Biomedical subjects

P Chou

Publications and source records attributed to P Chou.

At least 73 records · Page 4Linked to original sources

PubMed1998

Acupuncture utilization in Taiwan.

BACKGROUND: The objective of this study was to examine the prevalence of acupuncture utilization in Taiwan by people over 20 years of age. METHODS: Stratified cluster sampling was used to randomly select 20 villages and neighborhoods (townships), a total of 8,280 people, from northern, central, southern and eastern Taiwan. A structured questionnaire was used to collect information during home visits. A total of 5,805 questionnaires were valid for use in the study. RESULTS: The complete rate of home visits was 70.1%; 73.2% of those interviewed recognized acupuncture as one of the common therapeutic methods used in traditional Chinese medicine, whereas only 12.4% had received acupuncture treatment. Typical interviewees who had received acupuncture treatment were generally ethnic from southern Fukien and aged from 30-39 years; 58.3% of the 716 interviewees had received acupuncture treatment from licensed practitioners, while the remainder were treated by non-licensed practitioners. CONCLUSIONS: The response rate to the questionnaire was high (70.1%). However, the percentage of people who had received acupuncture treatment was only 12.4%, while many people (73.2%) were familiar with it. Approximately 40% of those who received acupuncture treatment did so from non-licensed practitioners. This may reveal either a lack of awareness by the public or a lack of public protection of health and safety.

Acupuncture Therapy↗

PubMed1997

Changes in plasma levels of lipids and lipoprotein composition in patients with Kawasaki disease.

Studies on the response of plasma lipids and lipoproteins to Kawasaki disease are scarce so far. The purpose of this study was to investigate the changes in plasma levels of lipids and apolipoproteins as well as the composition of different lipoproteins in patients during the acute and convalescence phases of Kawasaki disease. The results showed that during the acute phase, the concentrations of plasma high density lipoprotein (HDL)-cholesterol, apolipoprotein A-I (apoA-I) and A-II (apoA-II) were significantly reduced. While the reduction of HDL-cholesterol was mainly related to the lowering of esterified and unesterified cholesterols in HDL2 during the acute stage of Kawasaki disease, most of which recovered during the subsequent convalescence phase. The plasma concentration of triglycerides was 46% higher in patients during the acute phase of Kawasaki disease than in the control subjects, which may be ascribed to the increase of triglycerides in very low density lipoprotein (VLDL), low density lipoprotein (LDL) and HDL2. The variables studied above did not appear to be independent parameters. The level of plasma apoA-I showed a stronger negative association with triglyceride concentration (r = -0.22) than apoA-II (r = -0.11) and HDL-cholesterol (r = -0.07). Furthermore, the levels of cholesterol, apoA-I and apoA-II in HDL2, but not in HDL3, were inversely correlated with the levels of triglyceride. We conclude that the temporary changes of lipid levels associated with Kawasaki disease results predominantly from alterations of lipoprotein composition.

Apolipoproteins↗

PubMed1997

Enhanced expression of bcl-2 following antisense oligonucleotide mediated growth factor deprivation.

Although the role of bcl-2 in apoptosis has been described, its involvement in prostate cancer (CAP) progression is less well understood, but thought to be involved with the transition of CAP from androgen-sensitivity to androgen-independence, where its expression is augmented following androgen ablation. For treating these recurrent androgen-independent tumors, following hormone treatment failure, a new tier of therapy based upon growth factor deprivation has been suggested, implemented by antisense oligonucleotides (oligos) directed against mRNA encoding a critical growth regulatory autocrine loop (comprised of transforming growth factor-alpha (TGF-alpha) and its binding site, the epidermal growth factor receptor (EGFR). To determine whether oligo-induced growth factor deprivation therapy similarly enhanced expression of bcl-2 (as follows androgen deprivation) human prostate cancer derived PC-3 cells were treated in vitro with oligos directed against TGF-alpha (MR-1) and/or EGFR (MR-2). After 5 days of treatment cells were immunochemically stained for human bcl-2. In similar experiments, cells were treated for 3 days prior to extraction of proteins, Western blot analysis, photography and computer evaluation of protein density by SigmaScan software. Immunostained cells treated with oligos directed against mRNA encoding TGF-alpha (MR-1) either alone or in combination with that directed against EGFR (MR-2) had increased bcl-2 expression (+3 to +5). In addition, the intensity of Western blots scanned for bcl-2 expression were 19%, 32% and 30% greater in cells treated with oligos directed against TGF-alpha, EGFR or their combination, respectively. We conclude that enhanced bcl-2 expression followed antisense oligo induced growth factor deprivation. This result is similar to that found upon androgen deprivation therapy, and also demonstrates additional biologic activity of this new class of molecular therapeutic agents.

Apoptosis↗

PubMed1997

MR imaging of symptomatic neurocutaneous melanosis in children.

Neurocutaneous melanosis is a syndrome consisting of cutaneous nevi and melanocytosis of the leptomeninges. Over a 5-year period (1989-1994) we evaluated with MR imaging the central nervous system of five children with a confirmed histologic diagnosis of neurocutaneous melanosis. The children ranged in age from 7 to 10 years and consisted of two girls and three boys. They all had multiple pigmented skin lesions (cutaneous nevi) and presented with seizures, signs of raised intracranial pressure, cranial nerve palsies and/or myelopathy. The MR studies were performed with T1-weighted, T2-weighted and T1-weighted post-gadolinium images of the brain in addition to T1-weighted post-gadolinium images of the entire spine. The MR findings in all the children consisted of marked, diffuse enhancement of thickened leptomeninges surrounding the brain and spinal cord which was only demonstrated on the post-gadolinium T1-weighted images and mild to moderate hydrocephalus. We present our MR findings and compare these findings with other imaging findings in the literature. Our findings represent part of a spectrum of imaging abnormalities seen in patients with neurocutaneous melanosis.

Brain↗

PubMed1997

An analysis of unnatural deaths between 1990 and 1994 in A-Lein, Taiwan.

This is an analysis of all unnatural deaths (ICD-9, E47-E55) that occurred between 1990 and 1994 in A-Lein, Taiwan. Unnatural deaths for this period totalled 134, or 89.66 per 100,000 per year. The crude accidental mortality rate (E47-E53) and road traffic accident (RTA) mortality rate (E54 is many times larger than in other industrialized countries: 2.1-5.1 times and 2.4-7.7 times, respectively. These figures are even higher for males. The reported suicide rate in A-Lein is approximately equal to that in the UK, but less than other industrialized countries. The actual suicide mortality rate in A-Lein as computed in this survey was 1.8 times higher than reported, which was 2.4 times that of Taiwan as a whole and 2.1 times Great Britain; 30.9 per cent of male and 75 per cent of female unnatural deaths excluding RTAs were suicides (ICD-9 E48-E55). RTA deaths were 3.2 times higher among males than among females (P < 0.05) and 26.8 per cent were associated with alcohol consumption. Only 21.4 per cent of killed motorcyclists wore helmets and only 8.3 per cent of killed car drivers used seat belts. Unnatural deaths excluding RTAs were mostly among people of low socio-economic status aged 50-60 years with less than a college education. Of these, 75 per cent occurred at home or at work. The most common cause of non-traffic unnatural death excluding RTAs was suicide, and the second most common was drowning. In conclusion, it was found that high unnatural death rates in A-Lein are related to low socio-economic level, sex (males), drinking, inadequate safety protection while working and driving, and inadequate law enforcement.

Accidents↗

PubMed1997

Comparison of the prevalence in two diabetes surveys in Pu-Li, Taiwan, 1987-1988 and 1991-1992.

The objective of this study was to investigate the prevalence of non-insulin-dependent diabetes mellitus (NIDDM) in Pu-Li, Taiwan from 1991-1992, and to compare the results with a similar study conducted in 1987-1988. We also wished to compare different approaches in asking about patient history and to determine how this effects data authenticity. Both were community-based cross-sectional studies with stratified cluster sampling of residents age > or = 30. Blood samples were taken for screening and 75 g oral glucose tolerance tests were performed for diagnosis. The total number of eligible subjects in the second study was 2719 (1424 men, 1295 women). Complete data and samples were collected for 1118 (536 men, 582 women). The response rate was 41.1% (37.6% for men, 44.9% for women). The crude prevalence was 10.3% (5.6% known, 4.7% new). Using standard world population (Segi), the age-adjusted prevalence rate was 8.3% (4.0% known, 4.3% new). The 1991-1992 study had a response rate (crude 41.1%, adjusted 51.3%) which was slightly lower than the 1987-1988 study (crude 44.8%, adjusted 55.9%). The age-adjusted prevalence rates for new NIDDM were similar (4.4 vs. 4.3%) while the age-adjusted prevalence of known NIDDM in the second survey (4.0%) was lower than the first survey (6.9%), which apparently was overestimated due to the simplicity of questions regarding history. In conclusion, prevalence of new DM in this area appears to be stable, and when doing a survey regarding previous DM, it is better to include treatment history rather than depending on self-reporting of NIDDM alone.

Administration, Oral↗

PubMed1997

Depressive disorders among older residents in a Chinese rural community.

BACKGROUND: Two recent surveys of depression among Chinese elderly people sampled different populations, used different case ascertainment methods and resulted in a seven-fold difference in prevalence rates. The present study was conducted to compare prevalence rates obtained with two commonly used methods in the same population, and to examine the risk factors for depression. METHODS: The target population included all residents aged 65 years and over in a rural Chinese community. Participants were interviewed for demographic and medical information, examined by a neurologist and administered Chinese versions of the Geriatric Depression Scale-Short Form (GDS-S), the Cognitive Abilities Screening Instrument (CASI) and an Activities of Daily Living (ADL) form. Individuals who screened positive on the GDS-S were also interviewed by a psychiatrist for diagnosis according to the DSM-III-R criteria. RESULTS: Among the 1313 participants, 26% screened positive on the GDS-S and 13% were diagnosed as having a depressive disorder, including 6.1% with major depression. Individuals with depressive disorders were more likely to have poor ADL scores, lower CASI scores, and chronic physical illnesses. They were also more likely to be female, older, illiterate and without a spouse, but adding these variables did not increase the overall association with the GDS-S score. CONCLUSIONS: Depression was quite common in this Chinese rural geriatric population. The prevalence rate was twice as high when judged by depression symptomatology rather than clinical diagnosis. The critical risk factors were functional impairments, poor cognitive abilities and the presence of chronic physical illnesses.

Activities of Daily Living↗

PubMed1997

Characteristics of non-participants and reasons for non-participation in a population survey in Kin-Hu, Kinmen.

The aim was to characterize non-participants and to investigate reasons for non-participation in a health survey in Kin-Hu township, Kinmen, Republic of China. The non-participants represented 25.6% of the target population of 4,451 registered residents aged 30 and older. Baseline demographic characteristics and two-year mortality for the participants and non-participants were compared. A house-to-house visit was attempted to all of the non-participants for reasons of refusal. The mean age of the non-participants was significantly older than that of the participants (54.3 versus 48.5 years, p < 0.001). The response rate for women was significantly higher than that for men (77.2% versus 71.6%, p < 0.001). The probability of death was significantly different between the two groups (1.2% versus 8.8% for participants and non-participants, respectively, p < 0.001). Major reason for not having participated in the health survey was 'not notified or informed of the examination' (32.7%). These data suggest that non-participants were less healthy.

Adult↗

PubMed1997

The Kinmen Neurological Disorders Survey (KINDS): a study of a Chinese population.

We conducted an epidemiological study of several neurological disorders among the Chinese aged 50 years or older on the islet of Kinmen. All participants were interviewed and examined by neurologists. From the targeted population of 5,061 individuals, 3,915 (77.4%) of them completed the evaluations. Among the 4,087 individuals with whom face-to-face contact was made, the refusal rate was 4.2%. The disorders of interest were dementia, Parkinson's disease, essential tremor, stroke, transient ischemic attacks, and migraine. Among the 3,915 participants, 366 cases were found with 1 or more of the surveyed neurological disorders on the prevalence day, August 1, 1993, yielding a prevalence of 93.5/1,000. The purpose of this study, the general methodology, and some overall findings are presented in this communication in order to provide a common background for detailed findings on each disorder to be reported separately.

Age Factors↗

PubMed1997

A hypertension control program in Yu-Chi, Taiwan: preliminary results.

The purpose of this study was to evaluate the feasibility and effectiveness of a community approach to hypertension control in both high risk and general populations in an agricultural district with limited medical and community resources. It was conducted in Yu-Chi district of Nan-Tou county in central Taiwan from 1993 to 1994. The study included blood pressure screening, follow-up, health education, village-based campaigns, and program evaluation after 6 months of intervention. Two villages each were randomly assigned to intervention and control groups. Intervention comprised visits by trained volunteers to measure blood pressure and body weight, and education related to hypertension. All residents 40 years of age and older were enrolled. A total of 471 residents from the intervention villages and 426 residents from the control villages completed the study. Overall, for the intervention and control groups, the knowledge and behavior related to hypertension improved significantly 6 months after the baseline survey. The improvement was greater in the subgroup of hypertensives in the intervention group than in the controls. The educational intervention also significantly improved the status of awareness, treatment, and the control of hypertension, and reduced blood pressure in the hypertensive subjects. We conclude that a hypertension control program that relies solely on limited community resources is feasible and effective.

Adult↗

PubMed1996

Inhibition of angiogenesis in human glioblastomas by chromosome 10 induction of thrombospondin-1.

Glioblastoma multiforme is distinguished from its less malignant astrocytoma precursors by intense angiogenesis and frequent loss of tumor suppressor genes on chromosome 10. Here we link these traits by showing that when a wild-type chromosome 10 was returned to any of three human glioblastoma cell lines U251, U87, or LG11, they lost their ability to form tumors in nude mice and switched to an antiangiogenic phenotype, as measured by the inhibition of capillary endothelial cell migration and of corneal neovascularization. This change in angiogenesis was directly due to the increased secretion of a potent inhibitor of angiogenesis, thrombospondin-1, because: (a) neutralizing thrombospondin completely relieved the inhibition; (b) the inhibitory activity of thrombospondin was not dependent on transforming growth factor beta; and (c) chromosome 10 introduction did not alter secreted inducing activity. The inducing activity was dependent on vascular endothelial cell growth factor and had an ED50 of 10 microg/ml in media conditioned by parental cells and 9-13 microg/ml in media conditioned by chromosome 10 revertants. Normal human astrocytes were also antiangiogenic due to secreted thrombospondin. The effect of chromosome 10 on thrombospondin production in vitro was reflected in patient material. Normal brain and lower grade astrocytomas known to retain chromosome 10 stained strongly for thrombospondin, but 12 of 13 glioblastomas, the majority of which lose chromosome 10, did not. These data indicate that the loss of tumor suppressors on chromosome 10 contributes to the aggressive malignancy of glioblastomas in part by releasing constraints on angiogenesis that are maintained by thrombospondin in lower grade tumors.

Animals↗

PubMed1996

Prevalence of coronary heart disease in Kin-Chen, Kinmen.

We estimated the prevalence of coronary heart disease (CHD) by the Minnesota code of a 12-lead resting electrocardiogram, Rose chest pain questionnaire and self-reported previous medical history in Kin-Chen, Kinmen (Quemoy), an island under military control for 40 years and the focal point of confrontation between mainland China and Taiwan. Among the target population of 6346 who accounted for all residents aged over 30, 3826 (60.3%) responded with complete data. The prevalence of probable CHD (Minnesota code 1.1-1.2) was 4.1% (71/1732) in men and 4.0% (84/2094) in women, whereas the prevalence of possible CHD (Minnesota code 1.3, 4.1-4.4, 5.1-5.3 and 7.1.1) was significantly higher in women (21.4%) than in men (11.6%). When compared to Chinese populations elsewhere, the increased overall prevalence may suggest a link to long-term stress conditions under military control. We also found the abnormal ECG was associated with many risk factors of CHD, particularly win women. The prevalence of Rose angina and self-reported angina or myocardial infarction was, however, low and associated poorly with any cardiovascular risk factors. Long-term follow-up studies are needed to determine the predictive value of these electrocardiographic abnormalities for cardiovascular disease morbidity and mortality in this population.

Adult↗

PubMed1996

A population-based epidemiological study of human T-cell leukemia virus type I infection in Kin-Hu, Kinmen.

Kinmen is a group of small islands located between Taiwan and Fu-Kien Province of mainland China. The general population in Kinmen are descendants of immigrants from mainland China who began arriving around 317 A.D. Since it has been reported that 0.48% of adults in Taiwan have HTLV-I infection, the decision was made to conduct a community-based epidemiological study in Kinmen to understand the origin and dissemination of HTLV-I in north-east Asia. Over 68% of residents of Kin-Hu township in Kinmen over 30 years of age participated in this study. Eight of 1,425 males and 14 of 1,595 females had HTLV-I infection. Antibody reactivities were further tested by Western blot assays with HTLV-I or HTLV-II type-specific recombinant envelope glycoproteins, and it was determined that all of those infected had HTLV-I and none had HTLV-II. Logistic regression was used for multivariate analysis. The final model indicated that the significant factors associated with HTLV-I infection in Kinmen were age and coastal residency. Age was positively correlated with HTLV-I infection. The eastern coastal area had a rate of HTLV-I infection 3.1 times higher than other areas in Kin-Hu. Further genetic analysis in Kinmen is needed to elucidate a relationship with other HTLV-I isolates in the world.

Adult↗

PubMed1996

A door-to-door survey of Parkinson's disease in a Chinese population in Kinmen.

BACKGROUND: Most published studies have shown lower prevalence rates of Parkinson's disease (PD) in Asian and black African than in Western countries, leading to the hypothesis that Asians and blacks might be protected from PD. OBJECTIVE: To investigate the prevalence of PD in a Chinese population. DESIGN: Community-based survey. SETTING: Registered residents 50 years of age or older (N = 5061) on the islet of Kinmen located off the southeastern coast of China [corrected]. METHOD: Single-phase door-to-door survey by neurologists. All participants were administered a questionnaire and received motor examinations of the Unified Parkinson's Disease Rating Scale. RESULTS: The participation rate was 96% (N = 3915) among 4158 contacted individuals. Twenty-three cases of PD were identified, including three cases with dementia. The crude prevalence rate of PD was 587 (95% confidence interval (CI), 373 to 884) per 100,000 persons 50 years of age or older. Assuming no case of PD among individuals under 50 years of age, the prevalence rate was 119 (95% CI, 80 to 169) per 100,000 for the total population. CONCLUSIONS: The prevalence rates of PD in Kinmen were much higher than those reported from mainland China, but slightly lower than those reported from more developed countries. The present findings suggest that, instead of genetic factors, differences in case-ascertainment, life expectancy, and the length of survival with PD may be more important contributors to the variations in observed PD prevalence rates.

Aged↗

PubMed1996

Antisense oligonucleotide intralesional therapy for human PC-3 prostate tumors carried in athymic nude mice.

Previously we reported hemorrhagic necrosis in human-derived PC-3 prostate tumors, in athymic nude mice, produced by the intralesional injection of antisense oligonucleotides (oligos) directed against mRNAs encoding transforming growth factor-alpha (TGF-alpha) and its target, the epidermal growth factor receptor (EGFR). We now describe our experience with these oligos in treating additional mice with various doses and modes of administration. During prolonged treatment, a dose-response effect was observed, with the optimal dosage consisting of the combination of 400 micrograms of each oligo. Although responses varied, based upon amount and how oligos were administered, we found that tumors were best treated when initially less than 156 mm3. Intralesional inoculations produced necrosis and yielded responses, ranging from complete response (CR) or cure to partial responses (PR) in 9 of 12 tumors treated with full dose (400 micrograms of each oligo) and 1 of 1 treated with 800 micrograms of each oligo, against a large tumor. Included among the 9 positive responses with full-dose administration were 2 tumors that regressed (one completely). A single tumor treated with twice (2X) the normal dosage (800 micrograms of each oligo) also regressed. A single tumor treated with half (1/2) dose (200 micrograms of each) progressed similar to controls, as did 3 of 12 treated with the full dose. Limited experience with ALZET diffusion pumps gave CR (1 of 3) or PR (2 of 3) in 100% of tumors treated (including one mouse cured of multiple tumors in a five day period). It appears that multiple inoculations consisting of 400 micrograms of each oligo is most effective against these tumors, particularly when administered against tumors of <156 mm3 in initial size.

Animals↗

PubMed1996

Suramin as adjuvant therapy with radical prostatectomy.

Suramin is a newer agent employed in the management of prostate cancer. One suggested method of action is growth factor inhibition. While suramin has been employed to treat advanced disease its adjuvant role remains unexplored. To address this question we have employed a new model: the orthotopic placement of the Dunning AT-3 tumor. The purpose of this research was to assess the efficacy of adjuvant therapy in controlling residual disease. The method consisted of the injection of 2.4 to 2.6 x 10(6) AT-3 cells (harvested from flank tumors) into the ventral prostates of 29 Copenhagen X Fischer rats. The animals were then divided into four groups: 1) untreated controls (6 rats); 2) ventral prostatectomy only (10 rats); 3) ventral prostatectomy plus suramin (300mg/Kg) on post-op day 3 (5 rats); and 4) ventral prostatectomy plus cytoxan (50 mg/Kg) on post-op day 3 (8 rats). Prostatectomies were performed 10-12 days following AT-3 cell inoculation. Animals were sacrificed 10 days following prostatectomy, autopsied, and residual diseased weighed. All operating procedures: tumor cell inoculations, ventral prostatectomies, and necropsies were performed microsurgically employing a Zeiss operating microscope. The results (in mean tumor weights) were: Group 1, 20 +/- 1.4 gms; Group 2, 6.7 +/- 11.5 gms; Group 3, 2.7 +/- 3.8 gms; and Group 4, 2.2 +/- 2.5 gms. The differences between control and all treatment groups were significant: Group 1 vs. Group 2, P < 0.02; and Group 1 vs. Groups 3 and 4, P < 0.001. We conclude that prostatectomy resulted in a diminished weight of residual disease. Of more importance was the fact that adjuvant therapy further reduced residual disease. The orthotopic placement of the Dunning tumor may serve as a model to evaluate the place of suramin following radical prostatectomy.

Animals↗

PubMed1996

Increased expression of intercellular adhesion molecule 1, CD11/CD18 cell surface adhesion glycoproteins and alpha 4 beta 1 integrin in a rat model of chronic interstitial lung fibrosis.

The expression of the intercellular adhesion molecule 1 (ICAM-1), and the integrins CD49, CD11b/c, and CD11a (LFA-1 alpha chain) was analyzed in an experimental model of pulmonary fibrosis. Adult rats were exposed to 75% oxygen during 10 weeks, and to 2.0 mg/kg of paraquat twice weekly. Rats were sacrificed at 2 days, and at 2 and 10 weeks after the first injection of paraquat. Lungs were fixed in 4% paraformaldehyde and used for histology and immunohistochemistry. At 2 days the lungs showed a diffuse inflammation composed of a mixed polymorphonuclear and mononuclear cell infiltrate. Afterwards, the inflammatory process was predominantly mononuclear, and an increasing fibroblast proliferation was observed. Early inflammatory events (48 h) correlated with a moderate increased expression of ICAM-1, LFA, and CD11b/c in epithelial cells as well as a pronounced expression of ICAM-1 and CD11b/c in macrophages. At 2 and 10 weeks, there was a progressive increased expression of CD11b/c and ICAM-1 by macrophages, as well as of LFA in epithelial cells, and of ICAM-1 and CD49 by epithelial and interstitial cells. Lymphocytes showed a slight increased expression of LFA at 2 weeks, and of CD49 at 2 and 10 weeks. These results suggest that macrophages expressing ICAM-1, CD11b/c, and CD49 are involved in the earlier and late phases of the disease whereas fibroblast and epithelial cells expressing ICAM-1 and CD49 might play a role in the cell interactions involved in the fibrotic phase.

Animals↗

PubMed1996

The prevalence and motivating factors of adolescent smoking at a rural middle school in Taiwan.

The purpose of this survey is to study the prevalence and motivating factors of smoking among 1,372 students at a rural middle school in Taiwan. The prevalence of smokers for total, male, and female students is 5.7, 11.5, and 0.4%, respectively. Prevalence increased with age and grade among males, but no significant differences were found among females. Prevalence was higher among students from nuclear families than those from extended families (OR = 2.8, 95% C.I. 1.4-5.5). Prevalence was also higher among students from families with very strict parental control or very little parental control (OR = 4.25, 95% C.I. 2.24-8.08). The majority (70-80%) began smoking during primary school. Smokers who had attempted abstinence in the past had a better understanding of the hazards of smoking and smoked less frequently and with lower average consumption (P < .05). For 60% of the students the first source of cigarettes was friends or classmates; only 22% bought them. Health education increased understanding of the hazards of smoking (OR = 2.2, 95% C.I. 1.10-4.45). In conclusion, the primary factors that affect adolescent smoking are age, family structure, abstinence experience, strictness of upbringing, family influence, peer pressure, and health education.

Adolescent↗