1
|
Kelly CS, Nguyen H, Chapman KS, Wolf WA. The emotional burden of type 1 diabetes: A cross-sectional study to understand associations between diabetes distress and glucose metrics in adulthood. Diabet Med 2024:e15425. [PMID: 39149967 DOI: 10.1111/dme.15425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 08/01/2024] [Indexed: 08/17/2024]
Abstract
AIMS Advancements in type 1 diabetes (T1D) management, such as continuous glucose monitoring (CGM), have helped people achieve narrower glucose ranges, but associations between CGM and diabetes distress are unclear. Although higher HbA1c is associated with higher distress, associations with other glucose metrics are unknown. To better understand this relationship, we characterized diabetes distress in a sample of CGM users and compared differences in glucose metrics (measured via CGM) between those with higher versus lower distress. METHODS CGM users with T1D from the T1D Exchange Registry completed an online survey including diabetes distress (DDS-2) and shared CGM data (N = 199). CGM metrics were computed from all available data within 3 months prior to survey completion. Participants were grouped by distress level: lower (DDS-2 < 3, n = 120) or higher (DDS-2 ≥ 3, n = 79). Welch's t-tests were used to compare mean differences in CGM metrics between groups and MANCOVA was used to further probe mean differences. RESULTS Approximately 39.7% participants reported higher diabetes distress. Welch's t-tests revealed participants with higher distress spent significantly more time in higher glucose ranges (above 180 mg/dL and above 250 mg/dL), less time in target glucose ranges (between 70 and 180 mg/dL and between 70 and 140 mg/dL) and had higher glucose management index values compared to those with lower distress (p < 0.01). MANCOVA models showed similar results. CONCLUSIONS CGM users continue to experience diabetes distress. Moreover, higher distress appears to be associated with hyperglycaemia. These findings provide support for broader screening efforts for diabetes distress.
Collapse
|
2
|
Yılmaz Karaman İG, Altınöz AE, Aydın Buyruk B, Yorulmaz G, Köşger F, Kirel B. Comparison of anxiety, stress, and social support levels of female patients with type 1 diabetes and mothers whose children have type 1 diabetes. J Diabetes Metab Disord 2023; 22:333-340. [PMID: 37255808 PMCID: PMC10225375 DOI: 10.1007/s40200-022-01144-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 08/31/2022] [Accepted: 10/10/2022] [Indexed: 06/01/2023]
Abstract
Purpose Patients with type 1 diabetes mellitus (T1DM) are insulin-dependent from diagnosis. Both the individual and their immediate circle are at risk for psychiatric morbidity. We aimed to compare the anxiety, stress, and social support levels of adult women with a diagnosis of T1DM and adult women with a child diagnosed with T1DM. Besides, the study intended to examine two groups' stress and anxiety factors. Methods The data were collected using the Sociodemographic Data Form, State-Trait Anxiety Inventory, Perceived Stress Scale, Multidimensional Scale of Perceived Social Support. Sixty-three women participated in the study. Results There was no difference between the groups regarding anxiety, stress, and perceived social support score averages (p > 0.05 each). However, clinically significant state anxiety was higher in the group of mothers (χ²=4.234 df = 1 p = 0.040). In women with T1DM, higher education was associated with lower stress, lower state, and lower trait anxiety (r=-0.455 p = 0.004, r=-0.428 p = 0.007, r=-0.317 p = 0.049); higher numbers of insulin injections were associated with higher state anxiety (r = 0.368 p = 0.021), social support was associated with lower stress and lower trait anxiety (r=-0.478 p = 0.002, r = 0.449 p = 0.004). In mothers of diabetic children, the increase in the child's HbA1c level was associated with an increase in the mother's state anxiety (r = 0.433 p = 0.035); social support was associated with lower trait anxiety (r=-0.421 p = 0.040). Conclusion Caring for a child with T1DM was stressful and anxiety-provoking as having T1DM. Interventions including social support, may benefit mental health in mothers of diabetic children and women with T1DM.
Collapse
Affiliation(s)
| | - Ali Ercan Altınöz
- Department of Psychiatry, Faculty of Medicine, Eskişehir Osmangazi University, Eskişehir, Turkey
| | - Betül Aydın Buyruk
- Clinic of Endocrinology and Metabolic Diseases, İzmir Çiğli Regional Training and Research Hospital, İzmir, Turkey
| | - Göknur Yorulmaz
- Division of Endocrinology, Department of Internal Diseases, Faculty of Medicine, Eskişehir Osmangazi University, Eskişehir, Turkey
| | - Ferdi Köşger
- Department of Psychiatry, Faculty of Medicine, Eskişehir Osmangazi University, Eskişehir, Turkey
| | - Birgül Kirel
- Department of Pediatric Endocrinology, Faculty of Medicine, Eskisehir Osmangazi University, Eskisehir, Turkey
| |
Collapse
|
3
|
Baruffaldi I. Perceived stress can negatively affect blood glucose control and fear of hypoglycaemia in people with type 1 diabetes. Evid Based Nurs 2023; 26:52. [PMID: 36180201 DOI: 10.1136/ebnurs-2022-103555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/21/2022] [Indexed: 11/03/2022]
Affiliation(s)
- Ilaria Baruffaldi
- Paula Carr Diabetes Centre, Maidstone and Tunbridge Wells NHS Trust, Maidstone, Kent, UK
| |
Collapse
|
4
|
Grau-Del Valle C, Marco-Expósito JF, Bosch-Sierra N, Zaragoza-Villena B, Solá E, Montoya-Castilla I, Morillas C, Bañuls C. Effect of perceived stress, concern about hypoglycaemia and level of knowledge of management of the disease on glycaemic control in type 1 diabetes mellitus. J Clin Nurs 2023; 32:264-272. [PMID: 35224806 DOI: 10.1111/jocn.16270] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 11/10/2021] [Accepted: 01/10/2022] [Indexed: 12/14/2022]
Abstract
AIMS AND OBJECTIVES To evaluate perceived stress, concern about hypoglycaemia and the level of knowledge of management of the disease in patients with type 1 diabetes mellitus and their relationship with glycaemic control, gender and age. BACKGROUND Perceived stress and concern about hypoglycaemia are significant obstacles to achieving adequate glycaemic control in patients with type 1 diabetes mellitus, and notably influence management of the disease itself. MATERIAL AND METHODS A cross-sectional study was carried out in 193 adult patients with type 1 diabetes mellitus. Study quality was scored using the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist for cohort studies. Glycaemic control was evaluated by number and type of hypoglycaemic event and glycosylated haemoglobin. Questionnaires about hypoglycaemia concern (HFS II), perceived stress (PSS), unrecognised hypoglycaemia (Clarke Test) and level of knowledge of the disease were completed. RESULTS Perceived stress was significantly associated with glycosylated haemoglobin (p < 0.001) and concern about hypoglycaemia (p < 0.037). With respect to level of knowledge, we observed that an advanced level was associated with lower glycosylated haemoglobin (p < 0.001), number (p < 0.001) and type (p < 0.001) of hypoglycaemic episode, and less perceived stress (p = 0.006). In addition, age was negatively correlated with perceived stress (p < 0.030) and positively correlated with the number of unrecognised hypoglycaemic episodes (p < 0.002), which was associated, in turn, with a higher number of daily glycaemia tests (p < 0.037) and concern about hypoglycaemia (p < 0.006). CONCLUSION In type 1 diabetes mellitus, perceived stress can negatively influence glycaemic control and concern about hypoglycaemia, and level of knowledge about the condition has a bearing on glycosylated haemoglobin levels, perceived stress and number and type of hypoglycaemic events. In addition, higher age is associated with more frequent unrecognised hypoglycaemic events. RELEVANCE TO CLINICAL PRACTICE It is essential to identify and address the psychological needs of patients with type 1 diabetes mellitus with the aim of achieving an adequate management of the disease itself and generating a change in future intervention strategies.
Collapse
Affiliation(s)
- Carmen Grau-Del Valle
- Department of Endocrinology and Nutrition, University Hospital Doctor Peset- Foundation for the Promotion of Health and Biomedical Research in the Valencian Region (FISABIO), Valencia, Spain
| | - José Francisco Marco-Expósito
- Department of Endocrinology and Nutrition, University Hospital Doctor Peset- Foundation for the Promotion of Health and Biomedical Research in the Valencian Region (FISABIO), Valencia, Spain
| | - Neus Bosch-Sierra
- Department of Endocrinology and Nutrition, University Hospital Doctor Peset- Foundation for the Promotion of Health and Biomedical Research in the Valencian Region (FISABIO), Valencia, Spain
| | - Begoña Zaragoza-Villena
- Department of Endocrinology and Nutrition, University Hospital Doctor Peset- Foundation for the Promotion of Health and Biomedical Research in the Valencian Region (FISABIO), Valencia, Spain
| | - Eva Solá
- Department of Endocrinology and Nutrition, University Hospital Doctor Peset- Foundation for the Promotion of Health and Biomedical Research in the Valencian Region (FISABIO), Valencia, Spain.,Departament of Medicine, University of Valencia, Valencia, Spain
| | | | - Carlos Morillas
- Department of Endocrinology and Nutrition, University Hospital Doctor Peset- Foundation for the Promotion of Health and Biomedical Research in the Valencian Region (FISABIO), Valencia, Spain.,Departament of Medicine, University of Valencia, Valencia, Spain
| | - Celia Bañuls
- Department of Endocrinology and Nutrition, University Hospital Doctor Peset- Foundation for the Promotion of Health and Biomedical Research in the Valencian Region (FISABIO), Valencia, Spain
| |
Collapse
|
5
|
Prevalence and predictors of diabetes-related distress in adults with type 1 diabetes. Sci Rep 2022; 12:15758. [PMID: 36130979 PMCID: PMC9492762 DOI: 10.1038/s41598-022-19961-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Accepted: 09/07/2022] [Indexed: 11/20/2022] Open
Abstract
Type 1 diabetes (T1DM) is a chronic disease requiring lifelong insulin therapy and rigorous self-management. As it negatively impacts the affected individuals’ quality of life, it may eventually lead to diabetes-related distress. This study evaluated the prevalence and identified the predictors of diabetes-related distress in a representative sample of adults with T1DM treated at secondary and tertiary levels in Croatia. A multicenter, cross-sectional study was conducted in adults with T1DM in Croatia (N = 100). Data were collected between January 2018 and December 2018 from medical records and interviews during a single clinical visit, when participants completed a 20-item Problem Area in Diabetes (PAID) Questionnaire. The proportion of participants with a total PAID score ≥ 40 indicating high diabetes-related distress was calculated, and binary logistic regression was run to determine predictors. High diabetes-related distress was found in 36% of participants, with a mean PAID total score of 31.9 (21.1). The predictors of diabetes-related distress were higher HbA1c level (OR = 1.491, p = 0.037, CI = 1.025–2.169) and the presence of microvascular complications (OR = 4.611, p = 0.005; 95%CI 1.546–13.754). Worrying about the future and chronic complications and feeling guilty when off-track with diabetes management were identified as items that contribute the most to distress. Diabetes-related distress is a frequent condition in adults with T1DM in Croatia. Special attention should be given to patients with suboptimal glycemic control and microvascular complications. Given the high prevalence and impact of psychosocial problems in diabetes, psychological care should be integrated into routine care for adults with type 1 diabetes.
Collapse
|
6
|
Huhn F, Lange K, Jördening M, Ernst G. Real-World Use of Continuous Glucose Monitoring (CGM) Systems Among Adolescents and Young Adults With Type 1 Diabetes: Reduced Burden, but Little Interest in Data Analysis. J Diabetes Sci Technol 2022:19322968221081216. [PMID: 35255729 DOI: 10.1177/19322968221081216] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Since 2016, German health insurance companies reimburse continuous glucose monitoring (CGM) systems for persons with insulin-dependent diabetes, leading to a tremendous increase of CGM use. This study assessed the use of CGM, the satisfaction with, and the data analysis behavior among young people. METHODS During a diabetes camp for young people from all over Germany, participants anonymously answered a questionnaire on their method of glucose monitoring, satisfaction and quality of CGM use, HbA1c, and diabetes distress (Problem Areas in Diabetes Scale [PAID]-5). RESULTS A total of 308 participants (age 21.4 ± 3.5 years; 73% female; diabetes duration 10.1 ± 5.9 years) completed the questionnaire. Approximately, 25% used self-monitoring of blood glucose (SMBG), 46% intermittent-scanning continuous glucose monitoring (iscCGM), and 30% real-time continuous glucose monitoring (rtCGM). Mean HbA1c was slightly, but not significantly, higher among SMBG users compared with CGM users (8.0% ± 1.9% vs. 7.7% ± 1.4%; P = .791). Diabetes distress was not associated with the method of glucose monitoring (SMBG 5.6 vs. iscCGM 6.2 vs. rtCGM 6.5; P = .386). Overall, satisfaction with CGM use was very high; 98% of the CGM users reported better well-being with CGM compared with previous SMBG use. Only 19% of CGM users reported regular data analyses; their HbA1c was lower compared with other CGM users (7.2% ± 1.2% vs. 7.7% ± 1.4%; P = .039). CONCLUSIONS In this large sample of young people, 75% were using a CGM system. Treatment satisfaction was very high, but CGM use was not associated with reduced diabetes distress or better glycemic control. However, young people who regularly analyzed their CGM data reported lower HbA1c levels.
Collapse
Affiliation(s)
- Friederike Huhn
- Department of Medical Psychology, Hannover Medical School, Hannover, Germany
| | - Karin Lange
- Department of Medical Psychology, Hannover Medical School, Hannover, Germany
| | - Mia Jördening
- Department of Medical Psychology, Hannover Medical School, Hannover, Germany
| | - Gundula Ernst
- Department of Medical Psychology, Hannover Medical School, Hannover, Germany
| |
Collapse
|
7
|
Deshmukh H, Wilmot EG, Gregory R, Barnes D, Narendran P, Saunders S, Furlong N, Kamaruddin S, Banatwalla R, Herring R, Kilvert A, Patmore J, Walton C, Ryder REJ, Sathyapalan T. Predictors of diabetes-related distress before and after FreeStyle Libre-1 use: Lessons from the Association of British Clinical Diabetologists nationwide study. Diabetes Obes Metab 2021; 23:2261-2268. [PMID: 34142425 DOI: 10.1111/dom.14467] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 06/02/2021] [Accepted: 06/14/2021] [Indexed: 02/05/2023]
Abstract
AIM To identify the baseline demographic and clinical characteristics associated with diabetes-related distress (DRD) and factors associated with improvement in DRD after initiating use of the FreeStyle Libre (FSL) in people living with type 1 diabetes (T1D). METHODS The study was performed using baseline and follow-up data from the Association of British Clinical Diabetologists nationwide audit of people with diabetes who initiated use of the FSL in the United Kingdom. DRD was assessed using the two-item diabetes-related distress scale (DDS; defined as the average of the two-item score ≥3). People living with T1D were categorized into two groups: those with high DRD, defined as an average DDS score ≥3 and those with lower DRD, defined as a DDS score <3. We used a gradient-boosting machine-learning (GBM) model to identify the relative influence (RI) of baseline variables on average DDS score. RESULTS The study population consisted of 9159 patients, 96.6% of whom had T1D. The median (interquartile range [IQR]) age was 45.1 (32-56) years, 50.1% were women, the median (IQR) baseline body mass index was 26.1 (23.2-29.6) kg/m2 and the median (IQR) duration of diabetes was 20 (11-32) years. The two components of the DDS were significantly correlated (r2 = 0.73; P < 0.0001). Higher DRD was prevalent in 53% (4879/9159) of people living with T1D at baseline. In the GBM model, the top baseline variables associated with average DDS score were baseline glycated haemoglobin (HbA1c; RI = 51.1), baseline Gold score (RI = 23.3), gender (RI = 7.05) and fear of hypoglycaemia (RI = 4.96). Follow-up data were available for 3312 participants. The top factors associated with improvement in DDS score following use of the FSL were change in Gold score (RI = 28.2) and change in baseline HbA1c (RI = 19.3). CONCLUSIONS In this large UK cohort of people living with T1D, diabetes distress was prevalent and associated with higher HbA1c, impaired awareness of hypoglycaemia and female gender. Improvement in glycaemic control and hypoglycaemia unawareness with the use of the FSL was associated with improvement in DRD in people living with T1D.
Collapse
Affiliation(s)
- Harshal Deshmukh
- Hull University Teaching Hospitals NHS Trust and the University of Hull, Hull, UK
| | - Emma G Wilmot
- University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | | | | | - Parth Narendran
- Queen Elizabeth Hospital Birmingham and University of Birmingham, Birmingham, UK
| | - Simon Saunders
- Warrington and Halton Teaching Hospitals NHS Foundation Trust, Warrington, UK
| | - Niall Furlong
- St Helens and Knowsley Teaching Hospitals NHS Trust, St Helens, UK
| | | | | | | | - Anne Kilvert
- Northampton General Hospital NHS Trust, Northampton, UK
| | - Jane Patmore
- Hull University Teaching Hospitals NHS Trust and the University of Hull, Hull, UK
| | - Chris Walton
- Hull University Teaching Hospitals NHS Trust and the University of Hull, Hull, UK
| | | | | |
Collapse
|
8
|
Sánchez-Urbano C, Pino MJ, Herruzo C. Personality Prototypes in People with Type 1 Diabetes and Their Relationship with Adherence. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:4818. [PMID: 33946437 PMCID: PMC8124777 DOI: 10.3390/ijerph18094818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 04/27/2021] [Accepted: 04/28/2021] [Indexed: 11/17/2022]
Abstract
Type 1 diabetes (Dm1) is a chronic endocrine and metabolic disease that affects the whole person and requires active, decisive treatment. However, personality traits may influence a patient's adherence to treatment guidelines. The objective of this work is firstly to identify the 3 Asendorpf personality prototypes (resilient, undercontrolled and overcontrolled) in a sample of Dm1 individuals and determine whether there are any differences in comparison with a control sample; and, secondly, to study their association with adherence to self-care guidelines using both physiological indicators (HbA1C) and self-report measures. To achieve these objectives, a descriptive cross-sectional study was carried out. The sample comprised 294 participants, of whom 104 were people with Dm1 and 190 were controls. The participants, aged between 14 and 34 years, were classified by their scores in NEO-FFI-R, according to the personality characteristics inherent to Asendorpf's prototypes. Asendorpf's 3 prototypical personality patterns were found both in the group of people with Dm1 and in the control sample. These patterns showed different degrees of association with adherence to self-care guidelines for this disease and with psychological health factors. Importance should therefore be attached to the personality traits and Asendorpf prototypes of people with Dm1 when proposing interventions to address medical, psychological, and behavioral aspects.
Collapse
Affiliation(s)
| | | | - Carlos Herruzo
- Psychology Department, Facultad de Ciencias de la Educación, University of Cordoba, 14071 Cordoba, Spain; (C.S.-U.); (M.J.P.)
| |
Collapse
|
9
|
Martyn‐Nemeth P, Birlingmair R, Idemudia E, Park C. Hypoglycaemic treatment adherence and the association with psychological, self-management and glycaemic characteristics in adults with type 1 diabetes. Nurs Open 2019; 6:871-877. [PMID: 31367410 PMCID: PMC6650663 DOI: 10.1002/nop2.267] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Revised: 01/24/2019] [Accepted: 02/18/2019] [Indexed: 01/24/2023] Open
Abstract
AIM The purpose of this study was to examine adherence to hypoglycaemia treatment guidelines in adults with type 1 diabetes (T1DM). The American Diabetes Association recommends consumption of 15-20 g of glucose to treat hypoglycaemia. Overtreatment may result in poor glycaemic control and greater glycaemic variability. It is not fully understood how well T1DM adults comply with hypoglycaemia treatment recommendations. DESIGN A secondary analysis using a descriptive comparative design. METHODS Using real-time measures over six consecutive days, we examined (a) adherence to hypoglycaemia treatment guidelines and (b) comparisons of demographic self-management behaviour, psychological characteristics and glycaemia between adherent and non-adherent groups. RESULTS Findings revealed those who overtreated consumed more daily grain servings and reported higher stress and depressed mood compared with those who followed treatment recommendations. Findings suggest that hypoglycaemia treatment practices and psychological factors influencing self-management should be assessed.
Collapse
Affiliation(s)
- Pamela Martyn‐Nemeth
- Department of Biobehavioral Health Science, College of NursingUniversity of Illinois at ChicagoChicagoIllinois
| | - Reid Birlingmair
- Department of Biobehavioral Health Science, College of NursingUniversity of Illinois at ChicagoChicagoIllinois
| | - Esema Idemudia
- Department of Biobehavioral Health Science, College of NursingUniversity of Illinois at ChicagoChicagoIllinois
| | - Chang Park
- Department of Health Systems Science, College of NursingUniversity of Illinois at ChicagoChicagoIllinois
| |
Collapse
|
10
|
Gonzalez Rodriguez H, Wallace DD, Barrington C. Contextualizing Experiences of Diabetes-Related Stress in Rural Dominican Republic. QUALITATIVE HEALTH RESEARCH 2019; 29:857-867. [PMID: 30451066 DOI: 10.1177/1049732318807207] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Type 2 diabetes (T2D) is changing the burden of disease across Latin America. In this formative, qualitative study, we explored experiences of T2D diagnosis and management among adults in rural Dominican Republic. We conducted 28 in-depth interviews (12 men, 16 women) and used inductive analysis to explore the emotional burden of T2D and identify coping strategies. We found that stress relating to T2D began at diagnosis and persisted throughout management. Stress was produced by concerns about healthy food and medication access, fears about illness-induced injury, and the cyclical process of experiencing stress. Participants identified diabetes care and free medication services as external stress-reducers. Internally, participants' mitigated stress by not thinking about diabetes (" no dar mente"). Our study highlights the importance of a contextualized understanding of diabetes-related stress and the need for individual, clinic, and community-level interventions to reduce stressors and improve health outcomes among adults with T2D.
Collapse
Affiliation(s)
| | - Deshira D Wallace
- 1 The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Clare Barrington
- 1 The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| |
Collapse
|