1
|
Andersen JA, Rowland B, Gloster E, Felix HC, Riklon S, Jenkins D, Bing WI, Mendoza Kabua P, Hudson JS, Edem D, Niedenthal J, McElfish PA. Assessment of diabetes self-care behaviors and knowledge among Marshallese adults with type 2 diabetes in the Republic of the Marshall Islands. Prim Care Diabetes 2024; 18:74-78. [PMID: 38040537 PMCID: PMC10922376 DOI: 10.1016/j.pcd.2023.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 10/09/2023] [Accepted: 11/19/2023] [Indexed: 12/03/2023]
Abstract
AIMS The aim of this study is to assess and document engagement in type 2 diabetes mellitus (T2DM) self-care behaviors and self-reported diabetes knowledge among Marshallese adults living in the Republic of the Marshall Islands (RMI). METHODS The study uses data from a T2DM health screening study completed in the RMI; survey and biometric data were captured as part of the health screenings. Study objectives were examined using descriptive statistics to describe the characteristics of the participants, their diabetes self-care behaviors, and their levels of self-reported diabetes knowledge. RESULTS Results indicate many Marshallese diagnosed with T2DM did not engage in adequate self-care behaviors, including blood sugar checks and foot examinations. Participants reported having forgone needed medical care and medication due to issues with cost and/or access, and participants reported low levels of diabetes knowledge. CONCLUSIONS The results demonstrate the need for further work in improving engagement in diabetes self-care by Marshallese living in the RMI. Increased engagement in self-care and diabetes education programs may help Marshallese with T2DM to improve control of their glucose and avoid long-term health complications, as well as reduce costs to the healthcare system.
Collapse
Affiliation(s)
- Jennifer A Andersen
- College of Medicine, University of Arkansas for Medical Sciences Northwest, 2708 S. 48th St., Springdale, AR 72762, USA
| | - Brett Rowland
- Office of Community Health and Research, University of Arkansas for Medical Sciences Northwest, 2708 S. 48th St., Springdale, AR 72762, USA
| | - Erin Gloster
- Office of Community Health and Research, University of Arkansas for Medical Sciences Northwest, 2708 S. 48th St., Springdale, AR 72762, USA
| | - Holly C Felix
- Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, 4301 W. Markham St., Little Rock, AR 72205, USA
| | - Sheldon Riklon
- College of Medicine, University of Arkansas for Medical Sciences Northwest, 2708 S. 48th St., Springdale, AR 72762, USA
| | - Desiree Jenkins
- Office of Community Health and Research, University of Arkansas for Medical Sciences Northwest, 2708 S. 48th St., Springdale, AR 72762, USA
| | - Williamina Ioanna Bing
- Office of Community Health and Research, University of Arkansas for Medical Sciences Northwest, 2708 S. 48th St., Springdale, AR 72762, USA
| | - Philmar Mendoza Kabua
- College of Nursing, University of Arkansas for Medical Sciences Northwest, 1125 N. College Ave., Fayetteville, AR 72703, USA
| | - Jonell S Hudson
- College of Pharmacy, University of Arkansas for Medical Sciences Northwest, 1125 N. College Ave., Fayetteville, AR 72703, USA
| | - Dinesh Edem
- College of Medicine, University of Arkansas for Medical Sciences, 4301 W. Markham St., Little Rock, AR 72205, USA
| | - Jack Niedenthal
- Republic of the Marshall Islands Ministry of Health & Human Services, PO Box 16, Majuro, MH 96960, MH
| | - Pearl A McElfish
- College of Medicine, University of Arkansas for Medical Sciences Northwest, 2708 S. 48th St., Springdale, AR 72762, USA.
| |
Collapse
|
2
|
McElfish PA, Felix HC, Bursac Z, Rowland B, Yeary KHK, Long CR, Selig JP, Kaholokula JK, Riklon S. A Cluster Randomized Controlled Trial Comparing Diabetes Prevention Program Interventions for Overweight/Obese Marshallese Adults. INQUIRY : A JOURNAL OF MEDICAL CARE ORGANIZATION, PROVISION AND FINANCING 2023; 60:469580231152051. [PMID: 36799349 PMCID: PMC9940234 DOI: 10.1177/00469580231152051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 12/15/2022] [Accepted: 01/03/2023] [Indexed: 02/18/2023]
Abstract
This study compared the effectiveness of two Diabetes Prevention Program (DPP) interventions on weight loss among overweight and obese Marshallese adults. The study was a two-arm cluster randomized controlled trial conducted in 30 churches in Arkansas and Oklahoma. Marshallese adults with a body mass index ≥25 kg/m2 were eligible for the study. The study sample included 380 participants. Participants received either a faith-based adaptation of the DPP or a family-focused adaptation of the DPP, each delivered over 24 weeks. The primary outcome was weight change from baseline. Secondary outcomes included changes in Hemoglobin A1c, blood pressure, dietary intake, family support for healthy behaviors, and physical activity. Outcomes were examined longitudinally using general linear mixed effects regression models, adjusting for baseline outcomes, sociodemographic covariates, and clustering of participants within churches. Reductions in weight were small for both groups. Overall, only 7.1% of all participants lost 5% or more of their baseline body weight. There were no significant differences in weight loss between the 2 arms at 6 months (P = .3599) or at 12 months (P = .3207). Significant differences in systolic and diastolic blood pressure were found between the 2 arms at 6 months (P = .0293; P = .0068, respectively). Significant within-arm changes were found for sugar-sweetened beverage consumption and family support for both arms at both follow-ups. Both interventions achieved a modest weight loss. While even modest weight loss can be clinically significant, future research is needed to identify chronic disease prevention interventions that can successfully reduce weight for this at-risk population.
Collapse
Affiliation(s)
- Pearl A. McElfish
- University of Arkansas for Medical Sciences Northwest, Springdale, AR, USA
| | - Holly C. Felix
- University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Zoran Bursac
- Florida International University, Miami, FL, USA
| | - Brett Rowland
- University of Arkansas for Medical Sciences Northwest, Springdale, AR, USA
| | | | | | - James P. Selig
- University of Arkansas for Medical Sciences Northwest, Springdale, AR, USA
| | | | - Sheldon Riklon
- University of Arkansas for Medical Sciences Northwest, Springdale, AR, USA
| |
Collapse
|
3
|
Andersen JA, Willis DE, Malhis JR, Long CR, McElfish PA. The Association Between Education and Basic Needs Insecurity for Marshallese During the COVID-19 Pandemic. J Racial Ethn Health Disparities 2022; 9:1882-1887. [PMID: 34403123 PMCID: PMC8370049 DOI: 10.1007/s40615-021-01125-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 07/29/2021] [Accepted: 07/29/2021] [Indexed: 11/08/2022]
Abstract
BACKGROUND The purpose of this study was to explore the prevalence of basic needs insecurity and to examine the association between education and basic needs insecurity during the COVID-19 pandemic for Marshallese living in the USA. METHODS Survey data describing Marshallese experiences during the pandemic were analyzed using descriptive statistics and complementary log-log regression to test the association between education and basic needs insecurity. RESULTS Marshallese respondents reported no usual source of care (46%), less healthcare (22.3%), and difficulty obtaining medication (34.8%). Nearly 80% reported being food insecure, and 47.5% reported being housing insecure. Marshallese with a high school education or less had higher odds of reporting being food and housing insecure. DISCUSSION Basic needs insecurities are a serious threat to the health of Marshallese during the pandemic. Results from this study can inform interventions addressing food and housing insecurity, access to healthcare, and medication access for Marshallese communities.
Collapse
Affiliation(s)
- Jennifer A Andersen
- College of Medicine, University of Arkansas for Medical Sciences Northwest, 1125 N. College Avenue, Fayetteville, AR, 72703, USA
| | - Don E Willis
- College of Medicine, University of Arkansas for Medical Sciences Northwest, 1125 N. College Avenue, Fayetteville, AR, 72703, USA
| | - Joseph R Malhis
- College of Medicine, University of Arkansas for Medical Sciences Northwest, 1125 N. College Avenue, Fayetteville, AR, 72703, USA
| | - Christopher R Long
- College of Medicine, University of Arkansas for Medical Sciences Northwest, 1125 N. College Avenue, Fayetteville, AR, 72703, USA
| | - Pearl A McElfish
- College of Medicine, University of Arkansas for Medical Sciences Northwest, 1125 N. College Avenue, Fayetteville, AR, 72703, USA.
| |
Collapse
|
4
|
Study protocol for family model diabetes self-management education with Marshallese participants in faith-based organizations. Contemp Clin Trials Commun 2022; 30:101007. [PMID: 36186543 PMCID: PMC9515595 DOI: 10.1016/j.conctc.2022.101007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 08/25/2022] [Accepted: 09/17/2022] [Indexed: 01/12/2023] Open
Abstract
Background Culturally-appropriate family models of diabetes self-management education and support (DSMES) using community health workers (CHWs) have been shown to help address barriers to improving type 2 diabetes mellitus (T2DM) self-management for racial/ethnic minority communities; however, there is limited DSMES research among Marshallese and other Pacific Islanders. Using a community-based participatory research approach, we engaged community stakeholders to co-design a study to implement a culturally adapted family model DSMES (F-DSMES) intervention in faith-based organizations (FBOs) (i.e., churches). Methods Using a cluster-randomized controlled trial design, we will assess the effectiveness of the F-DSMES intervention for Marshallese patients with T2DM in Arkansas and Oklahoma. Twenty-four FBOs (with 12 primary participants per FBO) will be randomized to one of two study arms: the intervention arm or the wait-list control arm. Primary participants must have at least one family member willing to attend education sessions and data collection events. The F-DSMES intervention consists of ten h of diabetes education delivered by CHWs over eight to ten weeks. Data will be collected from the intervention arm at pre-intervention (baseline), immediate post-intervention (12 weeks), and three months post-intervention. The wait-list control arm will complete a second pre-intervention data collection before receiving the intervention. The primary study outcome will be glycemic control, as measured by HbA1c. Secondary measures include glucose, weight, body mass index, blood pressure, diabetes self-management behaviors, and diabetes management self-efficacy. Conclusion The knowledge gained from this research will inform future DSMES and other health promotion interventions conducted with Marshallese and other Pacific Islander communities.
Collapse
|
5
|
Onwuchuluba EE, Oyetunde OO, Soremekun RO. Medication Adherence in Type 2 Diabetes Mellitus: A Qualitative Exploration of Barriers and Facilitators From Socioecological Perspectives. J Patient Exp 2021; 8:23743735211034338. [PMID: 34368436 PMCID: PMC8317237 DOI: 10.1177/23743735211034338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Adherence to antidiabetic medications (ADMs) remains a serious challenge among type 2 diabetes mellitus (T2DM) patients. Factors affecting medication adherence are not fully understood in Nigeria. This qualitative study explored patients' views on barriers and facilitators of medication adherence. Data collection was through face-to-face, semistructured, in-depth interviews conducted on 25 purposively sampled patients attending a public tertiary hospital. The interviews were audio recorded, transcribed verbatim, and analyzed using thematic analysis based on socioecological framework. NVIVO version 10 identified more codes. Most commonly identified barriers were organizational (clinic structure), personal (perception of T2DM as a dangerous illness), interpersonal (lack of spousal support), and community (concerns about taking ADMs in social gatherings). It was observed that female patients received more spousal support than the males. The facilitators of adherence include perceiving medication-taking a routine, the need to live longer, having savings for ADMs, purchasing medications to last until the next clinic visit. This study identified barriers and facilitators unique to Nigerian T2DM patients. Interventions anchored on these factors would improve medication adherence.
Collapse
Affiliation(s)
- EE Onwuchuluba
- Department of Clinical Pharmacy & Biopharmacy, Faculty of Pharmacy, University of Lagos, Idi-araba, Lagos, Nigeria
| | - OO Oyetunde
- Department of Clinical Pharmacy & Biopharmacy, Faculty of Pharmacy, University of Lagos, Idi-araba, Lagos, Nigeria
| | - RO Soremekun
- Department of Clinical Pharmacy & Biopharmacy, Faculty of Pharmacy, University of Lagos, Idi-araba, Lagos, Nigeria
| |
Collapse
|
6
|
Andersen JA, Felix HC, Eswaran H, Payakachat N, Willis DE, Bogulski C, McElfish PA. Factors Associated with First-Time Telehealth Utilization for Marshallese Living in the United States. TELEMEDICINE REPORTS 2021; 2:217-223. [PMID: 34841421 PMCID: PMC8621619 DOI: 10.1089/tmr.2021.0023] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/24/2021] [Indexed: 05/07/2023]
Abstract
Background: Mitigation efforts to prevent the spread of COVID-19 included the robust utilization of telehealth. However, racial/ethnic minority populations have demonstrated low telehealth utilization in the past. The aim of this study was to examine the first-time use of telehealth by Marshallese adults during the COVID-19 pandemic, using online survey data collected from 109 Marshallese respondents between July and November of 2020. Methods: To evaluate the relationships between sociodemographic characteristics, health care access, physical/mental health, and COVID-19-specific measures and the decision to use telehealth, we use bivariate analyses, including t-tests and chi-square analysis. Results: Eighteen respondents (16.5%) indicated they utilized telehealth for the first time during the pandemic. The number of chronic conditions reported was positively associated with the first-time use of telehealth (p = 0.013). Although not statistically significant, a higher proportion of Marshallese first-time telehealth users reported limited English proficiency, changes in health status, and changes in health insurance. Discussion: Although telehealth has been shown to reduce the absolute gaps in health disparities for minority populations, there is limited utilization by Marshallese communities. Conclusions: Significant research remains on the utilization of telehealth by Marshallese during the COVID-19 pandemic and to increase utilization in the future.
Collapse
Affiliation(s)
- Jennifer A. Andersen
- College of Medicine, University of Arkansas for Medical Sciences Northwest, Fayetteville, Arkansas, USA
| | - Holly C. Felix
- Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Hari Eswaran
- Institute of Digital Health and Innovation, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Nalin Payakachat
- College of Pharmacy, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Don E. Willis
- College of Medicine, University of Arkansas for Medical Sciences Northwest, Fayetteville, Arkansas, USA
| | - Cari Bogulski
- Office of Community Health and Research, University of Arkansas for Medical Sciences Northwest, Fayetteville, Arkansas, USA
| | - Pearl A. McElfish
- College of Medicine, University of Arkansas for Medical Sciences Northwest, Fayetteville, Arkansas, USA
- *Address correspondence to: Pearl A. McElfish, PhD, MBA, College of Medicine, University of Arkansas for Medical Sciences Northwest, 1125 North College Avenue, Fayetteville, AR 72703, USA,
| |
Collapse
|
7
|
Dickey TA, Balli ML, Warmack TS, Rowland B, Hudson J, Seaton V, Riklon S, Purvis RS, McElfish PA. Perceptions and utilization of traditional healing among Marshallese adults residing in Arkansas. JOURNAL OF COMPLEMENTARY & INTEGRATIVE MEDICINE 2020; 17:/j/jcim.ahead-of-print/jcim-2018-0198/jcim-2018-0198.xml. [PMID: 32284443 DOI: 10.1515/jcim-2018-0198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Accepted: 09/29/2019] [Indexed: 11/15/2022]
Affiliation(s)
- Tiffany A Dickey
- College of Pharmacy, University of Arkansas for Medical Sciences Northwest, 1125 N. College Ave, Fayetteville, AR, USA
| | - Michelle L Balli
- College of Pharmacy, University of Arkansas for Medical Sciences Northwest, 1125 N. College Ave, Fayetteville, AR, USA
| | - T Scott Warmack
- College of Pharmacy, University of Arkansas for Medical Sciences Northwest, 1125 N. College Ave, Fayetteville, AR, USA
| | - Brett Rowland
- Office of Community Health and Research, University of Arkansas for Medical Sciences Northwest, 1125 N. College Ave, Fayetteville, AR, USA
| | - Jonell Hudson
- College of Pharmacy, University of Arkansas for Medical Sciences Northwest, 1125 N. College Ave, Fayetteville, AR, USA
| | - Victoria Seaton
- College of Pharmacy, University of Arkansas for Medical Sciences Northwest, 1125 N. College Ave, Fayetteville, AR, USA
| | - Sheldon Riklon
- College of Medicine, University of Arkansas for Medical Sciences Northwest, 1125 N. College Ave, Fayetteville, AR 72703-5011, USA
| | - Rachel S Purvis
- Office of Community Health and Research, University of Arkansas for Medical Sciences Northwest, 1125 N. College Ave, Fayetteville, AR, USA
| | - Pearl A McElfish
- College of Medicine, University of Arkansas for Medical Sciences Northwest, 1125 N. College Ave, Fayetteville, AR 72703-5011, USA
| |
Collapse
|
8
|
McElfish PA, Purvis RS, Esquivel MK, Sinclair KA, Townsend C, Hawley NL, Haggard-Duff LK, Kaholokula JK. Diabetes Disparities and Promising Interventions to Address Diabetes in Native Hawaiian and Pacific Islander Populations. Curr Diab Rep 2019; 19:19. [PMID: 30887399 PMCID: PMC7171975 DOI: 10.1007/s11892-019-1138-1] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW The Native Hawaiian and Pacific Islander (NHPI) population is rapidly growing in the USA. NHPIs face significant health disparities and have a high prevalence of diabetes compared to the general US population. RECENT FINDINGS Recent culturally-adapted diabetes interventions have shown promise in addressing these disparities among NHPI communities. The interventions showed success by utilizing a community-based approach that honored NHPIs' collectivist culture, addressed social determinants of health that influence disease control and prevention, and utilized NHPI community health workers (CHWs) and peer educators for key roles in implementation of the intervention. To address health disparities in the NHPI community, much can be learned from existing, successful interventions. Promising interventions share several attributes. The interventions were: culturally adapted using a community-based participatory research approach; addressed specific social determinants of health (i.e., cost of healthy food, transportation, access to health care) that influence disease control and prevention; honored the collectivist culture of NHPI communities by integrating social networks and extended family members; and utilized NHPI community members, including peer educators and CHWs, for intervention implementation. Further investment to scale these interventions for regional and national implementation is needed to address the significant diabetes disparities that NHPIs face.
Collapse
Affiliation(s)
- Pearl A McElfish
- College of Medicine, University of Arkansas for Medical Sciences Northwest, 1125 N. College Ave, Fayetteville, AR, 72703, USA.
| | - Rachel S Purvis
- Office of Community Health and Research, University of Arkansas for Medical Sciences Northwest, 1125 N. College Ave, Fayetteville, AR, 72703, USA
| | - Monica K Esquivel
- Department of Human Nutrition Food and Animal Sciences, College of Tropical Agriculture and Human Resources, University of Hawaii at Manoa, 1955 East West Road Ag Sci 314 L, Honolulu, HI, 96822, USA
| | - Ka'imi A Sinclair
- College of Nursing, Washington State University, 1100 Olive Way, Suite 1200, Seattle, WA, 98101, USA
| | - Claire Townsend
- Department of Native Hawaiian Health, John A. Burns School of Medicine, University of Hawaii at Manoa, 677 Ala Moana Blvd, Suite 1016, Honolulu, HI, 96813, USA
| | - Nicola L Hawley
- Yale School of Public Health, Yale University, 60 College St, New Haven, CT, 06510, USA
| | - Lauren K Haggard-Duff
- College of Nursing, University of Arkansas for Medical Sciences Northwest, 1125 N. College Ave, Fayetteville, AR, 72703, USA
| | - Joseph Keawe'aimoku Kaholokula
- Department of Native Hawaiian Health, John A. Burns School of Medicine, University of Hawaii at Manoa, 677 Ala Moana Blvd, Suite 1016, Honolulu, HI, 96813, USA
| |
Collapse
|
9
|
Balli ML, Dickey TA, Purvis RS, Warmack TS, Riklon S, McElfish PA. "You Want to Give the Best Care Possible, and You Know When They Leave Your Pharmacy, You Didn't Give the Best Care Possible Most of the Time": Pharmacist- and Community Health Worker-Identified Barriers and Facilitators to Medication Adherence in Marshallese Patients. J Racial Ethn Health Disparities 2019; 6:652-659. [PMID: 30737733 DOI: 10.1007/s40615-019-00563-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 01/22/2019] [Accepted: 01/23/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND The Marshallese experience high rates of chronic diseases including hypertension and diabetes. Medication adherence is crucial to successful disease management, and healthcare providers play a crucial role in assisting their patients with medication adherence. METHODS A qualitative study design was used with individual interviews and focus groups with pharmacists and community health workers (CHWs) serving the Marshallese community in Northwest Arkansas. Participants were asked about their experiences with and perceptions of barriers and facilitators to medication adherence among Marshallese adults in Northwest Arkansas. RESULTS Eight pharmacists and nine CHWs were interviewed. Five themes emerged regarding barriers to medication adherence: (1) financial, (2) transportation, (3) language, (4) health literacy and understanding of Western medicine, and (5) mistrust. Four themes emerged regarding facilitators to medication adherence: (1) in-depth patient education strategies, (2) efforts to address the language barrier, (3) family engagement, and (4) public transportation and prescription home delivery. DISCUSSION Pharmacists and CHWs identified the same barriers to medication adherence, which are consistent with those documented in previous studies. Pharmacists also reported distress over their inability to confirm Marshallese patient understanding in relation to the use of prescribed medications.
Collapse
Affiliation(s)
- Michelle L Balli
- College of Pharmacy, University of Arkansas for Medical Sciences, Northwest, 1125 N. College Ave, Fayetteville, AR, 72703, USA
| | - Tiffany A Dickey
- College of Pharmacy, University of Arkansas for Medical Sciences, Northwest, 1125 N. College Ave, Fayetteville, AR, 72703, USA
| | - Rachel S Purvis
- Office of Community Health and Research, University of Arkansas for Medical Sciences, Northwest, 1125 N. College Ave, Fayetteville, AR, 72703, USA
| | - T Scott Warmack
- College of Pharmacy, University of Arkansas for Medical Sciences, Northwest, 1125 N. College Ave, Fayetteville, AR, 72703, USA
| | - Sheldon Riklon
- College of Medicine, University of Arkansas for Medical Sciences, Northwest, 1125 N. College Ave, Fayetteville, AR, 72703, USA
| | - Pearl A McElfish
- College of Medicine, University of Arkansas for Medical Sciences, Northwest, 1125 N. College Ave, Fayetteville, AR, 72703, USA.
| |
Collapse
|