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Xu Z, Gu Y, Xu X, Topaz M, Guo Z, Kang H, Sun L, Li J. Developing a Personalized Meal Recommendation System for Chinese Older Adults: Observational Cohort Study. JMIR Form Res 2024; 8:e52170. [PMID: 38814702 PMCID: PMC11176883 DOI: 10.2196/52170] [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: 08/25/2023] [Revised: 12/21/2023] [Accepted: 03/22/2024] [Indexed: 05/31/2024] Open
Abstract
BACKGROUND China's older population is facing serious health challenges, including malnutrition and multiple chronic conditions. There is a critical need for tailored food recommendation systems. Knowledge graph-based food recommendations offer considerable promise in delivering personalized nutritional support. However, the integration of disease-based nutritional principles and preference-related requirements needs to be optimized in current recommendation processes. OBJECTIVE This study aims to develop a knowledge graph-based personalized meal recommendation system for community-dwelling older adults and to conduct preliminary effectiveness testing. METHODS We developed ElCombo, a personalized meal recommendation system driven by user profiles and food knowledge graphs. User profiles were established from a survey of 96 community-dwelling older adults. Food knowledge graphs were supported by data from websites of Chinese cuisine recipes and eating history, consisting of 5 entity classes: dishes, ingredients, category of ingredients, nutrients, and diseases, along with their attributes and interrelations. A personalized meal recommendation algorithm was then developed to synthesize this information to generate packaged meals as outputs, considering disease-related nutritional constraints and personal dietary preferences. Furthermore, a validation study using a real-world data set collected from 96 community-dwelling older adults was conducted to assess ElCombo's effectiveness in modifying their dietary habits over a 1-month intervention, using simulated data for impact analysis. RESULTS Our recommendation system, ElCombo, was evaluated by comparing the dietary diversity and diet quality of its recommended meals with those of the autonomous choices of 96 eligible community-dwelling older adults. Participants were grouped based on whether they had a recorded eating history, with 34 (35%) having and 62 (65%) lacking such data. Simulation experiments based on retrospective data over a 30-day evaluation revealed that ElCombo's meal recommendations consistently had significantly higher diet quality and dietary diversity compared to the older adults' own selections (P<.001). In addition, case studies of 2 older adults, 1 with and 1 without prior eating records, showcased ElCombo's ability to fulfill complex nutritional requirements associated with multiple morbidities, personalized to each individual's health profile and dietary requirements. CONCLUSIONS ElCombo has shown enhanced potential for improving dietary quality and diversity among community-dwelling older adults in simulation tests. The evaluation metrics suggest that the food choices supported by the personalized meal recommendation system surpass autonomous selections. Future research will focus on validating and refining ElCombo's performance in real-world settings, emphasizing the robust management of complex health data. The system's scalability and adaptability pinpoint its potential for making a meaningful impact on the nutritional health of older adults.
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Affiliation(s)
- Zidu Xu
- Institute of Medical Information, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- School of Nursing, Columbia University, New York, NY, United States
| | - Yaowen Gu
- Institute of Medical Information, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Department of Chemistry, New York University, New York, NY, United States
| | - Xiaowei Xu
- Institute of Medical Information, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Maxim Topaz
- School of Nursing, Columbia University, New York, NY, United States
| | - Zhen Guo
- Institute of Medical Information, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hongyu Kang
- Institute of Medical Information, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lianglong Sun
- Institute of Medical Information, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jiao Li
- Institute of Medical Information, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Addlesee A, Eshghi A. You have interrupted me again!: making voice assistants more dementia-friendly with incremental clarification. FRONTIERS IN DEMENTIA 2024; 3:1343052. [PMID: 39081607 PMCID: PMC11285561 DOI: 10.3389/frdem.2024.1343052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 02/20/2024] [Indexed: 08/02/2024]
Abstract
In spontaneous conversation, speakers seldom have a full plan of what they are going to say in advance: they need to conceptualise and plan incrementally as they articulate each word in turn. This often leads to long pauses mid-utterance. Listeners either wait out the pause, offer a possible completion, or respond with an incremental clarification request (iCR), intended to recover the rest of the truncated turn. The ability to generate iCRs in response to pauses is therefore important in building natural and robust everyday voice assistants (EVA) such as Amazon Alexa. This becomes crucial with people with dementia (PwDs) as a target user group since they are known to pause longer and more frequently, with current state-of-the-art EVAs interrupting them prematurely, leading to frustration and breakdown of the interaction. In this article, we first use two existing corpora of truncated utterances to establish the generation of clarification requests as an effective strategy for recovering from interruptions. We then proceed to report on, analyse, and release SLUICE-CR: a new corpus of 3,000 crowdsourced, human-produced iCRs, the first of its kind. We use this corpus to probe the incremental processing capability of a number of state-of-the-art large language models (LLMs) by evaluating (1) the quality of the model's generated iCRs in response to incomplete questions and (2) the ability of the said LLMs to respond correctly after the users response to the generated iCR. For (1), our experiments show that the ability to generate contextually appropriate iCRs only emerges at larger LLM sizes and only when prompted with example iCRs from our corpus. For (2), our results are in line with (1), that is, that larger LLMs interpret incremental clarificational exchanges more effectively. Overall, our results indicate that autoregressive language models (LMs) are, in principle, able to both understand and generate language incrementally and that LLMs can be configured to handle speech phenomena more commonly produced by PwDs, mitigating frustration with today's EVAs by improving their accessibility.
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Affiliation(s)
- Angus Addlesee
- Interaction Lab, Heriot-Watt University, Edinburgh, United Kingdom
| | - Arash Eshghi
- Interaction Lab, Heriot-Watt University, Edinburgh, United Kingdom
- Alana AI, Edinburgh, United Kingdom
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Shah RR, Dixon CC, Fowler MJ, Driesse TM, Liang X, Summerour CE, Gross DC, Spangler HB, Lynch DH, Batsis JA. Using Voice Assistant Systems to Improve Dietary Recall among Older Adults: Perspectives of Registered Dietitians. J Nutr Gerontol Geriatr 2024; 43:1-13. [PMID: 38287658 PMCID: PMC10922685 DOI: 10.1080/21551197.2024.2302619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2024]
Abstract
Dietary assessments are important clinical tools used by Registered Dietitians (RDs). Current methods pose barriers to accurately assess the nutritional intake of older adults due to age-related increases in risk for cognitive decline and more complex health histories. Our qualitative study explored whether implementing Voice assistant systems (VAS) could improve current dietary recall from the perspective of 20 RDs. RDs believed the implementing VAS in dietary assessments of older adults could potentially improve patient accuracy in reporting food intake, recalling portion sizes, and increasing patient-provider efficiency during clinic visits. RDs reported that low technology literacy in older adults could be a barrier to implementation. Our study provides a better understanding of how VAS can better meet the needs of both older adults and RDs in managing and assessing dietary intake.
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Affiliation(s)
- Rahi R. Shah
- Division of Geriatric Medicine, University of North Carolina School of Medicine, Chapel Hill NC
- Department of Nutrition, Gillings School of Global Public Health, University of North Carolina, Chapel Hill NC
| | - Claudia C. Dixon
- Department of Nutrition, Gillings School of Global Public Health, University of North Carolina, Chapel Hill NC
| | - Michael J. Fowler
- Department of Nutrition, Gillings School of Global Public Health, University of North Carolina, Chapel Hill NC
| | - Tiffany M. Driesse
- Division of Geriatric Medicine, University of North Carolina School of Medicine, Chapel Hill NC
- Department of Nutrition, Gillings School of Global Public Health, University of North Carolina, Chapel Hill NC
| | - Xiaohui Liang
- Department of Computer Science, University of Massachusetts Boston, Boston, MA
| | - Caroline E. Summerour
- Division of Geriatric Medicine, University of North Carolina School of Medicine, Chapel Hill NC
| | - Danae C. Gross
- Department of Nutrition, Gillings School of Global Public Health, University of North Carolina, Chapel Hill NC
| | - Hillary B. Spangler
- Division of Geriatric Medicine, University of North Carolina School of Medicine, Chapel Hill NC
| | - David H. Lynch
- Division of Geriatric Medicine, University of North Carolina School of Medicine, Chapel Hill NC
| | - John A. Batsis
- Division of Geriatric Medicine, University of North Carolina School of Medicine, Chapel Hill NC
- Department of Nutrition, Gillings School of Global Public Health, University of North Carolina, Chapel Hill NC
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Kannampallil T, Ronneberg CR, Wittels NE, Kumar V, Lv N, Smyth JM, Gerber BS, Kringle EA, Johnson JA, Yu P, Steinman LE, Ajilore OA, Ma J. Design and Formative Evaluation of a Virtual Voice-Based Coach for Problem-solving Treatment: Observational Study. JMIR Form Res 2022; 6:e38092. [PMID: 35969431 PMCID: PMC9419044 DOI: 10.2196/38092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 07/01/2022] [Accepted: 07/04/2022] [Indexed: 11/13/2022] Open
Abstract
Background
Artificial intelligence has provided new opportunities for human interactions with technology for the practice of medicine. Among the recent artificial intelligence innovations, personal voice assistants have been broadly adopted. This highlights their potential for health care–related applications such as behavioral counseling to promote healthy lifestyle habits and emotional well-being. However, the use of voice-based applications for behavioral therapy has not been previously evaluated.
Objective
This study aimed to conduct a formative user evaluation of Lumen, a virtual voice-based coach developed as an Alexa skill that delivers evidence-based, problem-solving treatment for patients with mild to moderate depression and/or anxiety.
Methods
A total of 26 participants completed 2 therapy sessions—an introductory (session 1) and a problem-solving (session 2)—with Lumen. Following each session with Lumen, participants completed user experience, task-related workload, and work alliance surveys. They also participated in semistructured interviews addressing the benefits, challenges and barriers to Lumen use, and design recommendations. We evaluated the differences in user experience, task load, and work alliance between sessions using 2-tailed paired t tests. Interview transcripts were coded using an inductive thematic analysis to characterize the participants’ perspectives regarding Lumen use.
Results
Participants found Lumen to provide high pragmatic usability and favorable user experience, with marginal task load during interactions for both Lumen sessions. However, participants experienced a higher temporal workload during the problem-solving session, suggesting a feeling of being rushed during their communicative interactions. On the basis of the qualitative analysis, the following themes were identified: Lumen’s on-demand accessibility and the delivery of a complex problem-solving treatment task with a simplistic structure for achieving therapy goals; themes related to Lumen improvements included streamlining and improved personalization of conversations, slower pacing of conversations, and providing additional context during therapy sessions.
Conclusions
On the basis of an in-depth formative evaluation, we found that Lumen supported the ability to conduct cognitively plausible interactions for the delivery of behavioral therapy. Several design suggestions identified from the study including reducing temporal and cognitive load during conversational interactions, developing more natural conversations, and expanding privacy and security features were incorporated in the revised version of Lumen. Although further research is needed, the promising findings from this study highlight the potential for using Lumen to deliver personalized and accessible mental health care, filling a gap in traditional mental health services.
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Affiliation(s)
| | | | - Nancy E Wittels
- University of Illinois at Chicago, Chicago, IL, United States
| | - Vikas Kumar
- University of Illinois at Chicago, Chicago, IL, United States
| | - Nan Lv
- University of Illinois at Chicago, Chicago, IL, United States
| | - Joshua M Smyth
- The Pennsylvania State University, University Park, PA, United States
| | - Ben S Gerber
- University of Massachusetts Medical School, Worcester, MA, United States
| | - Emily A Kringle
- University of Illinois at Chicago, Chicago, IL, United States
| | - Jillian A Johnson
- The Pennsylvania State University, University Park, PA, United States
| | - Philip Yu
- University of Illinois at Chicago, Chicago, IL, United States
| | | | - Olu A Ajilore
- University of Illinois at Chicago, Chicago, IL, United States
| | - Jun Ma
- University of Illinois at Chicago, Chicago, IL, United States
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Weng H, Chen J, Ou A, Lao Y. Leveraging Representation Learning for the Construction and Application of Knowledge Graph for Traditional Chinese Medicine (Preprint). JMIR Med Inform 2022; 10:e38414. [PMID: 36053574 PMCID: PMC9482071 DOI: 10.2196/38414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 07/04/2022] [Accepted: 07/27/2022] [Indexed: 11/13/2022] Open
Affiliation(s)
- Heng Weng
- State Key Laboratory of Dampness Syndrome of Chinese Medicine, Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Jielong Chen
- School of Information Science, Guangdong University of Finance & Economics, Guangzhou, China
| | - Aihua Ou
- State Key Laboratory of Dampness Syndrome of Chinese Medicine, Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Yingrong Lao
- State Key Laboratory of Dampness Syndrome of Chinese Medicine, Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
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Tennant R, Allana S, Mercer K, Burns CM. Caregiver Expectations for Interfacing with Voice Assistants to Support Complex Home Care: Mixed-Methods Study (Preprint). JMIR Hum Factors 2022; 9:e37688. [PMID: 35771594 PMCID: PMC9284358 DOI: 10.2196/37688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 05/11/2022] [Accepted: 05/31/2022] [Indexed: 12/03/2022] Open
Abstract
Background Providing care in home environments is complex, and often the pressure is on caregivers to document information and ensure care continuity. Digital information management and communication technologies may support care coordination among caregivers. However, they have yet to be adopted in this context, partly because of issues with supporting long-term disease progression and caregiver anxiety. Voice assistant (VA) technology is a promising method for interfacing with digital health information that may aid in multiple aspects of being a caregiver, thereby influencing adoption. Understanding the expectations for VAs to support caregivers is fundamental to inform the practical development of this technology. Objective This study explored caregivers’ perspectives on using VA technology to support caregiving and inform the design of future digital technologies in complex home care. Methods This study was part of a larger study of caregivers across North America on the design of digital health technologies to support health communication and information management in complex home care. Caregivers included parents, guardians, and hired caregivers such as personal support workers and home care nurses. Video interviews were conducted with caregivers to capture their mental models on the potential application of VAs in complex home care and were theoretically analyzed using the technology acceptance model. Interviews were followed up with Likert-scale questions exploring perspectives on other VA applications beyond participants’ initial perceptions. Results Data were collected from 22 caregivers, and 3 themes were identified: caregivers’ perceived usefulness of VAs in supporting documentation, care coordination, and person-centered care; caregivers’ perceived ease of use in navigating information efficiently (they also had usability concerns with this interaction method); and caregivers’ concerns, excitement, expected costs, and previous experience with VAs that influenced their attitudes toward use. From the Likert-scale questions, most participants (21/22, 95%) agreed that VAs should support prompted information recording and retrieval, and all participants (22/22, 100%) agreed that they should provide reminders. They also agreed that VAs should support them in an emergency (18/22, 82%)—but only for calling emergency services—and guide caregivers through tasks (21/22, 95%). However, participants were less agreeable on VAs expressing a personality (14/22, 64%)—concerned they would manipulate caregivers’ perceptions—and listening ambiently to remind caregivers about their documentation (16/22, 73%). They were much less agreeable about VAs providing unprompted assistance on caregiving tasks (9/22, 41%). Conclusions The interviews and Likert-scale results point toward the potential for VAs to support family caregivers and hired caregivers by easing their information management and health communication at home. However, beyond information interaction, the potential impact of VA personality traits on caregivers’ perceptions of the care situation and the passive collection of audio data to improve user experience through context-specific interactions are critical design considerations that should be further examined.
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Affiliation(s)
- Ryan Tennant
- Department of Systems Design Engineering, Faculty of Engineering, University of Waterloo, Waterloo, ON, Canada
| | - Sana Allana
- Department of Systems Design Engineering, Faculty of Engineering, University of Waterloo, Waterloo, ON, Canada
| | - Kate Mercer
- Department of Systems Design Engineering, Faculty of Engineering, University of Waterloo, Waterloo, ON, Canada
- Library, University of Waterloo, Waterloo, ON, Canada
| | - Catherine M Burns
- Department of Systems Design Engineering, Faculty of Engineering, University of Waterloo, Waterloo, ON, Canada
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Amiri M, Li J, Roy S. Meal Planning for Alzheimer's Disease Using an Ontology-Assisted Multiple Criteria Decision-Making Approach. INTERNATIONAL JOURNAL OF E-HEALTH AND MEDICAL COMMUNICATIONS 2022. [DOI: 10.4018/ijehmc.316133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
As healthy diets and nutrition are crucial for people with Alzheimer's disease (AD), caregivers of patients with AD need to provide a balanced diet with the correct nutrients to boost the health and well-being of patients. However, this is challenging as they are likely to suffer from aging-related problems (such as teeth or gum problems) that make eating more uncomfortable; the planners, who are usually patients' family members, generally face high pressure, a busy schedule, and little experience. To help unprofessional caregivers of AD plan meals with the right nutrition and flavors, in this paper, the authors propose a meal planning mechanism that uses a multiple criteria decision-making approach to integrate various factors that affect a caregiver's choice of meals for AD patients. Ontology-based knowledge has been used to model personal preferences and characteristics and customize general diet recommendations. Case studies have demonstrated the feasibility and usability of the proposed approach.
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Affiliation(s)
| | - Juan Li
- North Dakota State University, USA
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Wójcik D, Szczechowiak K, Konopka P, Owczarek M, Kuzia A, Rydlewska-Liszkowska I, Pikala M. Informal Dementia Caregivers: Current Technology Use and Acceptance of Technology in Care. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18063167. [PMID: 33808644 PMCID: PMC8003488 DOI: 10.3390/ijerph18063167] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 03/10/2021] [Accepted: 03/16/2021] [Indexed: 01/10/2023]
Abstract
(1) Background: Given the increased social isolation caused by the COVID-19 pandemic, the challenges faced by informal dementia caregivers have increased. An increasing use of technology, both in care and dementia clinical trials, depends upon caregivers' abilities as a user. Accordingly, the aim of our study was to verify the current technology (smartphone and computer) use and acceptance in care, regarding socio-demographic variables; (2) Methods: Questionnaires were distributed to 102 dementia caregivers, mostly of patients with moderate dementia; (3) Results: The majority of participants were women (63%), and large number of them used technological devices such as a smartphone (91%) or computer (81%). Results revealed differences between age, gender, and education level on technology acceptance. Interestingly, smartphone use and acceptance seemed to be feasible, regardless of age, whereas computer use was negatively correlated with age. Technology was perceived by respondents as most useful for patients' activities including locomotion, toileting, and meals; (4) Conclusions: The future of technology use in dementia care should indicate solutions tailored to individual characteristics such as new technology solutions (GPS trackers, smartphone apps, dietary intervention, and meal planning apps).
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Affiliation(s)
- Daniel Wójcik
- Department of Management and Logistics in Health Care, Medical University of Lodz, Poland InterDoktorMen Medical University of Lodz, 90-419 Lodz, Poland;
- Wroclaw’s Alzheimer Center, 53-659 Wroclaw, Poland;
- Department of Epidemiology and Biostatistics, Social and Preventive Medicine of the Medical University of Lodz, 90-752 Lodz, Poland;
- Correspondence: ; Tel.: +48-505134649
| | | | - Patrycja Konopka
- Institute of Psychology, Polish Academy of Sciences, 00-378 Warsaw, Poland;
| | - Mateusz Owczarek
- Institute of Psychology, University of Wroclaw, 50-527 Wroclaw, Poland; (M.O.); (A.K.)
| | - Agata Kuzia
- Institute of Psychology, University of Wroclaw, 50-527 Wroclaw, Poland; (M.O.); (A.K.)
| | - Izabela Rydlewska-Liszkowska
- Department of Management and Logistics in Health Care, Medical University of Lodz, Poland InterDoktorMen Medical University of Lodz, 90-419 Lodz, Poland;
| | - Małgorzata Pikala
- Department of Epidemiology and Biostatistics, Social and Preventive Medicine of the Medical University of Lodz, 90-752 Lodz, Poland;
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F Corbett C, M Combs E, J Wright P, L Owens O, Stringfellow I, Nguyen T, Van Son CR. Virtual Home Assistant Use and Perceptions of Usefulness by Older Adults and Support Person Dyads. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:1113. [PMID: 33513798 PMCID: PMC7908177 DOI: 10.3390/ijerph18031113] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 01/12/2021] [Accepted: 01/21/2021] [Indexed: 12/02/2022]
Abstract
AIM Describe virtual home assistant use and usefulness from the perspective of older adults and their support persons. METHODS This was a mixed-methods study with older adults and their support persons (n = 10 dyads). Virtual home assistant (VHA) equipment was installed in participants' homes, and its use was documented for 60 days. Participants received protocol-guided telephone calls to address their VHA questions or problems. The type and frequency of VHA use were summarized with descriptive statistics. End-of-study interviews about VHA use were conducted with dyad participants. Qualitative content analyses were used to describe the interview findings about the dyad's perceptions of using the VHA, how it was used, any difficulties experienced, and suggestions for future VHA uses. RESULTS Participant dyads reported positive VHA perceptions, including the potential for VHAs to promote aging in place. Participants discussed the challenges learning the technology and replacing old habits with new ones. Participants offered recommendations for future VHA skills and for more education and training about using the VHA. CONCLUSIONS The study findings suggest that VHAs may be useful for older adults as they age in place and offer reassurance for support persons.
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Affiliation(s)
- Cynthia F Corbett
- College of Nursing, University of South Carolina, Columbia, SC 29208, USA
| | - Elizabeth M Combs
- College of Nursing, University of South Carolina, Columbia, SC 29208, USA
| | - Pamela J Wright
- College of Nursing, University of South Carolina, Columbia, SC 29208, USA
| | - Otis L Owens
- College of Social Work, University of South Carolina, Columbia, SC 29208, USA
| | | | - Thien Nguyen
- College of Nursing, University of South Carolina, Columbia, SC 29208, USA
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