National Laboratory for Physical Sciences at the Microscale, School of Life Sciences, University of Science and Technology of China, Hefei, China
| | - Zhenni Wang
- Hefei National Laboratory for Physical Sciences at the Microscale, School of Life Sciences, University of Science and Technology of China, Hefei, China
| | - Xinxin Zhang
- Hefei National Laboratory for Physical Sciences at the Microscale, School of Life Sciences, University of Science and Technology of China, Hefei, China
| | - Sitong Li
- Hefei National Laboratory for Physical Sciences at the Microscale, School of Life Sciences, University of Science and Technology of China, Hefei, China
| | - Wei Wu
- Hefei National Laboratory for Physical Sciences at the Microscale, School of Life Sciences, University of Science and Technology of China, Hefei, China
| | - Xin Li
- Hefei National Laboratory for Physical Sciences at the Microscale, School of Life Sciences, University of Science and Technology of China, Hefei, China
| | - Yupeng Yang
- Hefei National Laboratory for Physical Sciences at the Microscale, School of Life Sciences, University of Science and Technology of China, Hefei, China
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4
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Institutionalisation and deinstitutionalisation of children 2: policy and practice recommendations for global, national, and local actors. THE LANCET CHILD & ADOLESCENT HEALTH 2020; 4:606-633. [PMID: 32589873 PMCID: PMC7311356 DOI: 10.1016/s2352-4642(20)30060-2] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 02/07/2020] [Accepted: 02/13/2020] [Indexed: 12/03/2022]
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5
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Olivier L, Sterkenburg P, van Rensburg E. The effect of a serious game on empathy and prejudice of psychology students towards persons with disabilities. Afr J Disabil 2019; 8:328. [PMID: 31049304 PMCID: PMC6489198 DOI: 10.4102/ajod.v8i0.328] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Accepted: 10/31/2018] [Indexed: 11/29/2022] Open
Abstract
Background Much has been done regarding the promotion of equality in rights in terms of legislation, but persons with disabilities remain marginalised in society. Negative attitudes and prejudice contribute towards numerous challenges for persons with disabilities. Objectives This study investigated the level of empathy and prejudice of students towards persons with disabilities, and the effect of the use of a serious game to enhance empathy and reduce prejudice. Method A randomised controlled experiment with pre-test, post-test and follow-up test was used. Availability sample (N = 83) of psychology university students (22% males; 78% females) was divided into an experimental group that played the serious game The World of Empa and two control groups. The first control group received texts on case studies and information on reacting in a sensitive and responsive way, and the second control group received no intervention. Results Participants have average levels of empathy (score: 32 to 52) and strong prejudice (score: 0.08 to −0.87) towards persons with disabilities. The intervention results in a slight short-term effect for prejudice and sub-scale measurements of empathy. A slight improvement was noted in participants’ ability to transpose themselves imaginatively into the experience of disabled characters. Conclusion The findings contribute to the understanding of empathy as a dynamic component that can be positively influenced by, for example, a serious game. These results have teaching implications on the facilitation of empathy. The short-term effect on empathy and prejudice towards persons with disabilities may contribute to bridge the inequality experienced by persons with disabilities. Keywords empathy; prejudice; serious games; persons with disabilities; psychology students.
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Affiliation(s)
- Linda Olivier
- School of Psychosocial Behavioural Sciences: Psychology, North-West University, Potchefstroom, South Africa
| | - Paula Sterkenburg
- Department of Clinical Child and Family Studies, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.,Amsterdam Public Health research institute (APH), Amsterdam, the Netherlands.,Bartiméus, Doorn, the Netherlands
| | - Esmé van Rensburg
- School of Psychosocial Behavioural Sciences: Psychology, North-West University, Potchefstroom, South Africa
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6
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Jones VF, Schulte EE, Springer S, Szilagyi MA, Forkey H, Greiner MV, Harmon D, Lee P, Nalven LM, Sagor LD, Thackery JD, Waite D, Zetley LW. Comprehensive Health Evaluation of the Newly Adopted Child. Pediatrics 2019; 143:peds.2019-0657. [PMID: 31036671 DOI: 10.1542/peds.2019-0657] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Children who join families through the process of adoption, whether through a domestic or international route, often have multiple health care needs. Pediatricians and other health care personnel are in a unique position to guide families in achieving optimal health for the adopted children as families establish a medical home. Shortly after placement in an adoptive home, it is recommended that children have a timely comprehensive health evaluation to provide care for known medical needs and identify health issues that are unknown. It is important to begin this evaluation with a review of all available medical records and pertinent verbal history. A complete physical examination then follows. The evaluation should also include diagnostic testing based on findings from the history and physical examination as well as the risks presented by the child's previous living conditions. Age-appropriate screenings may include, but are not limited to, newborn screening panels and hearing, vision, dental, and formal behavioral and/or developmental screenings. The comprehensive assessment may occur at the time of the initial visit to the physician after adoptive placement or can take place over several visits. Adopted children can be referred to other medical specialists as deemed appropriate. The Council on Adoption, Foster Care, and Kinship Care is a resource within the American Academy of Pediatrics for physicians providing care for children who are being adopted.
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Affiliation(s)
- Veronnie Faye Jones
- Division of General Pediatrics, Department of Pediatrics, School of Medicine, University of Louisville, Louisville, Kentucky; and
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Medizinische Maßnahmen bei immigrierenden Kindern und Jugendlichen – Aktualisierung vom 28.02.2018. Monatsschr Kinderheilkd 2018. [DOI: 10.1007/s00112-018-0497-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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8
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Bigler D, Burke K, Laureano N, Alfonso K, Jacobs J, Bush ML. Assessment and Treatment of Behavioral Disorders in Children with Hearing Loss: A Systematic Review. Otolaryngol Head Neck Surg 2018; 160:36-48. [PMID: 30200810 DOI: 10.1177/0194599818797598] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE There is evidence that children who are deaf and hard of hearing (DHH) have a higher incidence of behavioral disorders. Assessment of behavioral health in this population is often complicated by language developmental delays, which may result in unrecognized and untreated behavioral problems. The purpose of this study is to assess the association of behavioral disorders among children who are DHH and to explore behavioral interventions for children in this population. DATA SOURCES PubMed, CINALH, PsychINFO, and Web of Science. REVIEW METHODS Search terms included the following: problem behavior, child behavior disorders/diagnosis, child behavior disorders/psychology coupled with hearing loss, cochlear implants, hearing aids, or deafness. Studies from the last 30 years (1985-2016) were included. The articles were reviewed independently by 3 reviewers. RESULTS Thirty-six articles met criteria. There was an association between internalizing behaviors and hearing loss among children, which may persist after cochlear implantation. These problems may be more pronounced for children with additional disabilities. Conduct and hyperactivity disorders as well as emotional and executive function problems among children who are DHH may be related to poor language development. There was limited evidence regarding interventions to address the behavioral disorders of DHH children. CONCLUSIONS There is a significant body of evidence demonstrating behavioral problems among DHH children but a lack of clear understanding of the mechanisms involved. There is limited evidence on interventions to address the behavioral problems of DHH children. Future research is warranted to mitigate the long-term effects of disruptive behavior among these children.
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Affiliation(s)
- Diana Bigler
- 1 College of Medicine, University of Kentucky, Lexington, Kentucky, USA
| | - Kristen Burke
- 1 College of Medicine, University of Kentucky, Lexington, Kentucky, USA
| | - Nicholas Laureano
- 2 Department of Otolaryngology-Head and Neck Surgery, University of Kentucky Medical Center, Lexington, Kentucky, USA
| | - Kristan Alfonso
- 2 Department of Otolaryngology-Head and Neck Surgery, University of Kentucky Medical Center, Lexington, Kentucky, USA
| | - Julie Jacobs
- 3 Department of Health, Behavior and Society, College of Public Health, University of Kentucky Medical Center, Lexington, Kentucky, USA
| | - Matthew L Bush
- 2 Department of Otolaryngology-Head and Neck Surgery, University of Kentucky Medical Center, Lexington, Kentucky, USA
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Morgan A, O’Gara M, Bellucci CC, Linde S, Albert M, Curtis A, Patel P, Kapp-Simon KA. Speech Production Skills in Children With Cleft Palate Who Were Internationally Adopted. Cleft Palate Craniofac J 2018; 55:1225-1235. [DOI: 10.1177/1055665618765780] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective: The objective of this study was to investigate the impact of international adoption (IA), age at palatoplasty (PR age), and velopharyngeal sufficiency (VPS) on articulation outcomes. Design: This was a cross-sectional, prospective, observational study. Setting: Outpatient hospital clinic. Participants: Fifty-one IA and 65 not-adopted (NA) children between the ages of 3 and 9 with nonsyndromic cleft palate with or without cleft lip. Main Outcome Measure(s): The Goldman-Fristoe Test of Articulation—2nd Edition (GFTA-2) standard score and cleft-related articulation errors (CREs). Results: Articulation impairment was observed for 40% to 76% of NA children and 71% to 92% IA children, depending on age. PR age mean IA = 2.07 (0.86) years; NA = 1.23 (0.71) years. Children who were IA had poorer performance on the GFTA-2 ( B = −13.82, P = .015). Children who were IA were not significantly more likely to make CRE; rather, age at the time of assessment ( B = −.10, P = .002) and VPS ( B = .24, P = .021) were associated with CRE. Conclusions: Children who were IA demonstrated poorer articulation skills. Although primary palatoplasty was accomplished later among children who were IA, age at assessment and VP status (not PR age) were significantly correlated with articulation outcomes. Implications for timing of surgical intervention are discussed.
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Affiliation(s)
- Amy Morgan
- Pediatric Plastic Surgery, Shriners Hospitals for Children—Chicago, Chicago, IL, USA
| | - Mary O’Gara
- Pediatric Plastic Surgery, Shriners Hospitals for Children—Chicago, Chicago, IL, USA
| | | | | | - Meredith Albert
- Pediatric Plastic Surgery, Shriners Hospitals for Children—Chicago, Chicago, IL, USA
| | - Arthur Curtis
- Pediatric Plastic Surgery, Shriners Hospitals for Children—Chicago, Chicago, IL, USA
| | - Pravin Patel
- Pediatric Plastic Surgery, Shriners Hospitals for Children—Chicago, Chicago, IL, USA
- Department of Surgery, The Craniofacial Center, University of Illinois at Chicago, Chicago, IL, USA
| | - Kathleen A. Kapp-Simon
- Pediatric Plastic Surgery, Shriners Hospitals for Children—Chicago, Chicago, IL, USA
- Department of Surgery, The Craniofacial Center, University of Illinois at Chicago, Chicago, IL, USA
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10
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Narducci R, Baroncelli L, Sansevero G, Begenisic T, Prontera C, Sale A, Cenni MC, Berardi N, Maffei L. Early impoverished environment delays the maturation of cerebral cortex. Sci Rep 2018; 8:1187. [PMID: 29352131 PMCID: PMC5775315 DOI: 10.1038/s41598-018-19459-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Accepted: 12/27/2017] [Indexed: 12/26/2022] Open
Abstract
The influence of exposure to impoverished environments on brain development is unexplored since most studies investigated how environmental impoverishment affects adult brain. To shed light on the impact of early impoverishment on developmental trajectories of the nervous system, we developed a protocol of environmental impoverishment in which dams and pups lived from birth in a condition of reduced sensory-motor stimulation. Focusing on visual system, we measured two indexes of functional development, that is visual acuity, assessed by using Visual Evoked Potentials (VEPs), and VEP latency. In addition, we assessed in the visual cortex levels of Insulin-Like Growth Factor 1 (IGF-1) and myelin maturation, together with the expression of the GABA biosynthetic enzyme GAD67. We found that early impoverishment strongly delays visual acuity and VEP latency development. These functional changes were accompanied by a significant reduction of IGF-1 protein and GAD67 expression, as well as by delayed myelination of nerve fibers, in the visual cortex of impoverished pups. Thus, exposure to impoverished living conditions causes a significant alteration of developmental trajectories leading to a prominent delay of brain maturation. These results underscore the significance of adequate levels of environmental stimulation for the maturation of central nervous system.
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Affiliation(s)
- Roberta Narducci
- Institute of Neuroscience, National Research Council (CNR), Via Moruzzi 1, I-56124, Pisa, Italy.,Department of Neuroscience, Psychology, Drug Research and Child Health NEUROFARBA, University of Florence, Area San Salvi - Pad. 26, I-50135, Florence, Italy
| | - Laura Baroncelli
- Institute of Neuroscience, National Research Council (CNR), Via Moruzzi 1, I-56124, Pisa, Italy.
| | - Gabriele Sansevero
- Institute of Neuroscience, National Research Council (CNR), Via Moruzzi 1, I-56124, Pisa, Italy.,Department of Neuroscience, Psychology, Drug Research and Child Health NEUROFARBA, University of Florence, Area San Salvi - Pad. 26, I-50135, Florence, Italy
| | - Tatjana Begenisic
- Institute of Neuroscience, National Research Council (CNR), Via Moruzzi 1, I-56124, Pisa, Italy
| | - Concetta Prontera
- Fondazione G. Monasterio CNR-Regione Toscana, via Moruzzi 1, I-56124, Pisa, Italy
| | - Alessandro Sale
- Institute of Neuroscience, National Research Council (CNR), Via Moruzzi 1, I-56124, Pisa, Italy
| | - Maria Cristina Cenni
- Institute of Neuroscience, National Research Council (CNR), Via Moruzzi 1, I-56124, Pisa, Italy
| | - Nicoletta Berardi
- Institute of Neuroscience, National Research Council (CNR), Via Moruzzi 1, I-56124, Pisa, Italy.,Department of Neuroscience, Psychology, Drug Research and Child Health NEUROFARBA, University of Florence, Area San Salvi - Pad. 26, I-50135, Florence, Italy
| | - Lamberto Maffei
- Institute of Neuroscience, National Research Council (CNR), Via Moruzzi 1, I-56124, Pisa, Italy
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11
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Morgan AR, Bellucci CC, Coppersmith J, Linde SB, Curtis A, Albert M, O'Gara MM, Kapp-Simon K. Language Development in Children With Cleft Palate With or Without Cleft Lip Adopted From Non-English-Speaking Countries. AMERICAN JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2017; 26:342-354. [PMID: 28329403 DOI: 10.1044/2016_ajslp-16-0030] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Accepted: 10/07/2016] [Indexed: 06/06/2023]
Abstract
PURPOSE The purpose of this study was to determine whether language skills differed between children with cleft palate or cleft lip and palate (CP±CL) who were adopted into an English-speaking home from a non-English-speaking country (late English exposure [LE]) and children with CP±CL raised from birth in an English-speaking home (early English exposure [EE]). METHOD Children (51 LE, 67 EE), ages 3;0 (years;months) to 9;0, completed the Clinical Evaluation of Language Fundamentals (CELF), Preschool Second Edition or Fourth Edition. Linear regression analysis was used to assess the impact of age of adoption and time in an English-speaking home on language skills, as measured by the CELF-P2 and CELF-4. RESULTS Children with CP±CL who were adopted scored less well on all language indices, with mean adjusted differences between LE and EE children ranging from 0.4 to 0.7 SD on the CELF index scales. Only 53% of the EE children and 57% of the LE children obtained scores above 90 on all indices. For LE children, younger age at adoption was associated with better language skills. CONCLUSION CP±CL increases risk for language delay, with the highest risk for LE children. LE children with CP±CL should receive language services soon after adoption.
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12
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Esposito EA, Jones MJ, Doom JR, MacIsaac JL, Gunnar MR, Kobor MS. Differential DNA methylation in peripheral blood mononuclear cells in adolescents exposed to significant early but not later childhood adversity. Dev Psychopathol 2016; 28:1385-1399. [PMID: 26847422 PMCID: PMC5903568 DOI: 10.1017/s0954579416000055] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Internationally adopted adolescents who are adopted as young children from conditions of poverty and deprivation have poorer physical and mental health outcomes than do adolescents conceived, born, and raised in the United States by families similar to those who adopt internationally. Using a sample of Russian and Eastern European adoptees to control for Caucasian race and US birth, and nonadopted offspring of well-educated and well-resourced parents to control for postadoption conditions, we hypothesized that the important differences in environments, conception to adoption, might be reflected in epigenetic patterns between groups, specifically in DNA methylation. Thus, we conducted an epigenome-wide association study to compare DNA methylation profiles at approximately 416,000 individual CpG loci from peripheral blood mononuclear cells of 50 adopted youth and 33 nonadopted youth. Adopted youth averaged 22 months at adoption, and both groups averaged 15 years at testing; thus, roughly 80% of their lives were lived in similar circumstances. Although concurrent physical health did not differ, cell-type composition predicted using the DNA methylation data revealed a striking difference in the white blood cell-type composition of the adopted and nonadopted youth. After correcting for cell type and removing invariant probes, 30 CpG sites in 19 genes were more methylated in the adopted group. We also used an exploratory functional analysis that revealed that 223 gene ontology terms, clustered in neural and developmental categories, were significantly enriched between groups.
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Affiliation(s)
- Elisa A. Esposito
- Institute of Child Development, University of Minnesota, 51 East River Parkway, Minneapolis, MN 55455
- Widener University, One University Place, Chester, PA 19013
| | - Meaghan J. Jones
- Centre for Molecular Medicine and Therapeutics, Child and Family Research Institute, University of British Columbia, 950 West 28 Avenue, Vancouver, V5Z 4H4, Canada
| | - Jenalee R. Doom
- Institute of Child Development, University of Minnesota, 51 East River Parkway, Minneapolis, MN 55455
| | - Julia L MacIsaac
- Centre for Molecular Medicine and Therapeutics, Child and Family Research Institute, University of British Columbia, 950 West 28 Avenue, Vancouver, V5Z 4H4, Canada
| | - Megan R. Gunnar
- Institute of Child Development, University of Minnesota, 51 East River Parkway, Minneapolis, MN 55455
- Child and Brain Development Program, Canadian Institute for Advanced Research, Canada
| | - Michael S. Kobor
- Centre for Molecular Medicine and Therapeutics, Child and Family Research Institute, University of British Columbia, 950 West 28 Avenue, Vancouver, V5Z 4H4, Canada
- Child and Brain Development Program, Canadian Institute for Advanced Research, Canada
- Human Early Learning Partnership, School of Population and Public Health, University of British Columbia
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