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PubMed2004

A prescription for protecting the doctor-patient relationship.

The relationship between patients and their physicians is fundamental to high-quality care, yet this relationship is under stress in the current healthcare environment. Health plans have instituted a variety of policies to contain costs, not fully appreciating the adverse effect these decisions have on the doctor-patient interaction. Legislators have responded to the public's concern about managed care with "patient protection" bills that fail to address the fundamental causes of tension between doctors and patients. This paper presents a model describing how the need to contain costs affects the doctor-patient interaction and proposes a prescription for protecting the relationship. The model highlights how the healthcare environment affects patients' and physicians' expectations before a medical visit, the nature of their interaction during a visit, and patients' health outcomes. This prescription for protecting the doctor-patient relationship contains 4 key ingredients: (1) definition and promulgation of evidence-based standards for the doctor-patient relationship; (2) joint doctor-patient advocacy on behalf of the relationship; (3) positive incentives for exemplary doctor-patient relationships; and (4) expanded training and assessment of physicians' communication skills, both in general and related to discussing cost containment with patients. These measures will help restore the essential element of superb healthcare: a strong doctor-patient relationship.

Attitude↗
PubMed2000

Correlates of unprotected vaginal sex among African American female adolescents: importance of relationship dynamics.

OBJECTIVE: To determine the associations between the frequency of unprotected vaginal sex (UVS) and female adolescents' perceptions, particularly their perceptions of relationship dynamics. DESIGN: Cross-sectional study of 522 African American female adolescents enrolled in a sexually transmitted disease (STD) and human immunodeficiency virus prevention intervention trial. SETTING AND PARTICIPANTS: A volunteer sample of adolescents recruited from neighborhoods characterized by high rates of unemployment, substance abuse, violence, and STDs; 28% tested positive for STDs as assessed by DNA amplification or culture. MAIN OUTCOME MEASURE: Frequency of UVS assessed by interview using a 6-month recall period. RESULTS: Among adolescents having steady relationships, those spending more time with their boyfriends and having longer relationships reported a significantly greater frequency of UVS. Other significant correlates included perception of more girlfriends using condoms, no history of STDs, stronger normative beliefs favoring male decision making in relationships, greater pregnancy worry, and greater perceived invulnerability to STDs. For adolescents reporting casual relationships, personal barriers to condom use, no history of STDs, and reporting that their boyfriends typically decide when to have sex were associated with more frequent UVS. CONCLUSIONS: Adolescents' perceptions, particularly their perceptions of relationship dynamics, played an integral role in explaining female adolescents' frequency of UVS with both steady and casual partners. Female adolescents in steady relationships differ from those in casual relationships relative to their prevention needs. These findings have implications for clinic- or community-based STD and human immunodeficiency virus prevention programs.

Adolescent↗
PubMed2002

Effect of managed care on children's relationships with their primary care physicians: differences by race.

CONTEXT: Racial and ethnic disparities in the quality of the patient-provider relationship have been documented previously, but only among adults. Few studies have examined this aspect of primary care quality for children, and none has examined the role of managed care in mediating disparities. OBJECTIVE: To explore variations in the associations among 3 managed care policies and the sustained patient-provider relationship for children by racial and ethnic group. DESIGN, SETTING, AND PARTICIPANTS: Telephone survey of parents of a random sample of 413 children attending elementary school in a large school district spanning 3 cities in southern California. Self-reported managed care information was validated through contact with health plan representatives. MAIN OUTCOME MEASURE: Parent reporting of the strength of affiliation and interpersonal relationships among the child, the family, and the health care provider. RESULTS: Parents of Hispanic and black children reported significantly lower strength of affiliation than whites did (mean, 3.19 and 3.27 vs 3.57; P<.05 and P<.01, respectively). Asians and Hispanics reported significantly poorer interpersonal relationships with providers than whites did (mean, 3.35 and 3.38 vs 3.53; P<.05 for both). Managed care policies requiring patients to (1) sign up with a particular provider, (2) seek a referral for specialty care, and (3) stay within a network were associated with reductions in the interpersonal relationship. All minority groups, but not whites, reported significantly poorer relationships when managed care policies were present. Asian children were most sensitive to the managed care policies. CONCLUSIONS: Our data suggest that racial and ethnic minority children experience poorer patient-provider relationships compared with white children, even controlling for socioeconomic status and health system factors. Minority children are particularly sensitive to managed care policies that restrict patient freedom in choosing where to seek care. Implementing less restrictive policies may enhance the development of the patient-provider relationship.

Adult↗
PubMed2000

Assessing faculty financial relationships with industry: A case study.

CONTEXT: A growing number of academic researchers receive industry funding for clinical and basic research, but little is known about the personal financial relationships of researchers with their industry sponsors. OBJECTIVES: To assess the extent to which faculty researchers have personal financial relationships with the sponsors of their research, the nature of those financial relationships, and efforts made at the institutional level to address disclosed financial relationships and perceived conflicts of interest. DESIGN AND SETTING: Case study of the University of California, San Francisco (UCSF). Data sources included disclosure forms and official documents maintained by the UCSF Office of Research Administration from December 1980 to October 1999, including decisions made by the UCSF Chancellor's Advisory Panel on Relations with Industry. MAIN OUTCOME MEASURES: Number and types of personal financial relationships with external sponsors (positive financial disclosures from all clinical, basic, or social science faculty who were principal investigators), amount of annual income received from sponsors, and decisions and management strategies used by the advisory panel. RESULTS: By 1999, almost 7.6% of faculty investigators reported personal financial ties with sponsors of their research. Throughout the study period, 34% of disclosed relationships involved paid speaking engagements (range, $250-$20, 000 per year), 33% involved consulting agreements between researcher and sponsor (range, <$1000-$120,000 per year), and 32% involved the investigator holding a position on a scientific advisory board or board of directors. Fourteen percent involved equity ownership, and 12% involved multiple relationships. The advisory panel recommended managing perceived conflicts of interest in 26% of the cases, including recommending the sale of stock, refusing additional payment for talks, resigning from a management position, or naming a new principal investigator for a project. CONCLUSIONS: Faculty researchers are increasingly involved in financial relationships with their research sponsors. Guidelines for what constitutes a conflict and how the conflict should be managed are needed if researchers are to have consistent standards of behavior among institutions. JAMA. 2000;284:2209-2214.

Biomedical Research↗
PubMed2002

Relationships between authors of clinical practice guidelines and the pharmaceutical industry.

CONTEXT: Increasing contact has been reported between physicians and the pharmaceutical industry, although no data exist in the literature regarding potential financial conflicts of interest for authors of clinical practice guidelines (CPGs). These interactions may be particularly relevant since CPGs are designed to influence the practice of a large number of physicians. OBJECTIVE: To quantify the extent and nature of interactions between authors of CPGs and the pharmaceutical industry. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional survey of 192 authors of 44 CPGs endorsed by North American and European societies on common adult diseases published between 1991 and July 1999. One hundred authors (52%) provided usable responses representing 37 of 44 different CPGs that we identified. MAIN OUTCOME MEASURES: Nature and extent of interactions of authors with drug manufacturers; disclosure of relationships in published guidelines; prior discussion among authors regarding relationships; beliefs regarding whether authors' own relationships or those of their colleagues influenced treatment recommendations in guidelines. RESULTS: Eighty-seven percent of authors had some form of interaction with the pharmaceutical industry. Fifty-eight percent had received financial support to perform research and 38% had served as employees or consultants for a pharmaceutical company. On average, CPG authors interacted with 10.5 different companies. Overall, an average of 81% (95% confidence interval, 70%-92%) of authors per CPG had interactions. Similarly, all of the CPGs for 7 of the 10 diseases included in our study had at least 1 author who had some interaction. Fifty-nine percent had relationships with companies whose drugs were considered in the guideline they authored, and of these authors, 96% had relationships that predated the guideline creation process. Fifty-five percent of respondents indicated that the guideline process with which they were involved had no formal process for declaring these relationships. In published versions of the CPGs, specific declarations regarding the personal financial interactions of individual authors with the pharmaceutical industry were made in only 2 cases. Seven percent thought that their own relationships with the pharmaceutical industry influenced the recommendations and 19% thought that their coauthors' recommendations were influenced by their relationships. CONCLUSIONS: Although the response rate for this survey was low, there appears to be considerable interaction between CPG authors and the pharmaceutical industry. Our study highlights the need for appropriate disclosure of financial conflicts of interest for authors of CPGs and a formal process for discussing these conflicts prior to CPG development.

Authorship↗
PubMed1996

Estimating parental relationship in linkage analysis of recessive traits.

In linkage analysis of recessive traits, parental relationship is important. For the case that it is unknown, the question is investigated as to whether estimating parental relationship and using the estimated relationship in linkage analysis is beneficial. Results show that estimating parental relationship can reliably be carried out on the basis of 50-100 genetic marker loci (analysis based on theory by Thompson [1975: Am J Hum Genet 39:173-188]). Misspecification of parental relationship leads to a loss of linkage informativeness, but not to false-positive evidence for linkage. An asymptotic bias in the recombination fraction estimate occurs when parents are unrelated and falsely taken to be related, but no such bias is seen when related parents are taken to be unrelated. Results from this investigation suggest that an estimated parental relationship may be used in linkage analysis as if it were the correct relationship, when evidence for the estimated relationship is supported by a likelihood ratio of at least 10:1 against the parents being unrelated.

Computer Simulation↗
PubMed1997

The relationship between socioeconomic status and eating-disordered behaviors in a community sample of adolescent girls.

OBJECTIVE: Although previous research has demonstrated a relationship between socioeconomic status (SES) and weight, the research has not been consistent regarding the relationship between SES and eating disorders. This analysis was designed to examine this relationship in a large community sample of adolescent girls (Grades 7 to 12). METHOD: Items were selected from a comprehensive self-report health survey completed by 17,571 adolescent girls. The relationships between SES and dieting behaviors and attitudes were examined using chi-square tests and analysis of variance (ANOVA) to control for body mass index. RESULTS: Although there was a significant positive relationship between SES and some of the unhealthy dieting behaviors, there was no relationship between self-report of clinically significant eating-disordered behaviors (e.g., vomiting twice a week or more) and SES in this community sample. DISCUSSION: This study suggests that while there may be a significant relationship between SES and dieting or other behaviors associated with eating disorders, this relationship does not apply to diagnostically significant behaviors. SES may be associated with differences in dieting or eating behaviors; however, among those young women who meet psychiatric criteria for an eating disorder, SES does not appear to be a significant factor.

Adolescent↗
PubMed1984

Relationship between preferred orientation and receptive field position of neurons in extrastriate cortex (area 19) in the cat.

Orientation sensitivity is a characteristic of most retinal ganglion cells (Levick and Thibos, '82), most relay cells in the dorsal lateral geniculate nucleus (Vidyasagar and Urbas, '82), and most neurons in the visual cortex (Hubel and Wiesel, '62) in the cat. In the retina there is a systematic relationship between receptive field position (polar angle) and preferred orientation. Outside of the area centralis most retinal ganglion cells respond best to stimuli oriented radially, i.e., oriented parallel to the line connecting their receptive fields to the area centralis (Levick and Thibos, '82). This relationship is strongest along the horizontal meridian (the visual streak) and appears to reflect the innate, radial orientation of retinal ganglion cell dendritic fields (Leventhal and Schall, '83). A relationship between preferred orientation and polar angle also exists in cat striate cortex; outside of the area centralis representation most cells respond best to lines oriented radially. This relationship is strongest for S-type cells, the most orientation-selective cells, and cells in regions representing the horizontal meridian (Leventhal, '83). To determine if similar relationships exist in cat extrastriate cortex, the preferred orientations and receptive field positions of 226 neurons in area 19 were studied. We find that, as in area 17, most area 19 cells outside of the representation of the area centralis respond best to lines oriented radially; this relationship is strongest for the cells having the narrowest receptive fields and in regions subserving the horizontal meridian. Unlike in striate cortex, in area 19 the relationship between preferred orientation and polar angle is not dependent upon cell type (S or C) or to the degree of orientation sensitivity exhibited. Also, in area 19, but not in area 17, the relationship between preferred orientation and polar angle fails for the cells having the widest receptive fields.(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗
PubMed1992

Myelin-axon relationships in the rat phrenic nerve: longitudinal variation and lateral asymmetry.

It is known that the myelin sheath thickness-axon perimeter relationship varies between peripheral nerves. This study examines the possibility that that relationship may vary between levels along a given nerve or between corresponding levels of the right and left examples of the same nerve. The relationship is examined for large and small fibre classes at well separated upper and lower intrathoracic levels in the rat phrenic nerve. The study shows that the myelin-axon relationship differs between levels along the same nerve bundle in the same (intrathoracic) environment. Thus, for a given increase in the perimeter of large axons, sheath thickness increases significantly more at lower than at upper levels. In addition, myelin sheath thickness shows a statistically significant lateral asymmetry in favour of the left side for the large fibre class at the upper thoracic level. The setting of the myelin sheath thickness-axon perimeter relationship also differs between the large and small fibre classes at each level examined. Large fibres have proportionately thicker sheaths than small fibres and this difference is reflected in the significantly smaller g-ratio of the former. Systematic differences in the setting of the myelin sheath thickness-axon perimeter relationship between large and small fibre classes may be a widely occurring phenomenon. It may be concluded that the myelin-axon relationship varies significantly both within and between nerves and also between fibre classes. Accordingly, morphometric studies of normal or pathological nerves should take into account possible consistent longitudinal variation or lateral asymmetry in fibre parameters and myelin-axon relationships within a given nerve bundle or fibre class, in order to avoid introducing systematic bias and to minimize variance between samples.

Animals↗
PubMed2000

Sexual behaviors and relationship qualities in late adolescent couples.

This study examined the associations between relationship qualities, sexual behaviors, and relationship length in 61 adolescent couples (aged 16-20). For both male and female partners, positive relationship qualities were associated with physical expressions of affection. Perceptions of higher levels of conflict and frustration were associated with more frequent sexual intercourse. Factor analysis and multiple regression indicated that the frequency of sexual behavior and the perception of global relationship quality (support, depth and intimacy) predicted relationship length for these couples. While the frequency of sexual expression was associated with relationship longevity for both male and female partners, positive relationship qualities (depth and intimacy) were additionally associated with relationship longevity for male partners only. Implications of these findings are discussed in light of current gaps in understanding the relational context of adolescent sexual behavior.

Adolescent↗
PubMed2001

Adolescent romantic relationships: a look from the future.

Employing a narrative approach, 40 young adult romantic couples were interviewed about their current relationships as well as about their relationship with a romantic partner that lasted for at least about 2 months when they were aged 15 or 16. When analysed, the transcribed interviews were found to portray adolescent and young adulthood romantic relationships in different terms. Adolescent romance was described more as a form of companionship and was valued for its experiences of totality and enthusiasm. Young adulthood romance, by contrast, was described more as a mature relationship characterized by trust, support, and stability. In addition, adolescent romance was described as less enjoyable, enduring more relationship problems. Males and females described differently their adolescent romance in relation to the quality of their current romantic relationship. Males, but not females, related a current more positive perception of the relationship to a more positive perception of adolescent romance. Adolescent romance is discussed within the framework of the developmental processes that characterize the development of romantic relationships.

Adult↗
PubMed1996

The beta-sheets of proteins, the biosynthetic relationships between amino acids, and the origin of the genetic code.

Two forces are generally hypothesised as being responsible for conditioning the origin of the organization of the genetic code: the physicochemical properties of amino acids and their biosynthetic relationships (relationships between precursor and product amino acids). If we assume that the biosynthetic relationships between amino acids were fundamental in defining the genetic code, then it is reasonable to expect that the distribution of physicochemical properties among the amino acids in precursor-product relationships cannot be random but must, rather, be affected by some selective constraints imposed by the structure of primitive proteins. Analysis shows that measurements representing the 'size' of amino acids, e.g. bulkiness, are specifically associated to the pairs of amino acids in precurso-product relationships. However, the size of amino acids cannot have been selected per se but, rather, because it reflects the beta-sheets of proteins which are, therefore, identified as the main adaptive theme promoting the origin of genetic code organization. Whereas there are no traces of the alpha-helix in the genetic code table. The above considerations make it necessary to re-examine the relationship linking the hydrophilicity of the dinucleoside monophosphates of anticodons and the polarity and bulkiness of amino acids. It can be concluded that this relationship seems to be meaningful only between the hydrophilicity of anticodons and the polarity of amino acids. The latter relationship is supposed to have been operative on hairpin structures, ancestors of the tRNA molecule. Moreover, it is on these very structures that the biosynthetic links between precursor and product amino acids might have been achieved, and the interaction between the hydrophilicity of anticodons and the polarity of amino acids might have had a role in the concession of codons (anticodons) from precursors to products.

Amino Acids↗
PubMed2003

Young adults' relationship transitions and the incidence of mental disorders: a three-wave longitudinal study.

BACKGROUND: Relationship transitions have consistently been found to be associated with mental health in young adulthood, but previous studies have not demonstrated clearly whether such relationship transitions actually precede the development of mental health problems and have focused almost exclusively on subclinical levels of problem behavior. METHODS: Longitudinal associations between the incidence of mood, anxiety, and substance disorders (DSM-III-R) and relationship transitions during young adulthood were examined using data from 1,581 Dutch young adults aged 18-34, who participated in three waves (1996, 1997, and 1999) of a nationwide epidemiological survey. RESULTS: Concurrent 3-year longitudinal associations showed that the incidence of mood and substance disorders was linked to relationship stability and change (i. e., staying single, breaking up/divorcing), but more rigorous, prospective analyses demonstrated that only the incidence of substance disorders was associated with previous relationship developments. Earlier prevalence of mood disorders increased young adults' likelihood of subsequently experiencing a break-up/divorce and lowered the likelihood of becoming a parent, but mood disorders were in turn predicted by previously experienced relationship difficulties. CONCLUSIONS: Apart from the negative consequences of a break-up/divorce, having a relatively unattached relationship status (i. e., not stably cohabiting/married, not being a parent) may be an important factor in explaining the onset of substance disorders. Furthermore, results qualify the notion of de-selection in certain partner roles by mood disorders; mood disorders negatively affect individuals' chances of staying with one's partner, but are in turn dependent on earlier partner relationship quality.

Adolescent↗
PubMed2004

Distribution-abundance relationship for passerines breeding in Tunisian oases: test of the sampling hypothesis.

The positive relationship between local abundance and distribution of species is a widely recognized pattern in community ecology. However, it has been suggested that this relationship can simply be an artefact of sampling because locally rare species are less detectable then locally abundant ones, and hence their distribution can easily be underestimated. Here, we use count data to investigate the relationship between distribution and abundance of passerines breeding in a sample of oases from southern Tunisia, and we provide a test of the sampling artefact hypothesis. In particular, we checked for a difference in detection probability between localized and widespread species, and we tested if increasing the sampling effort affects the significance of the relationship. A significant positive relationship between the average local abundance of passerine species and the proportion of occupied oases was found. The use of a capture-recapture approach allowed us to estimate and to compare the detection probabilities of localized and widespread species subsets. We found that localized species were locally less detectable than widespread species, which is consistent with the main assumption of the sampling artefact hypothesis. However, increasing the detection probability of species by conducting more counts did not affect the significance of the relationship, which did not give support to the sampling artefact hypothesis. Our work implies that sampling contributed to the distribution-abundance relationship we found, but that it is unlikely that such a relationship could entirely be explained by an artefact of sampling. It also underlines the insight that can be gained by using probabilistic approaches of estimating species number and detection probability when attempting to disentangle sampling from ecological effects in community ecology studies.

Animals↗
PubMed2005

Diversity and structure of intergenerational relationships: elderly parent-adult child relations in Korea.

Korean society has undergone a rapid demographic transition that has challenged traditional patterns of family exchanges. The structure and directions of support flows have become more complex as multiple generations coexist. This article examines the complexity of contemporary Korean intergenerational relationships. The study analyzed two different samples to address anticipated differences in perceptions of and attitudes toward relationships between adult children and elderly parents. The researchers used maximum likelihood latent structure analysis to discover the latent patterns of the association among three main subdimensions of intergenerational relationships: geographic proximity, exchange of support, and cultural norms of family support. Results show that the perspectives on intergenerational relationships differ significantly between middle-aged children and elderly parents. Intergenerational relationships among middle-aged adults comprise five distinct patterns: strong reciprocal, strong traditional, intermediate normative, intermediate circumstantial, and weak. The interpretation of intergenerational relationships from the elders' perspectives is more straightforward, with only three patterns: traditional, reciprocal, and weak. Along with significant socioeconomic differences in the prevalent patterns of intergenerational relationships, these results emphasize the complex interplay of contingency and path dependency in diversifying the value and support exchanges of intergenerational relationships.

Adult↗
PubMed2005

Characteristics of natural mentoring relationships and adolescent adjustment: evidence from a national study.

This research investigated characteristics of natural mentoring relationships (mentor role, frequency of contact, closeness, duration) as predictors of adjustment outcomes among older adolescents and young adults (N = 2,053) in the Add Health study. Outcomes were assessed in the domains of education/work, problem behavior, psychological well-being, and physical health. Mentoring relationships with persons in roles outside of the family predicted greater likelihood of favorable outcomes in all domains except psychological well-being, relative to mentoring relationships with family members. Greater reported closeness in relationships was predictive of several favorable outcomes, particularly those in the domain of psychological well-being. These findings indicate that strategies to promote mentoring of adolescents may be more effective if particular categories of adults are targeted and an effort is made to cultivate relationships with strong emotional bonds. Editors' Strategic Implications: These data suggest that the cultivation of natural (especially non-familial) mentoring relationships during adolescence may be a promising strategy for prevention and health promotion. This study is impressive due to its large, nationally representative sample, the examination of relationship characteristics and multiple mentors, and the links to a variety of outcomes (controlling for earlier functioning). School officials and mentoring programs must consider how to capitalize on - and promote - naturally occurring mentor relationships.

Adolescent↗
PubMed2006

Men, multiple sexual partners, and young adults' sexual relationships: understanding the role of gender in the study of risk.

Heterosexual transmission of HIV and other sexually transmitted infections has become a primary health concern worldwide. Gender roles for heterosexual interactions appear to sanction men's sexual risk-taking, especially the pursuit of multiple sexual partners. Using measures developed in this study, the current study assessed the associations between men's and women's relationship attitudes and experiences and their sexual risk encounters. Participants were 104 men and 103 women (18-24 years) from a large, urban college located in a high HIV risk neighborhood of New York City. All completed a survey assessing HIV risk and the battery of relationship measures assessing traditional sexual roles, sexual conflicts, significance of sex, relationship investment, need for relationship, and unwanted sex. For men, greater sexual conflict in their primary relationships was associated with more sexual partners and fewer unprotected vaginal intercourse encounters with a primary partner and across sex partners overall. In addition, men's endorsement of more traditional sexual roles and lower relationship investment were associated with higher numbers of sexual partners. Among women, compliance with men to engage in unwanted sex was associated with higher levels of participation in unprotected sex. For both men and women, greater significance given to sex in a relationship was associated with fewer extradyadic partners. This study demonstrates the utility of measures of relationship attitudes and experiences to characterize sexual risk, especially among men. Findings are discussed in terms of implications for prevention program targeting young urban adults.

Adolescent↗
PubMed2006

Gender role and relationship norms among young adults in South Africa: measuring the context of masculinity and HIV risk.

In the global literature on HIV/AIDS, much attention has been paid to the role of gender inequalities in facilitating the transmission of HIV. For women, gender inequality may be manifested in sexual coercion, reduced negotiating power and partnering with older men, all practices that heighten risk for HIV. Less attention, however, has been paid to how men's relationship behaviors may place them at risk for HIV. Using six culturally specific psychometric scales developed in South Africa, this study examined men's and women's gender role and relationship norms, attitudes and beliefs in the context of ongoing partnerships. These measures were then examined in relation to four sexual risk behaviors: frequency of condom use (with primary or secondary partners) and number of partners (last 3 months and lifetime). Participants were 101 male and 199 female young adults aged, 18-24, recruited from a secondary school in northern KwaZulu/Natal province. Associations between gender and relationship scale scores and sexual risk outcomes yielded both expected and contradictory findings. For men, more frequent condom use was associated with higher levels of partner attachment (hyper-romanticism) but also with stronger approval of relationship violence and dominant behavior. In contrast, for women, more frequent condom use was correlated with a lower endorsement of relationship violence. Men with lower relationship power scores had fewer sexual partners in the preceding 3 months, while women with more egalitarian sexual scripts reported more sexual partners, as did those with higher hyper-romanticism scores. In logistic regression analysis, more egalitarian relationship norms among men were predictive of less consistent condom use, as were higher relationship power scores for women. These findings are discussed in relation to previous research on gender, heterosexual interactions and masculinity in this area, as well as the implications for HIV prevention programs.

Adolescent↗