1
|
Lightner JS, Moore E, Barnhart T, Rajabiun S. Cost and Activity Analysis of Patient Navigation for Persons With HIV: Comparing Health Department and Health Clinic Delivered Interventions. Health Promot Pract 2024:15248399241245059. [PMID: 38605560 DOI: 10.1177/15248399241245059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/13/2024]
Abstract
BACKGROUND Housing and employment are key factors in the health and well-being of people with HIV (PWH). Patient navigation programs to improve housing and employment show success in achieving viral suppression. Replicating patient navigation interventions to improve population health is needed. Understanding costs associated with patient navigation is a key next step. Therefore, the purpose of this study is to describe the costs associated with delivering patient navigator interventions in two different organizations to improve housing and employment for PWH. METHODS We conducted a cost analysis of two models of patient navigation. Costs were collected from two sites' payroll, invoices, contracts, and receipts. Pre-implementation and implementation costs and utilization of service costs are presented. Potential reimbursement costs were calculated based on salaries from the Department of Labor. RESULTS The health clinic's pre-implementation costs were higher ($169,133) than the health department's ($22,018). However, costs of patient navigation during the 2-year intervention were similar between health clinic and health department ($264,985 and $232,923, respectively). The health clinic reported more total time spent with clients (16,013.7 hours) than the health department (1,883.8 hours). The costs per additional person suppressed were $20,632 versus $37,810 for the health department and health clinic, respectively, which are lower than the average lifetime cost of HIV treatment. DISCUSSION Replicability and scalability of a patient navigation intervention are possible in both health clinic and health department settings. Each site had specific costs, client needs, and other factors that required adaptations to successfully implement the intervention. Future programs should consider tailoring costs to site-specific factors to improve outcomes. Policymakers and public health officials should consider using these results to improve planning and investment in HIV treatment and prevention interventions.
Collapse
Affiliation(s)
| | - Erik Moore
- Positive Impact Health Centers, Atlanta, GA, USA
| | - Travis Barnhart
- JSI Research and Training Institute, Inc, Arlington, VA, USA
| | | |
Collapse
|
2
|
Lightner JS, Schneider J, Grimes A, Wigginton M, Curran L, Gleason T, Prochnow T. Physical activity among transgender individuals: A systematic review of quantitative and qualitative studies. PLoS One 2024; 19:e0297571. [PMID: 38416705 PMCID: PMC10901310 DOI: 10.1371/journal.pone.0297571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 01/08/2024] [Indexed: 03/01/2024] Open
Abstract
Transgender individuals face stigma, discrimination, and other barriers impacting their ability to engage in physical activity (PA). We aim to review current literature on PA among transgender individuals. A systemic literature search of research studies from 2010-2023 was conducted. Studies must have reported a measure of PA and gender, be original research, and focus on transgender participants' PA. Rates of PA for transgender individuals were lower compared to cisgender or sexual minority individuals. Transgender women were less likely to engage in PA than other groups. Qualitative results suggest transgender oppression, stigma, discrimination, body image, unwelcoming environments (gyms, locker rooms, swimming pools), and the dichotomous structure of sport contribute to lower rates of PA among transgendered individuals. Disparities in PA for transgender individuals exist. Policy, environment, and system changes are needed to reduce transgender stigma in sport and PA settings. Current legislation is being developed and implemented in the United States regarding the place of transgender individuals in sport and PA. These results should inform public discourse on the topic.
Collapse
Affiliation(s)
- Joseph S. Lightner
- School of Nursing and Health Studies, University of Missouri-Kansas City, Kansas City, Missouri, United States of America
- American Public Health Association, Physical Activity Section, Washington, D.C., United States of America
| | - Justin Schneider
- Department of Nursing, California State University-San Bernardino, Palm Desert, California, United States of America
| | - Amanda Grimes
- School of Nursing and Health Studies, University of Missouri-Kansas City, Kansas City, Missouri, United States of America
- American Public Health Association, Physical Activity Section, Washington, D.C., United States of America
| | - Melissa Wigginton
- American Public Health Association, Physical Activity Section, Washington, D.C., United States of America
| | - Laurel Curran
- American Public Health Association, Physical Activity Section, Washington, D.C., United States of America
- Department of Health Behavior, School of Public Health, Texas A&M University, College Station, Texas, United States of America
| | - Tori Gleason
- University of Kansas Medical Centers, Kansas City, Kansas, United States of America
| | - Tyler Prochnow
- American Public Health Association, Physical Activity Section, Washington, D.C., United States of America
- Department of Health Behavior, School of Public Health, Texas A&M University, College Station, Texas, United States of America
| |
Collapse
|
3
|
Lightner JS, Valleroy E, Todd R, Eighmy KE, Grimes A. Cost Utility Analysis of an After-School Sports Sampling Program. Am J Health Promot 2024; 38:161-166. [PMID: 37889921 DOI: 10.1177/08901171231210386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/29/2023]
Abstract
PURPOSE The purposes of this study are to describe the costs of implementing an after-school physical activity intervention in three diverse, low-resourced, schools and to understand the potential aerobic impact of this program by cost. DESIGN We conducted a cost utilization study from an 8.5-month physical activity intervention. SETTING Three diverse, low-resourced, middle schools in the Midwest; The sample (N = 178) were mostly males (52.2%), African American or Black (54.8%), and divided between 6th, 7th, and 8th grades. METHOD Costs were collected from contracts, invoices, payroll, and receipts. Metabolic equivalents were collected from past literature. Costs/MET-hour were calculated for the schools and entire program by dividing costs by total MET-hours engaged in physical activity. RESULTS Costs were $2.51/MET-hour, $8.96/MET-hour, and $10.73/MET-hour for the three schools. On average, the intervention had a cost of $4.73/MET-hour. CONCLUSIONS Cost/MET-hour for the present study is comparable or lower than other school-based physical activity interventions that require additional staff time and programming outside of standard classroom activities. Scale-up of after-school programs may be one way to improve the costs of programs in both schools and districts.
Collapse
Affiliation(s)
- Joseph S Lightner
- School of Nursing and Health Studies, University of Missouri-Kansas City, Kansas, MO, USA
| | - Ella Valleroy
- School of Nursing and Health Studies, University of Missouri-Kansas City, Kansas, MO, USA
- Department of Population Health, University of Kansas Medical Center, Kansas, MO, USA
| | - Reagan Todd
- School of Nursing and Health Studies, University of Missouri-Kansas City, Kansas, MO, USA
| | - Katlyn E Eighmy
- Department of Population Health, University of Kansas Medical Center, Kansas, MO, USA
- Center for Healthy Lifestyles, Children's Mercy Hospital, Kansas, MO, USA
| | - Amanda Grimes
- School of Nursing and Health Studies, University of Missouri-Kansas City, Kansas, MO, USA
| |
Collapse
|
4
|
Falk GE, Okut H, Lightner JS, Farrokhian N, LaCrete F, Chiu A, Shnayder Y, Bond J, Sykes KJ. Forecasting Rural and Urban Otolaryngologists, Radiation Oncologists, and Oropharyngeal Carcinoma. Laryngoscope 2024; 134:136-142. [PMID: 37395265 DOI: 10.1002/lary.30809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 03/04/2023] [Accepted: 05/24/2023] [Indexed: 07/04/2023]
Abstract
OBJECTIVE To forecast oropharyngeal carcinoma (OPC) incidence with otolaryngologist and radiation oncologist numbers per population by rural and urban counties through 2030. METHODS Incident OPC cases were abstracted from the Surveillance, Epidemiology, and End Results 19 database, and otolaryngologists and radiation oncologists from the Area Health Resources File by county from 2000 to 2018. Variables were analyzed by metropolitan counties with over 1,000,000 people (large metros), rural counties adjacent to a metro (rural adjacent), and rural counties not adjacent to a metro (rural not adjacent). Data were forecasted via an unobserved components model with regression slope comparisons. RESULTS Per 100,000 population, forecasted OPC incidence increased from 2000 to 2030 (large metro: 3.6 to 10.6 cases; rural adjacent: 4.2 to 11.9; rural not adjacent: 4.3 to 10.1). Otolaryngologists remained stable for large metros (2.9 to 2.9) but declined in rural adjacent (0.7 to 0.2) and rural not adjacent (0.8 to 0.7). Radiation oncologists increased from 1.0 to 1.3 in large metros, while rural adjacent remained similar (0.2 to 0.2) and rural not adjacent increased (0.2 to 0.6). Compared to large metros, regression slope comparisons indicated similar forecasted OPC incidence for rural not adjacent (p = 0.58), but greater for rural adjacent (p < 0.001, r = 0.96). Otolaryngologists declined for rural regions (p < 0.001 and p < 0.001, r = -0.56, and r = -0.58 for rural adjacent and not adjacent, respectively). Radiation oncologists declined in rural adjacent (p < 0.001, r = -0.61), while increasing at a lesser rate for rural not adjacent (p = 0.002, r = 0.96). CONCLUSIONS Rural OPC incidence disparities will grow while the relevant, rural health care workforce declines. LEVEL OF EVIDENCE NA Laryngoscope, 134:136-142, 2024.
Collapse
Affiliation(s)
- Grace E Falk
- Department of Otolaryngology-Head and Neck Surgery, University of Kansas Health System, Kansas City, Kansas, U.S.A
| | - Hayrettin Okut
- Office of Research and Department of Population Health, University of Kansas School of Medicine-Wichita, Wichita, Kansas, U.S.A
| | - Joseph S Lightner
- School of Nursing and Health Studies, University of Missouri-Kansas City, Kansas City, Missouri, U.S.A
| | - Nathan Farrokhian
- Department of Otolaryngology-Head and Neck Surgery, University of Kansas Health System, Kansas City, Kansas, U.S.A
| | - Frantzlee LaCrete
- Department of Otolaryngology-Head and Neck Surgery, University of Kansas Health System, Kansas City, Kansas, U.S.A
| | - Alexander Chiu
- Department of Otolaryngology-Head and Neck Surgery, University of Kansas Health System, Kansas City, Kansas, U.S.A
| | - Yelizaveta Shnayder
- Department of Otolaryngology-Head and Neck Surgery, University of Kansas Health System, Kansas City, Kansas, U.S.A
| | - Justin Bond
- Department of Otolaryngology-Head and Neck Surgery, University of Kansas Health System, Kansas City, Kansas, U.S.A
| | - Kevin J Sykes
- Department of Otolaryngology-Head and Neck Surgery, University of Kansas Health System, Kansas City, Kansas, U.S.A
| |
Collapse
|
5
|
Rajabiun S, Lightner JS, Sullivan M, Flaherty J, Nguyen C, Ramirez-Forcier J, Myers JJ. "It Comes in Steps and Stages": Experiences of People Living with HIV in Achieving Employment. Int J Environ Res Public Health 2023; 20:6778. [PMID: 37754637 PMCID: PMC10531408 DOI: 10.3390/ijerph20186778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 08/11/2023] [Accepted: 08/16/2023] [Indexed: 09/28/2023]
Abstract
People living with HIV who are seeking jobs experience unique barriers to obtaining employment at the individual, group, and community levels. Traditional employment assistance programs can provide support but may not be tailored to some people living with HIV who often experience barriers to work related to their social needs (such as housing instability) or their lack of consistent engagement in the workforce. To understand how people living with HIV return to work, in-depth interviews were conducted with 43 participants enrolled in interventions coordinating HIV care with housing and employment services at eight sites across the US. Four themes emerged on strategies to increase employment: (1) assessing and responding to employment needs that align with their socio-economic environment; (2) using social networks among family and friends for referrals and support; (3) engaging with navigators who are able to connect clients to skills building opportunities and job resources; and (4) addressing the system barriers such as helping with unmet basic needs (e.g. transportation), finding employers who can accommodate workers with income limits associated with public benefits, and helping immigrants, transgender individuals, and people experiencing homelessness secure legal documentsthat facilitate entry into employment by reducing stigmatized identities.
Collapse
Affiliation(s)
- Serena Rajabiun
- Department of Public Health, University of Massachusetts—Lowell, Lowell, MA 01854, USA
| | - Joseph S. Lightner
- School of Nursing and Health Studies, University of Missouri-Kansas City, Kansas City, MO 64108, USA;
| | - Marena Sullivan
- Center for Innovation in Social Work and Health, School of Social Work, Boston University, Boston, MA 02215, USA; (M.S.); (J.F.)
| | - Jessica Flaherty
- Center for Innovation in Social Work and Health, School of Social Work, Boston University, Boston, MA 02215, USA; (M.S.); (J.F.)
| | - Chau Nguyen
- HIV/AIDS Bureau, Health Resources and Services Administration, Rockville, MD 20852, USA;
| | | | - Janet J. Myers
- School of Medicine, University of California—San Francisco, San Francisco, CA 94143, USA;
| |
Collapse
|
6
|
Lightner JS, Chesnut SR, Cory T, Sellers S, Woods L, Skarbek A, Willis-Smith N, Valleroy E, Colbert S, Witt J. Changes in HIV knowledge and interest among nursing and public health students at a large Midwest University: Outcomes of implementing the National HIV Curriculum. Nurse Educ Today 2023; 125:105802. [PMID: 36989636 DOI: 10.1016/j.nedt.2023.105802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 03/09/2023] [Accepted: 03/17/2023] [Indexed: 06/19/2023]
Abstract
BACKGROUND Ending the HIV epidemic requires additional healthcare and public health workers who are competent in HIV prevention and treatment. The National HIV Curriculum was developed to increase competency in HIV among healthcare workers in the US. OBJECTIVES The purpose of the current study was to examine the impact of implementing the National HIV Curriculum (NHC) for nursing and public health students. DESIGN This study employed a single-arm, cohort intervention design. SETTING This study was conducted at large, public university in the Midwestern United States of America in a state noted for high HIV transmission. PARTICIPANTS Undergraduate nursing, graduate nursing, and undergraduate public health students participated in this study. METHODS An online survey of nursing and public health students was conducted following implementation of the NHC at a large, public university in the Midwest. Students were assessed on knowledge and interest of HIV using a bootstrapped paired-samples t-test approach. RESULTS Participants (N = 175) were enrolled in the undergraduate nursing program (n = 72, 41.14 %), graduate nursing (n = 37, 21.14 %) public health (n = 37, 21.14 %), medicine (n = 10, 5.71 %), and biological, biomedical, and health sciences discipline (n = 19, 10.86 %). Overall, results suggest a consistent gain in knowledge of working with individuals living with HIV of 1.42 points (on a 4-point scale). About half (47.43 %) of all students increased interest to work with individuals living with HIV in the future. CONCLUSION The NHC increased knowledge and interest in students across a broad range of nursing, public health, medicine, and other disciplines. This study suggests that universities can integrate the curriculum across undergraduate and graduate programs. Students at varying degree levels may benefit from the NHC. Future longitudinal studies should be conducted on the career choices of those students exposed to the NHC.
Collapse
Affiliation(s)
- Joseph S Lightner
- School of Nursing and Health Studies, University of Missouri-Kansas City, Kansas City, MO, USA.
| | - Steven R Chesnut
- School of Nursing and Health Studies, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Tracy Cory
- School of Nursing and Health Studies, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Sherri Sellers
- School of Nursing and Health Studies, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Latoya Woods
- School of Nursing and Health Studies, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Anita Skarbek
- School of Nursing and Health Studies, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Nancy Willis-Smith
- School of Nursing and Health Studies, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Ella Valleroy
- School of Nursing and Health Studies, University of Missouri-Kansas City, Kansas City, MO, USA; Department of Population Health, University of Kansas Medical Center, Kansas City, KS, USA; School of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Sharon Colbert
- The Collaborative to Advance Health Services, School of Nursing and Health Studies, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Jacki Witt
- The Collaborative to Advance Health Services, School of Nursing and Health Studies, University of Missouri-Kansas City, Kansas City, MO, USA
| |
Collapse
|
7
|
Lightner JS, Collinson S, Grimes A. Cost Analysis of a Culturally Appropriate, Community-Delivered Intervention to Increase Physical Activity. Am J Health Promot 2023. [DOI: 10.1177/08901171231158098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
Purpose Understand the cost of delivering existing community-based, no cost to participant, aerobic dance and yoga classes in an underserved, racial and ethnic minority community in the Midwest. Design Pilot 4-month observational, descriptive, cost analysis of community fitness classes. Setting Community-wide, group-based, fitness classes online, and in parks and community centers in traditionally Black neighborhoods in Kansas City. Participants Participants (N = 1428) were recruited from underserved, racial and ethnic minority areas of Kansas City, Missouri. Intervention Aerobic dance and yoga classes were provided free of charge to all residents of Kansas City, Missouri online and in-person. Each class was approximately 1 hour, with a warmup and cooldown. All classes were delivered by African American women. Methods Descriptive statistics of the costs for the program are presented. Cost per metabolic equivalents (MET) were calculated. Independent samples t-tests were conducted to examine differences between aerobic dance and yoga cost per MET. Results The total program costs were $10,759.88 USD, with 1428 participants attending 82 classes over the 4-month intervention. The cost per MET was $1.67, $1.11, and $0.74/MET-hour/session/attendee for low, moderate, and high-intensity aerobic dance, respectively, and $3.02/MET-hour/session/attendee for yoga. Aerobic dance had a significantly lower cost per MET than yoga ( t = 13.6, P < .001, t = 47.6, P < .001, t = 92.8, P < .001, for low, moderate, and high-intensity, respectively). Conclusions Delivering community-based, physical activity interventions in racial and ethnic minority communities is a potential way to increase physical activity. The costs of group-based fitness classes are similar to other physical activity interventions. Further research needs to be conducted on the costs to increase physical activity of traditionally underserved populations who suffer from higher rates of inactivity and comorbidities.
Collapse
Affiliation(s)
- Joseph S. Lightner
- School of Nursing and Health Studies, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Samantha Collinson
- School of Nursing and Health Studies, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Amanda Grimes
- School of Nursing and Health Studies, University of Missouri-Kansas City, Kansas City, MO, USA
| |
Collapse
|
8
|
Valleroy E, Reed A, Lightner JS. Population-level predictors of sexually transmitted infection rate changes in Missouri: an ecological study. Arch Public Health 2023; 81:12. [PMID: 36691069 PMCID: PMC9872404 DOI: 10.1186/s13690-022-01019-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 12/26/2022] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Sexually transmitted infection rates continue to increase across the US, further developing health disparities and economic burdens of disease, especially as migration occurs. In this study, we aim to assess the relationship between STI rates and population-level variables from 2008 to 2017 at the county level in Missouri. METHODS Two data sources were used: STI rates of chlamydia, gonorrhea, syphilis, HIV reported to Missouri DHSS and ACS 1-year county population estimates. Linear regression models and ANOVA tests were conducted in SPSS for each STI from year-to-year and 2008-2017. Covariates included in the analyzes were county-level income, employment rate, race, ethnicity, age, and percent poverty. Further, Akaike Information Criterion tests were performed to indicate the best predictor models and averaged standardized beta values. RESULTS Significant relationships among STI rates and population growth were identified. Chlamydia, syphilis, and HIV were positively associated with population growth from 2008 to 2017 (β = 0.15; β = 0.01; β = 0.05, respectively). Gonorrhea was negatively associated with population growth (β = - 0.02) but positively associated with unemployment rates (β = 0.01) highlighting the need to address population growth, as well as other variables in a population. CONCLUSIONS There seems to be a positive relationship among population change and rates of STIs. As populations change, rates of STIs change. Moving forward, quantitative work should be conducted in various states and the nation to understand this relationship in different contexts. Future studies should be qualitative word focused on county health departments and community health improvement plans. Lastly, public policy should be implemented to buffer the impact of migration on health outcomes.
Collapse
Affiliation(s)
- Ella Valleroy
- grid.266756.60000 0001 2179 926XUniversity of Missouri-Kansas City, Kansas City, MO USA ,grid.412016.00000 0001 2177 6375University of Kansas – Medical Center, Kansas City, KS USA
| | - Aaron Reed
- grid.266756.60000 0001 2179 926XUniversity of Missouri-Kansas City, Kansas City, MO USA
| | - Joseph S. Lightner
- grid.266756.60000 0001 2179 926XUniversity of Missouri-Kansas City, Kansas City, MO USA
| |
Collapse
|
9
|
Baughn M, Arellano V, Hawthorne-Crosby B, Lightner JS, Grimes A, King G. Physical activity, balance, and bicycling in older adults. PLoS One 2022; 17:e0273880. [PMID: 36480563 PMCID: PMC9731420 DOI: 10.1371/journal.pone.0273880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 10/15/2022] [Indexed: 12/13/2022] Open
Abstract
Falls are a critical public health issue among older adults. One notable factor contributing to falls in older adults is a deterioration of the structures supporting balance and overall balance control. Preliminary evidence suggests older adults who ride a bicycle have better balance than those who do not. Cycling may be an effective intervention to prevent falls among older adults. This study aims to objectively measure the relationship between bicycling, physical activity, and balance for older adults. Older adult cyclists (n = 19) and non-cyclists (n = 27) were recruited to (1) complete a survey that assessed demographics; (2) wear an accelerometer for 3 weeks to objectively assess physical activity; and (3) complete balance-related tasks on force platforms. Mann-Whitney U-tests were performed to detect differences in balance and physical activity metrics between cyclists and non-cyclists. Cyclists were significantly more physically active than non-cyclists. Cyclists, compared to non-cyclists, exhibited differences in balance-related temporospatial metrics and long-range temporal correlations that suggest a more tightly regulated postural control strategy that may relate to higher stability. Cycling was observed to correlate more strongly with balance outcomes than other physical activity. Taken together, these results demonstrate the possible implications for cycling as an effective intervention to improve balance and reduce fall risk.
Collapse
Affiliation(s)
- Maya Baughn
- School of Nursing and Health Studies, University of Missouri-Kansas City, Kansas City, Missouri, United States of America
| | - Victor Arellano
- School of Nursing and Health Studies, University of Missouri-Kansas City, Kansas City, Missouri, United States of America
- * E-mail:
| | - Brieanna Hawthorne-Crosby
- Division of Energy, Matter and Systems, School of Science and Engineering, University of Missouri-Kansas City, Kansas City, Missouri, United States of America
| | - Joseph S. Lightner
- School of Nursing and Health Studies, University of Missouri-Kansas City, Kansas City, Missouri, United States of America
| | - Amanda Grimes
- School of Nursing and Health Studies, University of Missouri-Kansas City, Kansas City, Missouri, United States of America
| | - Gregory King
- Division of Energy, Matter and Systems, School of Science and Engineering, University of Missouri-Kansas City, Kansas City, Missouri, United States of America
| |
Collapse
|
10
|
Lightner JS, McKinney L, Hoppe K, Ziegler N, Gardiner K, Clardy S, Prochnow T, Collie-Akers V. Community health improvement plan: Study protocol for Kansas City's intervention and implementation evaluation. Public Health in Practice 2022; 4:100340. [PMID: 36389257 PMCID: PMC9649945 DOI: 10.1016/j.puhip.2022.100340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 10/24/2022] [Accepted: 11/01/2022] [Indexed: 11/06/2022] Open
Abstract
Objectives Community health improvement plans (CHIPs) are foundational public health practice, yet no studies have been conducted to understand implementation of these plans. This evaluation study of the Kansas City CHIP aims to 1) identify implementation strategies used in the CHIP, 2) assess changes in implementation, service, and client outcomes, 3) assess contextual factors associated with implementation, and 4) understand social networks of coalitions who implement the Kansas City CHIP. Study design This study protocol uses a unique, mixed methods approach to evaluating process and outcomes of the Kansas City CHIP. This study is supported by Proctor's Model of Implementation, RE-10.13039/100003582AIM (reach, effectiveness, adoption, implementation, maintenance), and the practical, robust implementation and sustainability model (PRISM). Methods Staff and community members involved in implementing the Kansas City, Missouri CHIP will be invited to participate in an annual online survey, a series of focus groups, and quarterly implementation logs to assess implementation and sustainability. Results RE-AIM and PRISM constructs are the primary and secondary outcomes of interest. Results of this study will be available from the first year of implementation in 2023, with future results provided annually. Conclusions This project will fill a much-needed gap in the literature by understanding how large-scale coalitions implement projects that aim to improve population health and health equity. CHIPs have the potential to improve population health, yet few studies have been conducted on CHIPs, with no studies to date assessing outcomes. To support effective implementation and sustainability as well as improve public health outcomes, researchers need to evaluate CHIPs and develop models of implementation that can quickly be integrated into practice to improve populations’ health.
Collapse
Affiliation(s)
- Joseph S. Lightner
- School of Nursing and Health Studies, University of Missouri-Kansas City, Kansas City, MO, USA
- Kansas City Health Commission, Kansas City Health Department, Kansas City, MO, USA
- Corresponding author. School of Nursing and Health Studies, University of Missouri-Kansas City, 2464 Charlotte St, 64108, Kansas City, MO, USA.
| | - Lana McKinney
- Kansas City Health Commission, Kansas City Health Department, Kansas City, MO, USA
- Wrights Hands Consulting, Kansas City, MO, USA
| | - Kate Hoppe
- Kansas City Health Commission, Kansas City Health Department, Kansas City, MO, USA
- CivicPoint Consulting, Kanas City, MO, USA
| | - Nancy Ziegler
- School of Nursing and Health Studies, University of Missouri-Kansas City, Kansas City, MO, USA
- Department of Population Health, University of Kansas Medical Center, Kansas City, KS, USA
| | - Kelsey Gardiner
- School of Nursing and Health Studies, University of Missouri-Kansas City, Kansas City, MO, USA
- Kansas City Health Commission, Kansas City Health Department, Kansas City, MO, USA
| | - Scott Clardy
- Kansas City Health Commission, Kansas City Health Department, Kansas City, MO, USA
| | - Tyler Prochnow
- Department of Health and Kinesiology, Texas A&M University, College Station, TX, USA
| | - Vicki Collie-Akers
- Department of Population Health, University of Kansas Medical Center, Kansas City, KS, USA
| |
Collapse
|
11
|
Lightner JS, Grimes A, Rhone J, Martin K, Moss J, Wray B, Eighmy K, Valleroy E, Baughn M. Fresh Produce Delivery to Middle School Youth: Outcomes of a Case Study in Providing Fresh Fruit and Vegetables to Underserved Youth. Am J Health Promot 2022; 37:529-533. [PMID: 36301692 DOI: 10.1177/08901171221136858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose The purpose of this study was to evaluate a weekly school-based fruit and vegetable delivery via a mobile market on urban middle schoolers’ nutrition behaviors. Design One-group, pretest-posttest design, quasi-experimental intervention in middle schoolers (6th-8th graders, N = 158) in Kansas City, MO Intervention Weekly delivery of free produce via a mobile market over 12 weeks. Measures A self-administered survey to assess self-report consumption of fruits, vegetables, soda, and sports drinks. Analysis Univariate and bivariate analyses were used. Proportions were compared and chi-square tests were conducted to compare youth at baseline and 12 weeks. Results More youth reported consuming fresh fruit (73.8% to 83.3%; χ2 = 7.76, P = .005) and vegetables (66.4% to 71.3%; χ2 = 13.55, P = <.001) from baseline to follow-up. Less youth reported soda (49.0% to 52.8%; χ2= 6.33, P = .012) and sports drinks (41.8% to 38.2%; χ2= 12.32, P < .001) from baseline to follow-up. Conclusions A mobile produce delivery intervention, like the Healthy Harvest Mobile Market, may be an effective strategy to increase fruit and vegetable consumption for adolescents.
Collapse
Affiliation(s)
- Joseph S Lightner
- School of Nursing and Health Studies, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Amanda Grimes
- School of Nursing and Health Studies, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Janet Rhone
- Community Health Strategies and Innovation, University Health Truman Medical Center, Kansas City, MO, USA
| | - Kael Martin
- Community Health Strategies and Innovation, University Health Truman Medical Center, Kansas City, MO, USA
| | - Justin Moss
- Community Health Strategies and Innovation, University Health Truman Medical Center, Kansas City, MO, USA
| | - Bridget Wray
- School of Nursing and Health Studies, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Katlyn Eighmy
- School of Nursing and Health Studies, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Ella Valleroy
- School of Nursing and Health Studies, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Maya Baughn
- School of Nursing and Health Studies, University of Missouri-Kansas City, Kansas City, MO, USA
| |
Collapse
|
12
|
Grimes A, Lightner JS, Eighmy K, Wray BD, Valleroy E, Baughn M. Physical Activity and Nutrition Intervention for Middle Schoolers (Move More, Get More): Protocol for a Quasi-Experimental Study. JMIR Res Protoc 2022; 11:e37126. [PMID: 35507392 PMCID: PMC9118081 DOI: 10.2196/37126] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 04/21/2022] [Accepted: 04/22/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Physical activity and nutrition behaviors are important to reducing the prevalence of childhood obesity. Previous research has identified school-based interventions as effective strategies to improve physical activity and nutrition. However, the results are often mixed, and middle schoolers are an under-studied population. OBJECTIVE Our study aims to fill this gap by developing an after-school intervention to increase physical activity and fruit and vegetable consumption that is influenced by national guidelines and formative research. METHODS This study was an after-school, quasi-experimental study spanning 9 months. Enrollment began in September 2021 and continued on a rolling basis through February 2022. Weekly, middle schoolers were offered 2-3 physical activity sessions and 1 produce kit. Physical activity was measured using accelerometers and questionnaires. Nutrition behaviors were assessed using questionnaires, and physical literacy was assessed using researcher observations. Follow-up data collection occurred in December 2021 and in April 2022. Difference scores will be calculated and analyzed for each outcome variable. RESULTS The intervention started in September 2021 and will conclude in May 2022. Published study results are expected in late 2022. CONCLUSIONS An increase in physical literacy, physical activity, and fruit and vegetable consumption is expected. If successful, future studies will focus on reach and sustainability. Lastly, this study may serve as a model for improving health outcomes in middle schools. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/37126.
Collapse
Affiliation(s)
- Amanda Grimes
- School of Nursing and Health Studies, University of Missouri, Kansas City, MO, United States
| | - Joseph S Lightner
- School of Nursing and Health Studies, University of Missouri, Kansas City, MO, United States
| | - Katlyn Eighmy
- School of Nursing and Health Studies, University of Missouri, Kansas City, MO, United States.,Department of Population Health, University of Kansas Medical Center, Kansas City, KS, United States
| | - Bridget D Wray
- School of Nursing and Health Studies, University of Missouri, Kansas City, MO, United States.,School of Urban Planning, University of Kansas, Lawrence, KS, United States
| | - Ella Valleroy
- School of Nursing and Health Studies, University of Missouri, Kansas City, MO, United States.,Department of Population Health, University of Kansas Medical Center, Kansas City, KS, United States
| | - Maya Baughn
- School of Nursing and Health Studies, University of Missouri, Kansas City, MO, United States
| |
Collapse
|
13
|
Grimes A, Lightner JS, Eighmy K, Steel C, Shook RP, Carlson J. Physical Activity Summer Slide Begins Early with COVID-19 School Closures: A Research Brief. JMIR Form Res 2022; 6:e35854. [PMID: 35297778 PMCID: PMC9014890 DOI: 10.2196/35854] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 02/25/2022] [Accepted: 03/16/2022] [Indexed: 02/06/2023] Open
Abstract
Background The COVID-19 pandemic has resulted in the closure of schools and may have inadvertently resulted in decreased physical activity for youth. Emerging evidence suggests that school closures due to the COVID-19 pandemic could have hastened the inactivity of youth, possibly due to a lack of structure outside of school and increased access to sedentary activities. Objective The purpose of this study was to assess changes in physical activity from pre–school closure (before the pandemic) to post–school closure (during the pandemic) among youth in spring 2020. Methods This study used a natural experimental design; youth were enrolled in a physical activity study prior to the lockdown, which was enforced due to the pandemic. The number of device-assessed steps per day and moderate-to-vigorous physical activity minutes per week were measured by using a Garmin Vivofit 4 (Garmin Ltd) accelerometer over 8 weeks. Mixed effects models were used to compare physical activity variables, which were measured before and during the COVID-19 pandemic. Results Youth were primarily Hispanic or Latinx (8/17, 47%) and female (10/17, 59%). The number of daily steps decreased by 45.4% during the school closure, from a pre–school closure mean of 8003 steps per day to a post–school closure mean of 4366 steps per day. Daily moderate-to-vigorous physical activity decreased by 42.5%, from a pre–school closure mean of 80.18 minutes per week to a post–school closure mean of 46.13 minutes per week. Conclusions Youth are engaging in roughly half as much physical activity during the school closure as they were prior to the school closure. If additional evidence supports these claims, interventions are needed to support youths’ engagement in physical activity in the Midwest.
Collapse
Affiliation(s)
- Amanda Grimes
- School of Nursing and Health Studies, University of Missouri-Kansas City, 2464 Charlotte St., Kansas City, US
| | - Joseph S Lightner
- School of Nursing and Health Studies, University of Missouri-Kansas City, 2464 Charlotte St., Kansas City, US
| | - Katlyn Eighmy
- School of Nursing and Health Studies, University of Missouri-Kansas City, 2464 Charlotte St., Kansas City, US.,University of Kansas Medical Center, Kansas City, US
| | - Chelsea Steel
- Center for Children's Healthy Lifestyles & Nutrition, Children's Mercy Kansas City, Kansas City, US
| | - Robin P Shook
- Center for Children's Healthy Lifestyles & Nutrition, Children's Mercy Kansas City, Kansas City, US
| | - Jordan Carlson
- Center for Children's Healthy Lifestyles & Nutrition, Children's Mercy Kansas City, Kansas City, US
| |
Collapse
|
14
|
Grimes A, Lightner JS, Pina K, Donis de Miranda ES, Meissen-Sebelius E, Shook RP, Hurley E. Designing an adolescent physical activity and nutrition intervention before and after COVID-19: A formative research study. JMIR Form Res 2021; 6:e33322. [PMID: 34932499 PMCID: PMC8785954 DOI: 10.2196/33322] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 11/15/2021] [Accepted: 12/13/2021] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND With rates of childhood obesity continually increasing, effective physical activity (PA) and nutrition interventions are needed. Formative research is used to tailor interventions to different cultural and geographic contexts and can also be vital in adapting intervention strategies in the face of significant disruptive circumstances (like COVID-19). OBJECTIVE We conducted formative research via in-person and online focus groups among middle schoolers and parents to better understand barriers and facilitators to PA and fruit and vegetable (FV) consumption and inform the design of a large intervention for a low-income, urban setting in the U.S. Midwest. METHODS We conducted two phases of qualitative focus groups with parents (n=20) and 6-9 grade middle schoolers (n=22). Phase 1 was conducted prior to the COVID-19 pandemic in late 2019, and phase 2 was conducted during the COVID-19 pandemic in the summer of 2020. Focus groups were transcribed and thematically coded using Dedoose software. RESULTS Main facilitators to PA prior to the pandemic included the opportunity to have fun, peer influence, competition (for some), and incentives, while main barriers to PA were time constraints and social discomfort. Main facilitators to eating FV included parental influence, preparation technique, and convenience, while barriers included dislike of vegetables, time constraints, and preparation or freshness. During the pandemic, facilitators to PA remained the same, while additional barriers to PA such as lack of motivation and limited time spent outside of the home were reported during the pandemic. For FV consumption, both facilitators and barriers remained the same for both time periods. Additionally, for some participants, the pandemic offered an opportunity to offer more FV to middle schoolers throughout the day. CONCLUSIONS Some themes identified were common to those reported in previous studies, such as peer influence on PA and parental influence on FV consumption. Novel themes, such as lack of motivation to be active and limited time outside the home, helped improve intervention adaptation, specifically during the COVID-19 pandemic. The continuity of formative research after a major, unexpected change in intervention context can be essential in targeting areas of an intervention that can be retained and those that need to be adjusted. CLINICALTRIAL
Collapse
Affiliation(s)
- Amanda Grimes
- School of Nursing and Health Studies, University of Missouri-Kansas City, 2464 Charlotte St., Kansas City, US
| | - Joseph S Lightner
- School of Nursing and Health Studies, University of Missouri-Kansas City, 2464 Charlotte St., Kansas City, US
| | - Kimberly Pina
- Division of Health Services and Outcomes Research, Children's Mercy Kansas City, Kansas City, US
| | | | - Emily Meissen-Sebelius
- Center for Children's Healthy Lifestyles & Nutrition, Children's Mercy Kansas City, Kansas City, Kansas City, US
| | - Robin P Shook
- Center for Children's Healthy Lifestyles & Nutrition, Children's Mercy Kansas City, Kansas City, Kansas City, US.,Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, US
| | - Emily Hurley
- Division of Health Services and Outcomes Research, Children's Mercy Kansas City, Kansas City, US.,Department of Population Health, University of Kansas Medical Center, Kansas City, US.,Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, US
| |
Collapse
|
15
|
Lightner JS, Rajabiun S, Cabral HJ, Flaherty J, Shank J, Brooks R. Associations of internalized and anticipated HIV stigma with returning to work for persons living with HIV. PLoS One 2021; 16:e0252783. [PMID: 34086826 PMCID: PMC8177530 DOI: 10.1371/journal.pone.0252783] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 05/23/2021] [Indexed: 11/19/2022] Open
Abstract
Introduction Employment is particularly beneficial for persons living with HIV (PLWH). However, PLWH experiencing internalized stigma or anticipating that they may experience stigma may be less likely to seek employment due to additional barriers associated with HIV. The purpose of this study was to understand the associations between internalized and anticipated stigma and employment barriers for PLWH. Methods Participants (N = 712) from 12 sites across the United States were recruited and interviewed about barriers to employment, HIV stigma, and several other factors related to health. A series of unadjusted and adjusted linear regression models were conducted using cross-sectional data. Results Adjusted models suggest that greater anticipated stigma was related to increased employment barriers (β = 0.12, p = 0.04). Mental and physical health functioning also positively predicted employment barriers (β = -0.18, p <0.001; β = -0.40, p <0.001, respectively). Discussion Employment among PLWH has beneficial impacts on HIV-related health outcomes. This study suggests that anticipated stigma may limit and individual’s willingness to seek out employment, or may cause them to leave employment. Internalized stigma may not play as large of a role in employment as anticipated stigma for PLWH. HIV-related stigma reduction interventions focused on community-level and employers are essential to improve employment opportunities for PLWH.
Collapse
Affiliation(s)
- Joseph S. Lightner
- School of Nursing and Health Studies, University of Missouri-Kansas City, Kansas City, Missouri, United States of America
- HIV Services, Kansas City Health Department, Kansas City, Missouri, United States of America
- * E-mail:
| | - Serena Rajabiun
- Department of Public Health, Zuckerberg College of Health Sciences, University of Massachusetts, Lowell, Massachusetts, United States of America
| | - Howard J. Cabral
- Department of Biostatistics, School of Public Health, Boston University, Boston, Massachusetts, United States of America
| | - Jessica Flaherty
- School of Social Work, Boston University, Boston, Massachusetts, United States of America
| | - Jamie Shank
- HIV Services, Kansas City Health Department, Kansas City, Missouri, United States of America
| | - Ronald Brooks
- Center for HIV Identification, Prevention and Treatment Services, University of California Los Angeles, Los Angeles, California, United States of America
| |
Collapse
|
16
|
Lightner JS, Heinrich KM, Sanderson MR. A Population-Based Study of Coupling and Physical Activity by Sexual Orientation for Men. J Homosex 2020; 67:1533-1541. [PMID: 31020924 DOI: 10.1080/00918369.2019.1601435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Research has suggested that men in relationships are more physically active than men who are single. This study provides a weighted analysis of physical activity by coupling status for men of different sexual orientations. Aggregated data from the United States 2013-2014 National Health Interview Survey were used to conduct multivariate logistic regression analyses. Compared to straight men (n = 29,926), gay men (n = 623) were less likely to be in a relationship (AOR 0.32, CI: 0.25-0.41). Coupled gay men did more physical activity than coupled straight men and were 1.62 (CI: 1.05-2.50) times more likely to be active, 1.67 (CI: 1.10-2.51) times more likely to be high active, 1.89 (CI: 1.24-2.89) times more likely to engage in muscle-strengthening activities, and 2.00 (CI: 1.28-3.11) times more likely to meet aerobic and muscle-strengthening recommendations. Coupling facilitates physical activity for men. However, more research is needed to help explore underlying mechanisms for differences by sexuality.
Collapse
Affiliation(s)
- Joseph S Lightner
- School of Nursing and Health Studies, University of Missouri-Kansas City , Kansas City, Missouri, USA
- Missouri Health Department , Kansas City, Missouri, USA
| | - Katie M Heinrich
- Department of Kinesiology, Kansas State University , Manhattan, Kansas, USA
| | - Matthew R Sanderson
- Department of Sociology, Anthropology, and Social Work, Kansas State University , Manhattan, Kansas, USA
| |
Collapse
|
17
|
Lightner JS, Shank JR, McBain R, Prochnow T. The social network of medical case managers, housing providers, and health department staff in the Ryan White HIV/AIDS Program: A Midwest case study. PLoS One 2020; 15:e0238430. [PMID: 32857810 PMCID: PMC7454952 DOI: 10.1371/journal.pone.0238430] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 08/17/2020] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Broad networks of providers in the Ryan White system are essential to end the HIV epidemic. Yet, there is little evidence that has assessed social networks of providers within HIV care networks. The purpose of this study is to provide a cross-sectional analysis of the role medical case managers (MCM), housing providers (HP), and health department staff (HDS), play in a Ryan White-funded area. METHODS All MCMs, HPs, and HDS (N = 57) in a Midwest Transitional Grant Area were invited to participate in a social network survey. Social network composition scores, exponential random graph modeling and ANOVA tests were conducted using SPSS and R Studio. RESULTS Communication in this network was significantly more likely between SW of the same provider type (e.g. MCMs communicating with other MCMs, β = .87, p<.001). HDS reported larger overall social networks (F(2,54) = 4.59, p = <.01), larger networks with other provider types (F(2,54) = 9.23, p<.001), and higher quality of relationships with other provider types (F(2,54) = 3.90, p<.05) than MCM or HP. HDS were more likely to communicate across the system than MCMs or HPs (β = .75, p<.001). DISCUSSION HDS play an important role in communicating across provider types in care delivery for HIV. Our results indicate that health departments represent essential agencies for broad dissemination of resources and knowledge, and may bridge communication barriers for coordination of housing support and HIV care delivery.
Collapse
Affiliation(s)
- Joseph S. Lightner
- School of Nursing and Health Studies, University of Missouri - Kansas City, Kansas City, Missouri, United States of America
- HIV Services, Kansas City Health Department, Kansas City, Missouri, United States of America
| | - Jamie R. Shank
- HIV Services, Kansas City Health Department, Kansas City, Missouri, United States of America
| | - Ryan McBain
- RAND Corporation, Boston, Massachusetts, United States of America
| | - Tyler Prochnow
- Department of Health Promotion, Baylor University, Waco, Texas, United States of America
| |
Collapse
|