Is denial a maladaptive coping mechanism which prolongs pre-hospital delay in patients with ST-segment elevation myocardial infarction?

Denial, Attention-Seeking, and Posting Online While Intoxicated: Three Key Predictors of Collegiate Sadfishing

Sadfishing, or the exaggeration of one's emotional state online to generate sympathy, is a maladaptive behavior that can negatively affect mental health. A better understanding of the characteristics of individuals who sadfish could inform tailored interventions to decrease sadfishing and improve quality of life. However, to date, the phenomenon of sadfishing remains understudied. Thus, the current project was designed to identify some of the key psychological and behavioral characteristics that may be associated with sadfishing. Undergraduate college students (N = 374) recruited from introductory psychology courses at a large, Hispanic-serving institution completed an anonymous online survey assessing sadfishing and other online behaviors, psychological characteristics (coping, stress, resilience, and social support), and alcohol use. Both univariate and multivariate statistical analyses were conducted. Results of the binary logistic regression analysis found that students who reported using denial as a coping strategy (p = 0.005), who endorsed the attention-seeking behaviors associated with histrionic personality disorder (p = 0.021), and who used social media while intoxicated (p = 0.017) were most likely to report sadfishing. This study furthers our knowledge of the maladaptive online behavior of sadfishing and identifies several key predictors that could become targets for tailored interventions. In particular, our results highlight the importance of coping skills training for individuals who sadfish.

Development and validation of a nomogram model for predicting the risk of pre-hospital delay in patients with acute myocardial infarction

BACKGROUND

Acute myocardial infarction (AMI) is a severe cardiovascular disease caused by the blockage of coronary arteries that leads to ischemic necrosis of the myocardium. Timely medical contact is critical for successful AMI treatment, and delays increase the risk of death for patients. Pre-hospital delay time (PDT) is a significant challenge for reducing treatment times, as identifying high-risk patients with AMI remains difficult. This study aims to construct a risk prediction model to identify high-risk patients and develop targeted strategies for effective and prompt care, ultimately reducing PDT and improving treatment outcomes.

AIM

To construct a nomogram model for forecasting pre-hospital delay (PHD) likelihood in patients with AMI and to assess the precision of the nomogram model in predicting PHD risk.

METHODS

A retrospective cohort design was employed to investigate predictive factors for PHD in patients with AMI diagnosed between January 2022 and September 2022. The study included 252 patients, with 180 randomly assigned to the development group and the remaining 72 to the validation group in a 7:3 ratio. Independent risk factors influencing PHD were identified in the development group, leading to the establishment of a nomogram model for predicting PHD in patients with AMI. The model's predictive performance was evaluated using the receiver operating characteristic curve in both the development and validation groups.

RESULTS

Independent risk factors for PHD in patients with AMI included living alone, hyperlipidemia, age, diabetes mellitus, and digestive system diseases (P < 0.05). A nomogram model incorporating these five predictors accurately predicted PHD occurrence. The receiver operating characteristic curve analysis indicated area under the receiver operating characteristic curve values of 0.787 (95% confidence interval: 0.716-0.858) and 0.770 (95% confidence interval: 0.660-0.879) in the development and validation groups, respectively, demonstrating the model's good discriminatory ability. The Hosmer-Lemeshow goodness-of-fit test revealed no statistically significant disparity between the anticipated and observed incidence of PHD in both development and validation cohorts (P > 0.05), indicating satisfactory model calibration.

CONCLUSION

The nomogram model, developed with independent risk factors, accurately forecasts PHD likelihood in AMI individuals, enabling efficient identification of PHD risk in these patients.

Patient Denial of Myocardial Infarction in the Prehospital Phase: Prevalence and Correlates

BACKGROUND

Limited knowledge exists regarding patients' denial of myocardial infarction (MI) before hospitalization for an MI.

OBJECTIVE

The aim of this study was to determine the prevalence and correlates of denial of MI in the prehospital phase of a confirmed MI.

METHODS

This secondary analysis included 166 hospitalized patients (mean [SD] age, 54.1 [10.5] years) who developed MI outside a healthcare facility and had high congruence between their experienced and expected symptoms. Measurements included the Denial subscale of the Brief COPE Inventory, the modified Response to Symptoms Questionnaire, and a Likert scale measuring perceived risk for MI. Patients who arrived at a hospital at least 1 hour after the onset of their symptoms were considered to have prolonged prehospital delay.

RESULTS

Despite their high symptom congruence, 77% of patients denied the possibility of having an MI before hospitalization. The lower denial group was characterized by cardiac history, whereas the higher denial group was distinguished by nonsmoking, a lower perceived risk of MI, less anxiety at symptom onset, and more concerns about seeking medical help. Compared with the lower denial group, patients in the higher denial group were more likely to underestimate the seriousness of their symptoms and delay seeking medical help. The higher denial group responded to symptoms in a more passive manner (eg, waiting), whereas the lower denial group showed a more problem-solving approach (eg, contacting emergency services).

CONCLUSIONS

Denial of MI is highly prevalent in the prehospital phase and is negatively linked with cognitive, emotional, and behavioral responses to MI symptoms.

Illness Denial in Medical Disorders: A Systematic Review

INTRODUCTION

Illness denial pertains to medical patients who do not acknowledge the presence or severity of their disease or the need of treatment.

OBJECTIVE

This systematic review was performed to clarify the clinical role and manifestations of illness denial, its impact on health attitudes and behavior, as well as on short- and long-term outcomes in patients with medical disorders.

METHODS

The systematic search according to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines was conducted on PubMed, Scopus, and Web of Science.

RESULTS

The initial search yielded a total of 14,098 articles; 176 studies met the criteria for inclusion. Illness denial appeared to be a relatively common condition affecting a wide spectrum of health attitudes and behavior. In some cases, it may help a person cope with various stages of illness and treatment. In other situations, it may determine delay in seeking treatment, impaired adherence, and reduced self-management, leading to adverse outcomes. The Diagnostic Criteria for Psychosomatic Research (DCPR) were found to set a useful severity threshold for the condition. An important clinical distinction can also be made based on the DCPR for illness denial, which require the assessment of whether the patient has been provided with an adequate appraisal of the medical situation.

CONCLUSIONS

This systematic review indicates that patients with medical disorders experience and express illness denial in many forms and with varying degrees of severity. The findings suggest the need for a multidimensional assessment and provide challenging insights into the management of medical disorders.

Factors associated with prehospital delay in acute myocardial infarction in Maldives

BACKGROUND

Acute myocardial infarction (AMI) is the top cause of death in Maldives. Our study aims to determine the prehospital delay and its associated factors in AMI patients in Maldives.

METHODS

A cross-sectional study was conducted with 127 patients, divided into early (≤ 6 h) and delayed (> 6 h) presenters to the hospital. The data collection for the study was carried out by interviewing AMI patients, focusing on their socio-demographic characteristics, coronary artery disease risk factors, clinical symptoms, situational factors, and behavioral and cognitive responses to symptoms.

RESULTS

The median onset-to-door time was 230 (IQR 420) minutes. The mean age of AMI patients was 50.9 (SD ± 12.9) years old, and 39.4% of them had delayed presentation to the hospital. Smokers (adj OR = 0.3; 95% CI: 0.1, 0.9; P = 0.047) and those with previous episodes of chest pain or AMI (adj OR = 0.2; 95% CI: 0.03, 0.91; P = 0.038) were significant factors for early presentation to the hospital, while denial of symptoms (adj OR = 29.3; 95% CI: 1.6, 547.2; P = 0.024) and lack of knowledge (adj OR = 7.2; 95% CI: 1.77, 29.43; P = 0.006) led to a delayed decision to seek treatment. Situational factors such as onset at the workplace (adj OR = 5.8; 95% CI: 1.24, 26.83; P = 0.025) had lower odds of delay, whereas referral cases (adj OR = 7.7; 95% CI: 1.9, 30.94; P = 0.004) and use of sea ambulance (adj OR = 11.1; 95% CI: 2.8, 43.8; P = 0.001) were prone to delay in presentation to the hospital.

CONCLUSION

Sea ambulance, referral cases, lack of knowledge, and denial of symptoms are significant factors associated with prehospital delay among patients with AMI. Public awareness about the benefits of early presentation and improvement of the means of transportation between islands is suggested to improve emergency cardiac care in the country.

Mediation effect of coping strategies on general psychological health among middle-aged and older adults during the COVID-19 pandemic

OBJECTIVE

In this study, we aim to assess general psychological health, associated factors, and the potential of coping strategies as a mediator for middle-aged and older Malaysian adults during the COVID-19 pandemic.

METHODS

A total of 535 individuals aged 52 years and above from the previous cohort and interventional studies in Peninsular Malaysia were contacted during the Movement Control Order (MCO) issued during the COVID-19 pandemic. Telephonic interviews were conducted to obtain participant information concerning socio-demography, physical activity, subjective well-being (SWB) as assessed using flourishing scale, coping strategies, and general psychological health (GHQ-12). Simple linear regression (SLR) and multiple linear regression (MLR) analyses were performed to identify the factors associated with GHQ-12. The associated factors were further analysed using mediation analysis to determine the potential of coping strategies as a mediator.

RESULTS

It was observed that participants had a low mean GHQ-12 score (M = 0.80, SD = 2.19), indicating good psychological health. Living arrangement, physical activity, and flourishing scale were associated with psychological health (R² = 0.412, p < 0.05) in MLR. Positive reinterpretation, emotional support, instrumental support, humour, denial, and self-blame appear to partially mediate the relationship between socio-demography, physical activity, flourishing scale and GHQ-12, with lower coefficient values.

CONCLUSION

Middle-aged and older adults in Malaysia had good psychological health during the COVID-19 pandemic, especially when living with family, physically active, and having good subjective well-being. These findings provide the initial evidence to help promote the ageing population's general well-being and mental health and enable them to cope with change during the COVID-19 pandemic.

Psychosocial stressors predict lower cardiovascular disease risk among Mexican-American adults living in a high-risk community: Findings from the Texas City Stress and Health Study

The objective of this study was to examine the link between systemic and general psychosocial stress and cardiovascular disease (CVD) risk in a group of U.S. Latinos as a function of acculturation and education within the blended guiding conceptual framework of the biopsychosocial model of the stress process plus the reserve capacity model. We analyzed data from self-identifying Mexican-origin adults (n = 396, 56.9% female, Mage = 58.2 years, 55.5% < 12 years of education, 79% U.S.-born) from the Texas City Stress and Health Study. We used established measures of perceived stress (general stress), neighborhood stress and discrimination (systemic stress) to capture psychosocial stress, our primary predictor. We used the atherosclerotic CVD calculator to assess 10-year CVD risk, our primary outcome. This calculator uses demographics, cholesterol, blood pressure, and history of hypertension, smoking, and diabetes to compute CVD risk in the next 10 years. We also created an acculturation index using English-language use, childhood interaction, and preservation of cultural values. Participants reported years of education. Contrary to expectations, findings showed that higher levels of all three forms of psychosocial stress, perceived stress, neighborhood stress, and perceived discrimination, predicted lower 10-year CVD risk. Acculturation and education did not moderate the effects of psychosocial stress on 10-year CVD risk. Contextualized within the biopsychosocial and reserve capacity framework, we interpret our findings such that participants who accurately reported their stressors may have turned to their social networks to handle the stress, thereby reducing their risk for CVD. We highlight the importance of examining strengths within the sociocultural environment when considering cardiovascular inequities among Latinos.

Surviving to Acute Myocardial Infarction: The Role of Psychological Factors and Alexithymia in Delayed Time to Searching Care: A Systematic Review

The time from symptom onset to reperfusion is a critical determinant of myocardial salvage and clinical outcomes in patients with acute myocardial infarction (AMI). This time period could be delayed if people do not seek help promptly and/or if the health system is not efficient in responding quickly and attending to these individuals. The aim of this study was to identify psychological factors associated with pre-hospital delay (PHD) or patients’ decisional delay (PDD) in people with an ongoing AMI. A search in PubMed/Medline from 1990 to 2021 with the keywords “pre-hospital delay” OR “prehospital delay” OR “patient delay” OR “decisional delay” OR “care seeking behavior” AND “psychological factors” OR “alexithymia” AND “myocardial infarction” was performed. Thirty-six studies were included, involving 10.389 patients. Wrong appraisal, interpretation and causal beliefs about symptoms, denial of the severity of the symptoms and high levels of alexithymia were found related to longer PHD or PDD. Alexithymia may be an overarching construct that explains the disparate findings of the studies exploring the role of psychological factors in PHD or PDD. Further studies are needed in order to analyse the role of alexithymia in patients with risk factors for AMI to prevent delay.

Factors Affecting Resilience of Nursing, Optometry, Radiography and Medical Laboratory Science Students

Background: The concern over the high level of stress experienced by students of the caring professions has led to increased attention being paid to the promotion of their resilience. Most earlier studies have focused on the resilience of medical and nursing students. There has been little exploration of the resilience and associated factors of students of other health-care disciplines. The aim of this study was to gather data from students of pre-registration health-care disciplines to identify the factors that influence their resilience. Method: Valid questionnaires were used to assess respondents’ resilience, self-efficacy, mindfulness, coping and trait positive and negative affect. The data were analyzed using descriptive statistics and univariate and general linear regression. Results: A total of 1320 university students from nursing, medical laboratory science, radiography and optometry were recruited. The results showed that the subjects’ resilience scores were lower than those of students in Western countries. We found self-efficacy and denial to be the common predictors for students of all disciplines. Conclusion: The resilience of students in the four disciplines was predicted by a combination of predictors. Faculties of universities and clinical mentors should collaborate in building resilience in their health-care students and support them to grow both personally and professionally during their careers.

Associations between defense mechanisms and life satisfaction among North Korean refugees

BACKGROUND

The present study investigated associations between defense mechanisms and life satisfaction among North Korean refugees living in South Korea.

METHODS

A total of 178 North Korean refugees completed the Korean version of the Defense Style Questionnaire, a revised version of the Ways of Thinking of North Korean Defectors scale, the Center for Epidemiologic Studies-Depression Scale, and the State-Trait Anxiety Inventory. Multiple stepwise regression analysis was performed to investigate the defense mechanisms associated with North Korean refugees' life satisfaction in South Korea.

RESULTS

Among defense mechanisms, denial most strongly predicted higher overall and economic satisfaction among North Korean refugees living in South Korea (β = 0.145, p < 0.01; β = 0.137, p = 0.03, respectively) after controlling for age, gender, anxiety, depression, and number of traumatic events experienced. Furthermore, resignation predicted lower overall (β = -0.206, p < 0.001) and economic satisfaction (β = -0.134, p = 0.02). However, the association between resignation and life satisfaction was not significant after controlling for depression, anxiety, and number of traumatic events experienced.

CONCLUSIONS

Specific defense mechanisms such as high denial and low resignation were associated with life satisfaction in South Korea among North Korean refugees. Our findings suggest that refugees' psychological defense mechanisms may affect their satisfactory resettlement.

The impact of the Type D Personality pattern on prehospital delay in patients suffering from acute myocardial infarction

Background

The Type D Personality (TDP) has been specifically linked to acute myocardial infarction (AMI). However, the impact on prehospital delay of AMI patients is unclear. The aim of this study was to assess the relationship between TDP and pre-hospital delay time (PHT) in a Chinese population.

Methods

A total of 256 AMI patients (47 women and 209 men) were taken from the Multicenter Delay in Patients Experiencing AMI in Shanghai (MEDEA FAR-EAST) study. Sociodemographic and psycho-behavioral characteristics were assessed by bedside interviews and questionnaires. TDP was evaluated according to the Type D Personality Scale (DS14) subdivided in social inhibition (SI) and negative affectivity (NA). Based on a significant interaction analysis of TDP and sex on PHT, all analyses were stratified by sex.

Results

PHT of female patients with TDP were substantially shorter compared to non-TDP female patients (108 vs. 281 min, P=0.029). In male patients, no effect of TDT on PHT was found. Spearman correlation analysis suggests that NA was negatively correlated with PHT (r=−0.358, P=0.014). Further age-adjusted logistic regression analyses showed that female patients with TDP were generally less likely to prehospital delay compared with non-TDP patients (OR =0.28; 95% CI, 0.08–0.98) and had a lower risk of PHT >360 minutes (OR =0.10; 95% CI, 0.01–0.91). However, statistical significance disappeared after adjustment for psychological factors (anxiety, depression, suboptimal wellbeing, cardiac denial and stress event).

Conclusions

TDP is associated with less prehospital delay in female patients during AMI—an effect which may be particularly mediated by NA.

A systematic review of educational interventions aiming to reduce prehospital delay in patients with acute coronary syndrome

Interventions aiming at reducing prehospital delay (PHD) in patients with acute coronary syndrome (ACS) have yielded inconsistent findings. Therefore, we aimed to systematically review studies which investigated the impact of educational interventions on reducing PHD in patients with ACS. We searched four electronic databases (Cumulative Index to Nursing and Allied Health Literature, MEDLINE, Embase, Cochrane) from inception throughout December 2016 for studies that reported the impact of either mass-media or personalised intervention on PHD. Reporting quality was assessed with the Template for Intervention Description and Replication checklist for interventional trials. Two reviewers screened 12 184 abstracts and performed full-text screening on 86 articles, leading to 34 articles which met our inclusion criteria. We found 18 educational interventions with a total of 180 914 participants (range: n=100-125 161) and a median of 1342 participants. Among these educational interventions, 13 campaigns employed a mass-media approach and five a personalised approach. Ten studies yielded no significant effects on the primary outcome while the remaining interventions reported a significant reduction with a decrease between 17 and 324 min (median reduction: 40 min, n=5). The success was partly driven by an increase in emergency medical services use. Two studies reported an increase in acute myocardial infarction knowledge. We observed no superiority of the personalised over the mass-media approach. Although methodological shortcomings and the heterogeneity of included interventions still do not allow definite recommendations for future campaigns, it becomes evident that either mass media or personalised interventions can be successful in reducing PHD, especially those who address behavioural consequences and psychological barriers (eg, denial) and provide practical action plan considerations as part of their campaign messages. CRD42017055684 (PROSPERO registration number).

Psychosocial markers of pre-hospital decision delay and psychological distress in acute coronary syndrome patients

Objectives Both pre-hospital decision delay - the time patients wait before seeking medical attention after symptoms have started - and high psychological distress after the cardiac episode predict poor prognosis of patients with acute coronary syndromes (ACS). We aimed to identify psychosocial markers of these prognostic factors. Design A cross-sectional study of 102 consecutive, clinically stable ACS survivors. Methods Participants completed a questionnaire measuring pre-hospital decision delay, psychological distress, and several known psychosocial factors related to cardiovascular health: type D personality, resilience, social support, and concerns during the cardiac event. Multiple linear regression and mediation analyses were conducted. Results Type D personality and fewer concerns about the serious consequences of delaying help-seeking were related to more psychological distress post-ACS, and these relationships were mediated by longer pre-hospital decision delay. In contrast, resilience was related to lower psychological distress. Social support and social concerns about help-seeking were not related to the outcome variables. Conclusions Type D personality may be a risk factor for more delayed help-seeking for an ACS and higher psychological distress after the cardiac event. Resilience, in contrast, emerged as a potential protective factor of patients' mental health after the cardiac event. Pre-hospital decision delay was related to thinking about serious consequences (e.g., complications, protecting one's family) but not about social concerns (e.g., wasting other people's time) during the cardiac episode. Statement of Contribution What is already known on this subject? Longer pre-hospital decision delay, that is waiting longer to seek medical attention after symptoms have started, predicts poor prognosis of acute coronary syndrome patients. High psychological distress post-ACS, such as the development of anxiety and/or depression, also predicts poor prognosis of these patients. What does this study adds? This study identifies several psychosocial markers of longer prehospital decision delay and high psychological distress post-ACS. Prehospital decision delay was related to thinking about serious consequences (e.g., complications, protecting one's family) but not about social concerns (e.g., wasting other people's time) during the cardiac episode. Type D personality and fewer concerns about the serious consequences of delaying help-seeking were related to more psychological distress, and these relationships were mediated by longer prehospital decision delay. Resilience was related to lower psychological distress post-ACS.

Cardiac Denial and Expectations Associated With Depression in Adults With Congenital Heart Disease

Depression in adults with congenital heart disease is highly prevalent and strongly associated with adverse prognosis. Better management of risk factors for depression may improve clinical outcomes in this population. We conducted a single-site, cross-sectional study of 78 adults with congenital heart disease followed at Washington University School of Medicine. Data considered in the analyses included retrospectively obtained clinical information and patients' self-assessed psychosocial functioning and health status. To identify the clinical and psychosocial variables associated with depression, we built a stepwise multivariate model to measure the relative contribution of these variables to depression status. The prevalence of depression in our sample was 26%. Our model accounted for approximately 67% of the variability in depression scores. The final model consisted of the Cardiac Denial of Impact Scale, expectations domain of Barriers to Care, and the energy and social domains of the Rand 36-Item Short Form Health Survey. Clinical variables did not predict variability in depression scores. In conclusion, greater cardiac denial and negative expectations of the healthcare team were associated with increased depression symptoms in ACHD.

The MEDEA FAR-EAST Study: Conceptual framework, methods and first findings of a multicenter cross-sectional observational study

BACKGROUND

The substantial increase in cardiovascular diseases (CVD) in China over the last three decades warrants comprehensive preventive primary and secondary strategies. Prolonged prehospital delay (PHD) has been identified as a substantial barrier to timely therapeutic interventions for acute myocardial infarction (AMI). Despite worldwide efforts to decrease the patient's decision-making time, minimal change has been achieved so far. Here, we aim to describe the conceptual framework and methods and outline key data of the MEDEA FAR-EAST Study, which aimed to elucidate in-depth barriers contributing to delay in Chinese AMI-patients.

METHODS

Data sources of this multicenter cross-sectional observational study are a standardized bedside interview, a self-administered tailored questionnaire tool and the patient chart. PHD was defined as the main outcome and triangulated at bedside. Standard operation procedures ensured uniform data collection by trained study personnel. The study was ethically approved by Tongji-Hospital and applied to all participating hospitals.

RESULTS

Among 379 consecutively screened patients, 296 (78.1%) fulfilled eligibility criteria. A total of 241 (81.4%) AMI-patients were male and 55 (18.6%) female. Mean age was 62.9 years. Prehospital delay time was assessed for 294 (99.3%) patients. Overall median PHD was 151 min with no significant sex difference. Symptom mismatch was present in 200 (69.7%) patients and 106 (39.0%) patients did not attribute their symptoms to cardiac origin. A total of 33 (12.4%) patients suffered from depression, 31 (11.7%) from anxiety and 141 (53.2%) patients employed denial as their major coping style.

CONCLUSION

This is the first study on prehospital delay with emphasis on psychological variables in Chinese AMI-patients. A comprehensive assessment tool to measure clinical and psychological factors was successfully implemented. Socio-demographic key data proved a good fit into preexisting Chinese literature. Potential barriers including cardiac denial and symptom-mismatch were assessed for the first time in Chinese AMI-patients. The pretested selection of instruments allows future in depth investigations into barriers to delay of Chinese AMI-patients and enables inter-cultural comparisons.

The prevalence of medication nonadherence in post-myocardial infarction survivors and its perceived barriers and psychological correlates: a cross-sectional study in a cardiac health facility in Malaysia

BACKGROUND

Although evidence-based practice has shown the benefits of prescribed cardioprotective drugs in post-myocardial infarction (MI) survivors, adherence rates remain suboptimal. The aim of this study was to determine the prevalence and factors associated with medication nonadherence among post-MI survivors in Malaysia.

MATERIALS AND METHODS

This cross-sectional study was conducted from February to September 2016 among 242 post-MI survivors aged 24-96 years at the cardiology outpatient clinic in a Malaysian cardiac specialist center. The study utilized an interviewer-administered questionnaire that consisted of items adapted and modified from the validated Simplified Medication Adherence Questionnaire, sociodemographics, health factors, perceived barriers, and novel psychological attributes, which employed the modified Confusion, Hubbub, and Order Scale and the Verbal Denial in Myocardial Infarction questionnaire.

RESULTS

The prevalence of medication nonadherence was 74%. In the multivariable model, denial of illness (AOR 1.2, 95% CI 0.9-1.8; P=0.032), preference to traditional medicine (AOR 8.7, 95% CI 1.1-31.7; P=0.044), lack of information about illness (AOR 3.3, 95% CI 1.1-10.6; P=0.045), fear of side effects (AOR 6.4, 95% CI 2.5-16.6; P<0.001), and complex regimen (AOR 5.2, 95% CI 1.9-14.2; P=0.001) were statistically significant variables associated with medication nonadherence.

CONCLUSION

The relatively higher medication-nonadherence rate in this study was associated with patient-, provider-, and therapy-related factors and the novel psychological attribute denial of illness. Future research should explore these factors using robust methodological techniques to determine temporality among these factors.