1
|
Stapleton F, Abad JC, Barabino S, Burnett A, Iyer G, Lekhanont K, Li T, Liu Y, Navas A, Obinwanne CJ, Qureshi R, Roshandel D, Sahin A, Shih K, Tichenor A, Jones L. TFOS lifestyle: Impact of societal challenges on the ocular surface. Ocul Surf 2023; 28:165-199. [PMID: 37062429 PMCID: PMC10102706 DOI: 10.1016/j.jtos.2023.04.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 04/06/2023] [Indexed: 04/18/2023]
Abstract
Societal factors associated with ocular surface diseases were mapped using a framework to characterize the relationship between the individual, their health and environment. The impact of the COVID-19 pandemic and mitigating factors on ocular surface diseases were considered in a systematic review. Age and sex effects were generally well-characterized for inflammatory, infectious, autoimmune and trauma-related conditions. Sex and gender, through biological, socio-economic, and cultural factors impact the prevalence and severity of disease, access to, and use of, care. Genetic factors, race, smoking and co-morbidities are generally well characterized, with interdependencies with geographical, employment and socioeconomic factors. Living and working conditions include employment, education, water and sanitation, poverty and socioeconomic class. Employment type and hobbies are associated with eye trauma and burns. Regional, global socio-economic, cultural and environmental conditions, include remoteness, geography, seasonality, availability of and access to services. Violence associated with war, acid attacks and domestic violence are associated with traumatic injuries. The impacts of conflict, pandemic and climate are exacerbated by decreased food security, access to health services and workers. Digital technology can impact diseases through physical and mental health effects and access to health information and services. The COVID-19 pandemic and related mitigating strategies are mostly associated with an increased risk of developing new or worsening existing ocular surface diseases. Societal factors impact the type and severity of ocular surface diseases, although there is considerable interdependence between factors. The overlay of the digital environment, natural disasters, conflict and the pandemic have modified access to services in some regions.
Collapse
Affiliation(s)
- Fiona Stapleton
- School of Optometry and Vision Science, UNSW, Sydney, NSW, Australia.
| | - Juan Carlos Abad
- Department of Ophthalmology, Antioquia Ophthalmology Clinic-Clofan, Medellin, Antioquia, Colombia
| | - Stefano Barabino
- ASST Fatebenefratelli-Sacco, Ospedale L. Sacco-University of Milan, Milan, Italy
| | - Anthea Burnett
- School of Optometry and Vision Science, UNSW, Sydney, NSW, Australia
| | - Geetha Iyer
- C. J. Shah Cornea Services, Sankara Nethralaya, Chennai, Tamil Nadu, India
| | - Kaevalin Lekhanont
- Department of Ophthalmology, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Tianjing Li
- Department of Ophthalmology, School of Medicine, University of Colorado Anschutz Medical Campus, Denver, CO, USA
| | - Yang Liu
- Ophthalmology Department, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Alejandro Navas
- Conde de Valenciana, National Autonomous University of Mexico UNAM, Mexico City, Mexico
| | | | - Riaz Qureshi
- Department of Ophthalmology, School of Medicine, University of Colorado Anschutz Medical Campus, Denver, CO, USA
| | - Danial Roshandel
- Centre for Ophthalmology and Visual Science (incorporating Lions Eye Institute), The University of Western Australia, Nedlands, WA, Australia
| | - Afsun Sahin
- Department of Ophthalmology, Koc University Medical School, İstanbul, Turkey
| | - Kendrick Shih
- Department of Ophthalmology, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Anna Tichenor
- School of Optometry, Indiana University, Bloomington, IN, USA
| | - Lyndon Jones
- Centre for Ocular Research & Education (CORE), School of Optometry and Vision Science, University of Waterloo, Waterloo, ON, Canada
| |
Collapse
|
2
|
Trujillo-Trujillo J, Meza-Cárdenas M, Sánchez SB, Zamora SM, Porras A, López de Mesa CB, Bernal Parra LM, Bernal Lizarazú MC, Miller H, Silva JC. Knowledge, Attitudes, and Practices of Hygiene and the Prevention of Trachoma in the Indigenous Population of the Colombian Amazon Vaupés Department. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:4632. [PMID: 36901643 PMCID: PMC10001660 DOI: 10.3390/ijerph20054632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 02/23/2023] [Accepted: 03/02/2023] [Indexed: 06/18/2023]
Abstract
The Colombian program to end trachoma implements the component F of the SAFE strategy in the Vaupés department of the Amazon rainforest. Cultural, linguistic, and geographical barriers and the coexistence of an ancestral medical system demand the technical and sociocultural adaptation of this component. A cross-sectional survey combined with focus-group discussions to understand the knowledge, attitudes, and practices of the indigenous population related to trachoma was conducted in 2015. Of the 357 heads of households that participated, 45.1% associated trachoma with a lack of hygiene, and 94.7% associated the concept of hygiene with taking one or more body baths per day, using commercial or handcrafted soap. In total, 93% reported cleaning their children's faces and eyes more often when they have conjunctivitis, but 66.1% also did this with clothes or towels in use, and 52.7% of people shared towels; in total, 32.8% indicated that they would use ancestral medicine to prevent and treat trachoma. The SAFE strategy in Vaupés requires an intercultural approach to facilitate stakeholder support and participation to promote general and facial hygiene, washing clothes with soap, and not sharing towels and clothes to dry and clean children's faces for effective and sustainable elimination of trachoma as a public health problem. This qualitative assessment facilitated an intercultural approach locally and in other Amazonian locations.
Collapse
Affiliation(s)
- Julián Trujillo-Trujillo
- Ministry of Health and Social Protection, Bogotá 110311, Colombia
- Escuela de Ciencias de la Salud—ECISA, Universidad Nacional Abierta y a Distancia, UNAD, Bogotá 111511, Colombia
| | - Mónica Meza-Cárdenas
- Ministry of Health and Social Protection, Bogotá 110311, Colombia
- Grupo de Medicina Comunitaria y Salud Colectiva, Maestría en Epidemiología, Facultad de Medicina, Universidad El Bosque, Bogotá 110111, Colombia
| | | | | | - Alexandra Porras
- Grupo de Medicina Comunitaria y Salud Colectiva, Maestría en Epidemiología, Facultad de Medicina, Universidad El Bosque, Bogotá 110111, Colombia
| | | | - Luz Mery Bernal Parra
- Escuela de Ciencias de la Salud—ECISA, Universidad Nacional Abierta y a Distancia, UNAD, Bogotá 111511, Colombia
| | | | - Hollman Miller
- Department of Vaupés, Secretariate of Health, Mitú 970001, Colombia
| | | |
Collapse
|
3
|
Barton A, Ramadhani A, Mafuru E, Mtuy T, Massae P, Malissa A, Derrick T, Houghton J, Harte A, Payne T, Pickering H, Burton MJ, Roberts CH, Holland MJ. HLA-A, -B, -C, -DPB1, -DQB1 and -DRB1 allele frequencies of North Tanzanian Maasai. Hum Immunol 2023; 84:67-68. [PMID: 36335052 DOI: 10.1016/j.humimm.2022.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 10/25/2022] [Accepted: 10/26/2022] [Indexed: 11/06/2022]
Abstract
Locus-specific amplicon sequencing was used to HLA type 336 participants of Maasai ethnicity at the HLA-A, -B, -C, -DRB1, -DQB1 and -DPB1 loci. Participants were recruited from three study villages in North Tanzania, for the purpose of investigating risk factors for trachomatous scarring in children. Other than HLA-A, all loci significantly deviated from Hardy-Weinberg equilibrium, possibly due to high relatedness between individuals: 238 individuals shared a house with at least one another participant. The most frequent allele for each locus were A*68:02 (14.3 %), B*53:01 (8.4 %), C*06:02 (19.2 %), DRB1*13:02 (17.7 %), DQB1*02:01 (16.9 %) and DPB1*01:01 (15.7 %), while the most common inferred haplotype was A*68:02 ∼ B*18:01 ∼ C*07:04 ∼ DRB1*08:04 ∼ DQB1*04:02 ∼ DPB1*04:01 (1.3 %).
Collapse
Affiliation(s)
- Amber Barton
- Clinical Research Department, Faculty of Infectious and Tropiclal Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Athumani Ramadhani
- Eye Health Project, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Elias Mafuru
- Eye Health Project, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Tara Mtuy
- Clinical Research Department, Faculty of Infectious and Tropiclal Diseases, London School of Hygiene and Tropical Medicine, London, UK; Eye Health Project, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Patrick Massae
- Eye Health Project, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Aiweda Malissa
- Eye Health Project, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Tamsyn Derrick
- Clinical Research Department, Faculty of Infectious and Tropiclal Diseases, London School of Hygiene and Tropical Medicine, London, UK; Eye Health Project, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Joanna Houghton
- Clinical Research Department, Faculty of Infectious and Tropiclal Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Anna Harte
- Clinical Research Department, Faculty of Infectious and Tropiclal Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Thomas Payne
- Clinical Research Department, Faculty of Infectious and Tropiclal Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Harry Pickering
- Clinical Research Department, Faculty of Infectious and Tropiclal Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Matthew J Burton
- Clinical Research Department, Faculty of Infectious and Tropiclal Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Chrissy H Roberts
- Clinical Research Department, Faculty of Infectious and Tropiclal Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Martin J Holland
- Clinical Research Department, Faculty of Infectious and Tropiclal Diseases, London School of Hygiene and Tropical Medicine, London, UK.
| |
Collapse
|
4
|
Tanywe AC, Green H, Fernandez R. Perceptions and practices of community members relating to trachoma in Africa: a qualitative systematic review. JBI Evid Synth 2022; 20:2445-2474. [PMID: 36065912 DOI: 10.11124/jbies-21-00401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVE The objective of this review was to synthesize the perceptions and practices of community members relating to trachoma in Africa. INTRODUCTION Trachoma is the leading cause of blindness worldwide, and Africa is the worst-affected continent. Synthesized evidence relating to the disease has focused on various aspects including epidemiology, control, health education, facial cleanliness, interventions for trachomatous trichiasis, and the burden of trachoma on women. Currently, systematic reviews on perceptions and practices relating to trachoma are lacking despite the existence of primary studies. Filling this knowledge gap is critical for decision-making for effective community uptake of interventions. INCLUSION CRITERIA Qualitative studies on the perceptions and practices relating to trachoma in both health care and community settings in Africa were considered for inclusion. Studies with participants 14 years or older were considered, regardless of gender, health status, religion, or ethnicity. Perceptions included beliefs, perspectives, views, knowledge, and thoughts relating to trachoma. Practices included regular actions relating to trachoma, such as treatment and prevention behaviors. METHODS A search for studies in English was conducted in MEDLINE, CINAHL, Embase, PsycINFO, Sociological Abstracts, BioMed Central, Current Contents, Cochrane Library, and Google Scholar in May 2019 and updated in October 2021. Unpublished studies were searched in MedNar, Index to Thesis, ProQuest Dissertations and Theses Global, World Health Organization, and individual governments' commissioned trachoma reports. Two independent reviewers were involved in study selection, critical appraisal, and data extraction using the JBI tools. Data were synthesized using the JBI meta-aggregative approach. RESULTS Seven studies were included in this review. Participants were people either with or without trachoma. A total of 90 findings were extracted, from which 10 categories were produced and three synthesized findings derived from the categories. The synthesized findings are: understanding and awareness of trachoma influences perceptions of treatment and preventive methods; beliefs and behaviors influence treatment options; economic constraints, socio-cultural beliefs, and risk perceptions influence prevention behaviors and practices. CONCLUSION Various perceptions and practices relating to trachoma exist among community members in Africa. These perceptions and practices are influenced by knowledge, cultural beliefs, economic factors, and environmental factors. The findings suggest the need for decision-makers in policy and practice to consider and include these perceptions and practices when designing interventions to combat trachoma in endemic countries. However, due to the limited number of included studies and their methodological weaknesses, more high-quality studies are needed to have a deeper and broader view on these perceptions and practices.
Collapse
Affiliation(s)
- Asahngwa Constantine Tanywe
- Department of Anthropology, University of Yaounde, Cameroon.,The Cameroon Centre for Evidence Based Health Care: A JBI Centre of Excellence, Yaounde, Cameroon
| | - Heidi Green
- Centre for Research in Nursing and Health, St George Hospital, Kogarah, NSW Australia.,Centre for Evidence Based Initiatives in Health Care: A JBI Centre of Excellence, Wollongong, NSW, Australia
| | - Ritin Fernandez
- Centre for Research in Nursing and Health, St George Hospital, Kogarah, NSW Australia.,Centre for Evidence Based Initiatives in Health Care: A JBI Centre of Excellence, Wollongong, NSW, Australia.,School of Nursing, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, NSW, Australia
| |
Collapse
|
5
|
Adams MW, Sutherland EG, Eckert EL, Saalim K, Reithinger R. Leaving no one behind: targeting mobile and migrant populations with health interventions for disease elimination-a descriptive systematic review. BMC Med 2022; 20:172. [PMID: 35527246 PMCID: PMC9082871 DOI: 10.1186/s12916-022-02365-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 04/04/2022] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Mobile and migrant populations (MMPs) pose a unique challenge to disease elimination campaigns as they are often hard to survey and reach with treatment. While some elimination efforts have had success reaching MMPs, other campaigns are struggling to do so, which may be affecting progress towards disease control and elimination. Therefore, this paper reviews the literature on elimination campaigns targeting MMPs across a selection of elimination diseases-neglected tropical diseases, malaria, trypanosomiasis, polio, smallpox, and rinderpest. METHODS Through a systematic review process following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a three-person review team identified papers from databases, conference records, and citation searches using inclusion/exclusion criteria. Papers were divided into three key outcome domains during the synthetization process: (1) MMP movement patterns in East Africa including reasons for movement and consequences in terms of health outcomes and healthcare access; (2) MMP contribution to the transmission of disease across all geographies; (3) surveillance methods and treatment interventions used to implement programming in MMPs across all geographies. Experts in the field also provided supplemental information and gray literature to support this review. RESULTS The review identified 103 records which were descriptively analyzed using the outcome domains. The results indicate that in East Africa, there are various motivations for migration from economic opportunity to political unrest to natural disasters. Regardless of motivation, mobile lifestyles affect health service access such that MMPs in East Africa report barriers in accessing healthcare and have limited health knowledge. Often lower service delivery to these populations has resulted in higher disease prevalence. A minority of articles suggest MMPs do not pose challenges to reaching disease control and elimination thresholds. Finally, the literature highlighted surveillance methods (e.g., using satellite imagery or mobile phone data to track movement, participatory mapping, snowball sampling) and intervention strategies (e.g., integration with animal health campaigns, cross-border coordination, alternative mass drug administration [MDA] methods) to implement health interventions in MMPs. CONCLUSIONS Ultimately, the literature reviewed here can inform programmatic decisions as the community attempts to reach these never treated populations. SYSTEMATIC REVIEW REGISTRATION The protocol for this manuscript was registered with the International Prospective Registry of Systematic Reviews (PROSPERO) (No. CRD42021214743).
Collapse
Affiliation(s)
- Molly W Adams
- Research Triangle Institute (RTI) International, 701 13th St NW Ste 750, Washington , DC, 20005 USA
| | - Elizabeth G Sutherland
- Research Triangle Institute (RTI) International, 701 13th St NW Ste 750, Washington , DC, 20005 USA
| | - Erin L Eckert
- Research Triangle Institute (RTI) International, 701 13th St NW Ste 750, Washington , DC, 20005 USA
| | - Khalida Saalim
- Research Triangle Institute (RTI) International, 701 13th St NW Ste 750, Washington , DC, 20005 USA
| | - Richard Reithinger
- Research Triangle Institute (RTI) International, 701 13th St NW Ste 750, Washington , DC, 20005 USA
| |
Collapse
|
6
|
Mtuy TB, Mepukori J, Lankoi J, Lees S. Empowering Maasai women behind the camera: Photovoice as a tool for trachoma control. RESEARCH INVOLVEMENT AND ENGAGEMENT 2021; 7:51. [PMID: 34225822 PMCID: PMC8256559 DOI: 10.1186/s40900-021-00286-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 05/19/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND Photovoice is a method used to help engage community members to understand local realities and promote social change. Photovoice uses cameras in the hands of participants as a tool to visually document a specified topic. Photos taken by participants allow for reflection and stimulate dialog on an issue to ideally lead to social change. Trachoma, hyperendemic in Maasai communities in Northern Tanzania, is the commonest infectious cause of blindness worldwide, caused by chlamydia trachomatis. The bacterial infection commonly occurs in childhood and over many years repeated infections leads to inflammation and scarring of the eyelid. Often as adults this leads to the upper eyelid turning inward and eyelashes scratching the eye, resulting in pain and eventually blindness. We used photovoice as a tool for Maasai women to share their lived experiences of educating peers on trachoma and ultimately empowering women in this society. METHODS This public engagement intervention was conducted September thru October 2017. We held a workshop on trachoma control for 20 Maasai women including use of photovoice method. Women were asked to disseminate information from the trachoma control workshop to their community and to capture their experiences using disposable cameras. Five weeks post-workshop we facilitated a discussion and women displayed photos of the successes and challenges they encountered as advocates for trachoma control in their community. INTERVENTION OUTCOMES It was observed throughout the process and at the photo discussion meeting, that women articulated empowerment by this experience; as educators, agents of change and a source of valued information. CONCLUSION Photovoice should be considered for future interventions as a communication tool on health issues and to empower women to be ambassadors for health promotion.
Collapse
Affiliation(s)
- Tara B Mtuy
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK.
| | | | | | - Shelley Lees
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK
| |
Collapse
|
7
|
Understanding hard-to-reach communities: local perspectives and experiences of trachoma control among the pastoralist Maasai in northern Tanzania. J Biosoc Sci 2020; 53:819-838. [PMID: 32981544 DOI: 10.1017/s0021932020000553] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
As progress to eliminate trachoma is made, addressing hard-to-reach communities becomes of greater significance. Areas in Tanzania, inhabited by the Maasai, remain endemic for trachoma. This study assessed the effectiveness of Mass Drug Administration (MDA) through an ethnographic study of trachoma amongst a Maasai community. The MDA experience in the context of the livelihoods of the Maasai in a changing political economy was explored using participant observation and household interviews. Factors influencing MDA effectiveness within five domains were analysed. 1) Terrain of intervention: Human movement hindered MDA, including seasonal migration, domestic chores, grazing and school. Encounters with wildlife were significant. 2) Socio-cultural factors and community agency: Norms around pregnancy led women to accept the drug but hide refusal to swallow the drug. Timing of Community Drug Distributor (CDD) visits conflicted with livestock grazing. Refusals occurred among the ilmurrani age group and older women. Mistrust significantly hindered uptake of drugs. 3) Strategies and motivation of drug distributors: Maa-speaking CDDs were critical to effective drug delivery. Maasai CDDs, whilst motivated, faced challenges of distances, encounters with wildlife and compensation. 4) Socio-materiality of technology: Decreases in side-effects over years have improved trust in the drug. Restrictions to swallowing drugs and/or water were relevant to post-partum women and the ilmurrani. 5) History and health governance: Whilst perceptions of the programme were positive, communities questioned government priorities for resources for hospitals, medicines, clean water and roads. They complained of a lack of information and involvement of community members in health care services. With elimination in sight, hard-to-reach communities are paramount as these are probably the last foci of infection. Effective delivery of MDA programmes in such communities requires a critical understanding of community experiences and responses that can inform tailored approaches to trachoma control. Application of a critical social science perspective should be embedded in planning and evaluation of all NTD programmes.
Collapse
|
8
|
Stats MA, Hill DR, Ndirias J. Knowledge and misconceptions surrounding family planning among Young Maasai women in Kenya. Glob Public Health 2020; 15:1847-1856. [PMID: 32623957 DOI: 10.1080/17441692.2020.1788112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Adolescent fertility rates are high in Kenya and increase the likelihood of maternal and infant morbidity and mortality. Our objective was to explore the knowledge, perceptions, and barriers surrounding the use of family planning services among young Maasai women in Laikipia County, Central Kenya. Individual interviews with 50 participants were conducted in Laikipia County, Kenya during June and July of 2019. Qualitative data was visualised using JMP software and coded using the framework method for content analysis. Several overarching themes were identified. First, we identified a high rate of unintended pregnancy and a low rate of family planning use. Second, we found that many young Maasai women believe that only women that are married and have finished childbearing should utilise family planning services. Finally, we document highly prevalent myths among young women in the Maasai community that the use of family planning will lead to negative health consequences, such as infertility and cancer. We conclude that the Maasai community of Laikipia County, Kenya needs comprehensive family planning education that will improve knowledge and dispel myths in order to empower young Maasai women to make informed decisions surrounding family planning.
Collapse
Affiliation(s)
- Miriam A Stats
- Frank H. Netter School of Medicine, Quinnipiac University, North Haven, CT, USA
| | - David R Hill
- Frank H. Netter School of Medicine, Quinnipiac University, North Haven, CT, USA
| | | |
Collapse
|