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PubMed1997

Effectiveness of the public health policy for breast cancer screening in Finland: population based cohort study.

OBJECTIVE: To evaluate the effectiveness of screening for breast cancer as a public health policy. DESIGN: Follow up in 1987-92 of Finnish women invited to join the screening programme in 1987-9 and of the control women (balanced by age and matched by municipality of residence), who were not invited to the service screening. SETTING: Finland. SUBJECTS: Of the Finnish women born in 1927-39, 89893 women invited for screening and 68862 controls were followed; 1584 breast cancers were diagnosed. MAIN OUTCOME MEASURES: Rate ratio of deaths from breast cancer among the women invited for screening to deaths among those not invited. RESULTS: There were 385 deaths from breast cancer, of which 127 were among the 1584 incident cases in 1987-92. The rate ratio of death was 0.76 (95% confidence interval 0.53 to 1.09). The effect was larger and significant (0.56; 0.33 to 0.95) among women aged under 56 years at entry. 20 cancers were prevented (one death prevented per 10000 screens). CONCLUSIONS: A breast screening programme can achieve a similar effect on mortality as achieved by the trials for breast cancer screening. However, it may be difficult to justify a screening programme as a public health policy on the basis of the mortality reduction only. Whether to run a screening programme as a public health policy also depends on its effects on the quality of life of the target population and what the resources would be used for if screening was not done. Given all the different dimensions in the effect, mammography based breast screening is probably justifiable as a public health policy.

Aged↗
PubMed2002

First 5 years of measles elimination in southern Africa: 1996-2000.

BACKGROUND: Measles is the leading cause of vaccine-preventable death in Africa. Regional measles elimination is considered feasible using current vaccines and a series of WHO-recommended strategies. We aimed to interrupt transmission of measles, and to use case-based surveillance to show the effect of such interruption. METHODS: In southern Africa from 1996, seven countries with a total population of approximately 70 million and with relatively high routine vaccination coverage implemented measles elimination strategies. In addition to routine measles immunisation at 9 months of age, these included nationwide catch-up campaigns among children aged 9 months to 14 years, then follow-up campaigns every 3-4 years among children aged 9-59 months, and the establishment of case-based measles surveillance with serological diagnostic confirmation. RESULTS: Nearly 24 million children aged 9 months to 14 years were vaccinated, with overall vaccination coverage of 91%. Reported clinical measles cases declined from 60000 in 1996 to 117 laboratory-confirmed measles cases in 2000. Reported measles deaths declined from 166 in 1996 to zero in 2000. No increase in adverse events was noted after the measles vaccination campaign. CONCLUSION: A reduction in measles mortality and morbidity can be achieved in very low-income countries, in countries that split their vaccination campaigns by geographical area or by age-group of the target population, and where initial routine measles vaccination coverage among infants was <90%, even when prevalence of HIV/AIDS was extremely high. Continued high-level national commitment will be crucial to implementation and maintenance of proven strategies in southern Africa.

Adolescent↗
PubMed2002

Cost effectiveness of screening for Chlamydia trachomatis: a review of published studies.

OBJECTIVE: Screening for Chlamydia trachomatis in the lower genital tract may contribute to the prevention of pelvic inflammatory disease in women. The purpose of this review was to critically appraise, and summarise studies of the cost effectiveness of screening for C trachomatis. METHODS: A literature search was conducted on Medline and in Health Star from 1990-2000. Keywords were C trachomatis, screening, cost effectiveness. Bibliographies of reviewed articles were also searched. The population studied was asymptomatic sexually active women under 30 years of age in a primary care setting. The intervention assessed was screening for lower genital tract infection with C trachomatis and the outcomes studied were cases of C trachomatis detected, cases of PID prevented, and associated costs. Studies were assessed using the Drummond criteria for economic evaluations. They were assessed qualitatively as they were too heterogeneous to allow quantitative analysis. RESULTS: 10 studies were included. All were modelled scenarios and all found screening to be more cost effective than simply testing symptomatic women, although all were based on probabilities that were assumed. Six of the studies focused on DNA based testing, three of them using urine. The models showed screening to be cost effective at prevalences of 3.1-10.0%, and cost saving (overtesting symptomatic women) at a prevalence as low as 1.1%, if age was used as a selection factor and DNA based tests were used in urine samples. CONCLUSIONS: At the prevalence of infection expected in the target population, all studies suggest screening is cost effective. However, the assumptions used in the models have been difficult to confirm and there is a need for more data, particularly on the risk of complications in women with asymptomatic lower tract infection.

Chlamydia Infections↗
PubMed2006

Generalizability in two clinical trials of Lyme disease.

OBJECTIVE: To examine the generalizability of two National Institutes of Health (NIH)-funded double-blind randomized placebo-controlled clinical trials in patients with chronic Lyme disease and to determine whether selection factors resulted in the unfavorable outcomes. DESIGN: Epidemiologic review of the generalizability of two trials conducted by Klempner et al. This paper considers whether the study group was representative of the general chronic Lyme disease population. RESULTS: In their article in The New England Journal of Medicine, Klempner et al. failed to discuss the limitations of their clinical trials. This epidemiologic review argues that their results are not generalizable to the overall Lyme disease population. The treatment failure reported by the authors may be the result of enrolling patients who remained ill after an average of 4.7 years and an average of 3 previous courses of treatment. The poor outcome cited in these trials may be explained by having selected patients who had undergone delayed treatment or multiple treatments unsuccessfully. These selection factors were not addressed by the studies' authors, nor have they been discussed by reviewers. The trials have been over-interpreted by the NIH and widely publicized in a press release. The results have been extrapolated to other groups of Lyme disease patients by commentators, by a case discussant in an influential medical journal, and by health insurance companies to deny antibiotic treatment. CONCLUSION: The Klempner et al. trials are assumed to be internally valid based on a Randomized Control Trial (RCT) design. However, this review argues that the trials have limited generalizability beyond the select group of patients with characteristics like those in the trial. Applying the findings to target populations with characteristics that differ from those included in these trials is inappropriate and may limit options for chronic Lyme disease patients who might benefit from antibiotic treatment.

Journal Article↗
PubMed2000

Neurologic function among termiticide applicators exposed to chlorpyrifos.

Chlorpyrifos is a moderately toxic organophosphate pesticide. Houses and lawns in the United States receive a total of approximately 20 million annual chlorpyrifos treatments, and 82% of U.S. adults have detectable levels of a chlorpyrifos metabolite (3,5, 6-trichloro-2-pyridinol; TCP) in the urine. The U.S. Environmental Protection Agency has estimated that there are 5,000 yearly reported cases of accidental chlorpyrifos poisoning, and approximately one-fourth of these cases exhibit symptoms. Organophosphates affect the nervous system, but there are few epidemiologic data on chlorpyrifos neurotoxicity. We studied neurologic function in 191 current and former termiticide applicators who had an average of 2.4 years applying chlorpyrifos and 2.5 years applying other pesticides, and we compared them to 189 nonexposed controls. The average urinary TCP level for 65 recently exposed applicators was 629.5 microg/L, as compared to 4.5 microg/L for the general U.S. population. The exposed group did not differ significantly from the nonexposed group for any test in the clinical examination. Few significant differences were found in nerve conduction velocity, arm/hand tremor, vibrotactile sensitivity, vision, smell, visual/motor skills, or neurobehavioral skills. The exposed group did not perform as well as the nonexposed group in pegboard turning tests and some postural sway tests. The exposed subjects also reported significantly more symptoms, including memory problems, emotional states, fatigue, and loss of muscle strength; our more quantitative tests may not have been adequate to detect these symptoms. Eight men who reported past chlorpyrifos poisoning had a pattern of low performance on a number of tests, which is consistent with prior reports of chronic effects of organophosphate poisoning. Overall, the lack of exposure effects on the clinical examination was reassuring. The findings for self-reported symptoms raise some concern, as does the finding of low performance for those reporting prior poisoning. Although this was a relatively large study based on a well-defined target population, the workers we studied may not be representative of all exposed workers, and caution should be exercised in generalizing our results.

Adult↗
PubMed2006

Update on the evaluation and diagnosis of celiac disease.

PURPOSE OF REVIEW: Our understanding of the pathophysiology of celiac disease has advanced with associated improvement in diagnostic modalities. Recent studies have placed the prevalence of celiac disease in Western populations at between 1:250 and 1:67. Celiac disease is common throughout the world and most cases go undiagnosed. Understanding the risk factors, clinical presentations and diagnostic modalities is necessary to identify and treat patients with this commonly misdiagnosed disorder. RECENT FINDINGS: Increased prevalence of celiac disease in individuals with autoimmune diseases, reduced bone mineral density and undiagnosed liver disease have been confirmed. However, celiac disease may not be associated with Down's syndrome or epilepsy. Evidence supports high sensitivity and specificity of endomysial- and tissue transglutaminase-based tests in most settings. In children, high or low tissue transglutaminase levels may preclude the need for duodenal biopsy. Cost-effectiveness studies suggest using tissue transglutaminase or endomysial initially, while distal duodenal or jejunal biopsy may confirm celiac disease in the absence of proximal changes. SUMMARY: There is insufficient evidence to support mass screening for celiac disease. However, case finding in individuals with risk factors for celiac disease is recommended. Further study is necessary to define diagnostic algorithms and target populations likely to benefit from testing.

Autoimmune Diseases↗
PubMed1992

Embryonic Purkinje Cells Grafted on the Surface of the Cerebellar Cortex Integrate in the Adult Unlesioned Cerebellum.

The presence of an injury or the selective degeneration of specific neuronal populations is commonly assumed to be a necessary prerequisite for the survival and the integration of grafted neurons in the recipient brain. In the present study we have placed solid grafts of cerebellar anlage in the fourth ventricle of adult rats, in close contact with the host cerebellar cortex, to assess the capacity of embryonic Purkinje cells to interact with adult neurons and integrate in the unlesioned cerebellar cortex. Numerous grafted Purkinje cells are indeed able to leave the implant and migrate into the host molecular layer, where they develop adult structural features. In addition, such cells are able to elicit the growth of host climbing fibre sprouts which end in newly formed arborizations impinging upon their dendritic trees. Climbing fibre collateral branches also penetrate the implant to innervate Purkinje cells which have not migrated in the host cerebellum. These results show that embryonic Purkinje cells are able to survive and integrate in an adult unlesioned cerebellar cortex. In addition, adult olivary axons respond to the increased size of the target population by expanding their terminal domain to innervate grafted Purkinje cells.

Journal Article↗
PubMed1993

Dietary trends in the United States. Relevance to cancer prevention.

BACKGROUND: Diet may be an important factor in the cause and prevention of cancer. Thus, in part to reduce cancer risk, the United States has set two dietary goals for the Year 2000: to reduce fat intake by 18% so that fat constitutes no more than 30% of caloric intake (baseline level 35%), and to double the consumption of carbohydrate and fiber-containing foods by increasing fruit and vegetable consumption to five servings per day and grains to six servings per day (baseline levels 2.5 and 3.0). How far the US population has progressed toward these goals is uncertain. METHODS: Dietary trends in the United States during the past 20 years were examined by compiling food supply data and dietary intake estimates from US adults from various national surveys and from individual studies. RESULTS: Dietary fat intake, considered in absolute terms and as the proportion of calories derived from fat, has been declining slightly during the past 20 years but probably remains near 35% of kilocalories derived from fat. Fruit and vegetable intake appears to be increasing, yet probably averages no more than 3.4 servings per day among US adults. These dietary trends may not be occurring equally in all socioeconomic levels of our society. CONCLUSIONS: There is evidence of modest improvement in the American diet during the past 20 years, with decreasing fat and increasing fruits and vegetables in the diet, but changes must occur at a faster pace if the Year 2000 dietary goals are to be met. More cost-efficient and more timely methods of dietary surveillance of target populations must be developed to support the development and evaluation of more effective dietary interventions.

Diet↗
PubMed2006

Evaluation of the training of Korean community health workers for chronic disease management.

The use of community health workers (CHWs) or lay health advisors has been increasingly popular as an effective means of secondary prevention for cardiovascular health in hard-to-reach, underserved populations. Yet, published evaluations of the CHW training programs are rare. The purpose of this article is to report the results of an evaluation of a CHW training program for hypertension and diabetes management for Korean-American seniors. Forty-eight hours of training was developed and delivered to 12 Korean CHWs. Evaluation of the training program involved CHW surveys, trainer observation and debriefing and CHW focus groups. Testing of CHW knowledge showed that all CHWs met the minimum required knowledge level of 70%. Independent ratings by two trainer observations revealed that the overall CHW performance was satisfactory. Both CHW ratings and focus group data indicated that the training program met their expectation (average 9.3 on a 10-point scale) and was successful in empowering them to assume their role as a 'health initiator', 'health advertising agent' or 'health role model'. While this course is judged to be effective in general, future research is warranted to determine whether CHW provision of care and support will affect health outcomes in the target population.

Asian↗
PubMed1997

Evaluation of an educational program for asthma control in adults.

We have developed a 6-month educational plan associated with outpatient follow-up and special clinical care for asthmatic patients in a deprived population, with serious socioeconomic problems and a very low level of education. The objective was to determine the effects of the program on clinical asthma outcomes, lung function, and quality of life. Forty patients were enrolled in the program with a regular schedule of outpatient visits, and 31 finished the 6-month intervention, which included information about asthma, instruction in appropriate use of medication, training in metered-dose inhaler technique, how to identify and control asthma triggers, how to use symptom diary cards, and how to recognize early signs of deterioration. Patients included 8 males and 23 females, 47.8 +/- 16.5 years old, with 77.4% elementary school education and 22.6% illiterate, and an average monthly income of around $450. After the 6-month program there was a significant change in asthma control with a reduction in asthma emergency visits and hospitalization, reduction of score symptoms, and improvement in quality of life. Based on the results, educational programs are recommended and should be adapted to the socioeconomic and cultural characteristics of the target population.

Administration, Inhalation↗
PubMed1997

Association between lifetime ambient ozone exposure and pulmonary function in college freshmen--results of a pilot study.

Human health effects due to chronic exposure to ozone (O3) have not been established due to problems with exposure assignment and the use of measures of lung function which may not reflect the site of O3 toxicity in the lung. We investigated the feasibility of retrospective assessment of O3 exposure-relevant covariates and derived lifetime "effective exposure" to ozone. Mid- and end-expiratory flows (FEF25-75%, FEF75%) were regressed against effective exposure and ecological lifetime exposure. A convenience sample of 130 UC Berkeley freshmen, ages 17-21, participated twice in the same tests (residential history, questionnaire, pulmonary function), 5-7 days apart. Students had to be lifelong residents of Northern (SF) or Southern (LA) California. Monthly ambient O3 concentrations (OZ) were assigned based on the lifetime residential history. An "effective time" (T) spent in OZ environments was derived for each residence and age stratum (0-2, 3-5, 6-11, 12+) with the use of questions about "total time spent outdoors" and time spent in "moderate" and/or "heavy" activity. Effective exposure was calculated over the lifetime (OZ x T) of each subject. Ozone metrics used were 8-hr averages (10 AM-6 PM) and "hours above 60 ppb." FEF25-75% and FEF75% decreased with both effective exposure and ecologic assignment of O3 exposure. For a 20 ppb increase (interquartile range) in 8-hr O3, FEF75% decreased 334 ml/sec (95%Cl:11-657 ml/sec), which corresponds to 14% (1.0-28.3%) of the population mean FEF75%. The corresponding effect on FEF25-75% was -420 ml/sec (95%Cl: +46 to -886, P = 0.08) or 7.2% of the mean. Use of time-activity data to define exposure had no impact on estimates. Negative confounding factors were region (SF vs LA), gender, and ethnicity. Lifetime 8-hr average O3 concentrations ranged from 16 to 74 ppb with little overlap between regions. There was no evidence for different O3 effects across regions. Effects were independent of lifetime mean PM10, NO2, temperature, or humidity. Effects on FEV1 tended to be negative whereas those for FVC, although negative in some models, where inconsistent and small. The strong relationship of lifetime ambient O3 on mid- and end-expiratory flows of college freshmen and the lack of association with FEV1 and FVC are consistent with biologic models of chronic effects of O3 in the small airways. Since the present study was designed as a pilot study, these findings have to be confirmed in a larger sample that is representative of the target population.

Adolescent↗
PubMed2003

[Effects of a comprehensive health education program on reproductive tract infections/sexually transmitted diseases intervention among reproductive age population in the rural areas of China].

OBJECTIVE: To evaluate the effectiveness on comprehensive health education intervention program regarding reproductive tract infections/sexually transmitted diseases (RTIs/STDs) among reproductive age population in the rural areas of China. METHODS: Data were generated from the Reproductive Health/Family Planning Project implemented by the State Family Planning Committee and the Ministry of Health from 1998 to 2002, which covered 32 counties in 22 provinces. A quasi-experimental design was used. Six counties were selected from 32 project counties as intervention group, while 6 non-project counties were taken as controls which were similar in number of population and economic level to the counties as selected. Subjects of the study were mothers with children under 3 years and men under 35 years of age. A total number of 675 mothers and men were interviewed using a structured questionnaire by strictly trained investigators. Logistic model was used to compare the difference of knowledge on RTIs/STDs between intervention group and control group. OR value was used to describe the degree of the difference. RESULTS: Over the 18 month intervention period, persons in the intervention group had more knowledge of RTIs/STDs than those in control group. Logistic regression analysis indicated that intervention was significantly associated with better knowledge on factors as transmission, risks, symptoms, management and prevention of RTIs/STDs with 95% CI of OR as 2.4 - 6.4, 2.0 - 4.8, 3.0 - 6.4, 1.9 - 5.7 and 1.8 - 6.8 respectively, after controlling the demographic factors. Level of education was an important factor influencing the subjects to receive knowledge on RTIs/STDs. CONCLUSION: Comprehensive health education intervention programs had significant impact on knowledge about RTIs/STDs among the target population, indicating that the Reproductive Health/Family Planning Project implemented in the rural areas of China had been successful.

Adult↗
PubMed1998

Knowledge of diet and blood pressure among African Americans: use of focus groups for questionnaire development.

Though focus groups are widely used for development of interventions, little is known about their utility in questionnaire construction, particularly for health surveys in a south-eastern African-American population. In this study, focus groups aided in the development of questions, question sub-components, and response options identifying factors that may influence dietary behavior. Information was used for a survey of dietary knowledge, blood pressure knowledge, and measured blood pressure in a church-based, stratified random sample of middle-class African Americans in North Carolina. Each session, conducted in six churches, lasted 1-1 1/2 hours and had four to nine participants; thirty-four individuals participated. Recorded responses were reviewed and summarized by trained personnel. Results indicate that participants had a general understanding of hypertension, its risk factors, and modes of prevention. However, some misconceptions existed regarding blood pressure and sources of sodium. Television was the most common source of health information. Cost and Southern cultural traditions were deemed the major influences on dietary behavior. Many believed stress was strongly related to blood pressure. The focus group process generated useful information for developing questions about nutrition knowledge, blood pressure knowledge, and health attitudes and beliefs of the target population for the epidemiologic survey that followed.

Adult↗
PubMed1990

[Family health center follow-up in preschool children].

The duration of follow-up at family health centers (FHC) was determined from a national prevalence study of chronic conditions and illnesses causing disability in preschool children. The sample comprised 8,702 children (12% of the 71,372 in the national Jewish birth cohort of 1980) who had reached the age of 3 years at the time of the study. The sample originated from 118 of the 870 FHC in areas of Jewish population which included FHC managed by municipalities, sick funds and the Ministry of Health. With increase in age there was a significant decrease in attendance at the FHC. Thus at 6 months of age, 97% of the sample attended the FHC, while at 3.5 years the follow-up rate had fallen to 33%. Children of mothers of Asian origin, of mothers with less than 10 years of schooling, and of mothers 19 years old or less on delivery, as well as first-born children, showed a higher rate of attendance at age 3 than the others. Higher attendance at age 3 was also registered in the south of the country, especially rural areas. More children with diagnosed medical problems attended at age 3 than healthy children. More children born with birth weights of 1,500 g or less dropped out of the FHC during their first year of life. The findings suggest that the purpose, content and efficiency of FHC be reexamined in light of changes in the needs of the target population due to educational and technological progress.

Age Factors↗
PubMed2000

Sociodemographic factors related to self-medication in Spain.

To identify the sociodemographic factors associated to self-medication (i.e. use of non-prescription medicines) and undesirable self-medication, a cross-sectional study was carried out using a sample (n = 20,311) representative of the population of adults of 16 years of age and older in Spain. Multivariate Cox's regression was used. The prevalence of self-medication in the sample was 12.7% during the two weeks preceding the interview. Self-medication is more prevalent among women, persons who live alone, and persons who live in large cities. For persons who reported acute disorders, self-medication prevalence was higher among those with higher educational levels. The prevalence of undesirable self-medication in the sample was 2.5% during the two weeks previous to the interview. Undesirable self-medication is twice as common among persons older than 40 years, as compared to persons younger than 27 years. Undesirable self-medication prevalence is 53.0% higher among those who live alone as compared to those who live with their partner (95% confidence interval (CI): 15.2-103.2) and 36.8% higher among students as compared to full-time workers (95% CI: 1.9-83.5). People over 40 years of age, people living alone, and students should be the priority target populations for public health education programs aimed at improving the quality of self-medication behavior.

Adolescent↗
PubMedDate not supplied

Improving the health of Indian teenagers--a demonstration program in rural New Mexico.

The health status of Indian teenagers in the United States is below that of the general population. The usual barriers to the use of health care services that young people, including young Indians, encounter are compounded in rural areas by distance, isolation, and lack of appropriate services. To overcome these barriers in rural New Mexico, a public health demonstration project (a) established a single location where adolescents can receive multiple, integrated health care services free of charge; (b) set up the initial program of services at a rural school; (c) established links with existing agencies; and (d) incorporated community action toward creating change. The project began as a joint effort of three communities, the University of New Mexico (UNM), and the Albuquerque Area Indian Health Service (IHS) of the Public Health Service; a secondary level public school soon became a participant. The project is being replicated in two other communities that have formed separate partnerships with UNM and the area IHS; also the New Mexico Health and Environment Department has joined the effort in one community. Preliminary data suggest that the services are being used by a majority of the target population, with the proportions of boys and girls about equal.

Adolescent↗
PubMed2002

Maximum-likelihood estimation of sensitivity and specificity of ELISAs and faecal culture for diagnosis of paratuberculosis.

The accuracy of three diagnostic tests for paratuberculosis was evaluated using maximum-likelihood estimation of sensitivity and specificity. We also explored the variety of estimates that can be obtained if the tests are to be used in populations of different composition with regard to infection and disease states. Two enzyme-linked immunosorbent assays (ELISAs) were evaluated separately with the faecal culture (FC). The study was carried out as a cross-sectional field study to cover all likely states of infection with Mycobacterium avium subsp. paratuberculosis.The three basic assumptions for the maximum-likelihood technique were evaluated to validate the results. Our accuracy estimates for the ELISAs were not very different from those previously published, but those for faecal culture differed if a different cut-off value was chosen for the ELISA. If faecal culture was used for screening in a Danish dairy region where the median ELISA reading was a measure of the general disease situation, the sensitivity of the faecal culture was 20-25%. If faecal culture was used as a confirmatory test on cows with a high ELISA reading (and thus high level of antibodies), the sensitivity of the faecal culture would be in the range 60-70%. These results emphasise the importance of the composition of a target population before selecting a specific diagnostic test for a given purpose. We concluded that faecal culture is useful for confirmation but not for screening purposes.

Animals↗
PubMed2006

Awareness, knowledge, and perception of heart disease among adolescents.

BACKGROUND: Perceptions of cardiovascular risk among adolescents have not been studied recently. The rise in unattended risk factors and the obesity pandemic have created calculable cardiovascular disease risk in the adolescent population. DESIGN: We sought to assess the awareness, level of knowledge, and perception of cardiovascular disease in an adolescent population. METHODS: We administered a survey designed to collect data on demographics, beliefs regarding risk factor importance, perceived future risk and other knowledge-based assessment questions about cardiovascular disease. RESULTS: Students, n=873, (45.4% male, mean age 15.6 years) in grades 9-12, from four Michigan high schools completed the survey unassisted. Accidents were rated as the greatest perceived lifetime health risk (39.1%). A minority (16.6%) of respondents selected cardiovascular disease as the greatest lifetime risk placing it behind accidents and cancer. When asked to identify the greatest cause of death for each sex, 42.3% of respondents correctly recognized cardiovascular disease for men and 14.0% correctly recognized cardiovascular disease for women in the United States, P<0.0001. Forty percent of respondents incorrectly chose a substance abuse/use behavior, other than cigarettes, as the most important cardiovascular disease risk behavior. CONCLUSIONS: Our findings suggest that adolescents lack knowledge regarding the risk of cardiovascular disease and do not perceive themselves at risk for cardiovascular disease. These data will be useful in designing future preventive strategies and interventions aimed at this target population.

Adolescent↗