Psychological Factors Associated with a Better Quality of Life Following Head-Up Tilt Testing

Quality of life (QoL) is reduced in patients with recurrent vasovagal (VVS) or unexplained syncope (US). Little is known concerning the natural evolution of QoL following diagnosis. Psychological factors contributing to QoL improvement, such as psychological distress and self-efficacy remain to be explored. The objective of this study is to examine whether QoL changes 2 months and 6 months following head-up tilt (HUT) testing as well as to determine whether psychological factors are predictive of changes in QoL. Seventy-three patients undergoing HUT for recurrent syncope were interviewed 1 month before as well as 2 months and 6 months following HUT, using semi-structured interviews and questionnaires. Pre-HUT QoL was significantly worse than at the 2-month (p = 0.000) and 6-month follow-ups (p = 0.000). Psychological distress at baseline was associated with worse QoL 2 months post-HUT (Beta = .280; p = .024), independently of socio-demographic and clinical factors. Improved self-efficacy at follow-up predicted improvements in QoL (Beta = −.186; p = .023). Two and 6 months post-HUT, QoL is mproved in patients with recurrent syncope. Better QoL is predicted by low psychological distress and a heightened sense of self-efficacy following HUT. Strategies for enhancing self-efficacy and reducing psychological distress could be an efficient way to promote QoL in patients suffering from recurrent syncope.     

Reliability and Validity of the Thai “Global Person Generated Index”, an Individualised Measure of Quality of Life

The “Global Person Generated Index” (GPGI) is an individualised measure of global quality of life (QoL). Individualised measures have been used within a health context, however until recently have been rarely used to explore global QoL. This paper establishes the GPGI’s validity and reliability in Thailand. Data were collected from participants in two sites in Northeast Thailand. Participants completed the Thai GPGI, the “Satisfaction with Life Scale”(SWLS), a modified “Positive and Negative Affect Scale” (PANAS) and provided demographic data. 81 participants provided data at T1. 70 participants completed data for test-retest (two week interval) reliability comparisons. Test-retest reliability correlation was 0.678 (p < 0.001) for participants reporting no change in QoL. GPGI correlated moderately with SWLS (0.381, p < 0.01) and PANAS scales (0.291 and −0.378, both p < 0.01), indicating validity. GPGI scores were related to health and correlated to a moderate degree with income (0.379, p < 0.05). GPGI scores did not show the expected differences in scores based on gender, although this may be owing to cultural issues. Areas nominated as important to QoL included family, money, house, health and employment, which mirrors items on other QoL scales and previous work with individualised measures. The Thai GPGI is reliable for group comparisons and valid. The difficulties of designing cross-cultural construct validity hypotheses are acknowledged. Areas nominated as important to QoL were diverse and largely asset based. The GPGI is recommended for use to explore global QoL and potentially useful for needs assessment and exploration of response shift.     

The Impact of Demographic Characteristics on Health-related Quality of Life Profile of Malaysian Epilepsy Population

The possibilities of adverse drug reactions and disease-related psychosocial implications have led to the current emphasis on health-related quality of life (HRQoL) assessment in epilepsy. The main objective of this study was to determine the impact of various demographic characteristics i.e. gender, age, marital status, ethnic origin, religion, and employment status on HRQoL profiles in Malaysian epilepsy patients. Patients with epilepsy were recruited from ten public hospitals in Sabah, Malaysia. Upon written consents, they completed the Malay Quality of Life In Epilepsy-30 (QOLIE-30) instrument which assesses Seizure Worry, Overall QoL, Emotional Well-Being, Energy/Fatigue, Cognitive Functioning, Medication Effects and Social Functioning. An Overall Score was generated to represent a summarised HRQoL score. Univariate and multiple linear regression analyses were both carried out using SPSS 14 for (1) all patients and (2) patients possessing Poor QoL (Overall Score < median) and Good QoL (Overall Score ≥ median). One-hundred-and-thirteen patients participated in the study. The respondents ranged from 18–76 years with a mean age of 31 years. Majority were Kadazandusuns (n = 46; 40.7%) and many were unmarried (n = 68; 60.2%), Muslims (n = 50; 44.2%) and unemployed (n = 54; 47.8%). Age was the most significant factor across all patients (B = −0.372, t = −2.238, p = 0.027), regardless of Poor or Good QoL level. Older patients (>56 years) fared the worst in many HRQoL areas. Those with Poor QoL were mostly affected by marital status (widowed/divorced) and ethnic origin (Kadazandusun/Chinese). Religion (Buddhism/Hinduism) emerged as the most prominent HRQoL predictor for patients experiencing Good QoL and being Chinese too played a role. These outcomes indicate that specific demographic characteristics are influential in determining the HRQoL of epilepsy patients. Consequently, healthcare professionals could utilise such information in planning the best treatment and care by considering both the medical and psychosocial impacts towards patients. This paper was part of a research project and majority of its components had been presented at the 7th Conference On International Society For Quality Of Life Studies (ISQoLS) 2006, Rhodes University, Grahamstown, South Africa, 17–20 July 2006.     

Predictors of Heart-Focused Anxiety in Patients Undergoing Genetic Investigation and Counseling of Long QT Syndrome or Hypertrophic Cardiomyopathy: A One Year Follow-up

Since Long QT syndrome and Hypertrophic cardiomyopathy are inherited cardiac disorders that may cause syncope, palpitations, serious arrhythmias, and sudden cardiac death, at-risk individuals may experience heart-focused anxiety. In a prospective multi-site study, 126 Norwegian patients attending genetic counseling were followed 1 year with multiple administration of questionnaires, including the Cardiac Anxiety Questionnaire, measuring three distinct symptoms of heart-focused anxiety- avoidance, attention, and fear—in mixed linear analyses. Overall, at 1-year follow-up, patients with clinical diagnosis as compared to patients at genetic risk had significantly higher scores of avoidance (p < .002), attention (p < .005), and fear (p < .007). Sudden cardiac death in close relatives, uncertainty whether other relatives previously had undergone genetic testing, patients’ perceived general health, self-efficacy expectations and procedural satisfaction with genetic counseling were influential in predicting the different symptoms of heart-focused anxiety over time.     

In the Eye of the Beholder: Alcohol Use and Perceptions Among Student-Patrons of ‘Joints’ in Three Nigerian University Communities

Alcohol use and its associated problems among university students have attracted empirical investigation by researchers and scholars. While many of these studies have reported a very high level of alcohol consumption and highlighted the various problems this portends, alcohol-related perceptions of this vulnerable population, which could be germane to intervention aimed at curtailing the problem, have remained largely under-researched. This cross-sectional survey examined the use and perceptions of alcohol by student-patrons (n = 1,705) of beer parlours or ‘joints’ in three university communities in Southwest Nigeria. Respondents were interviewed using AUDIT, a socio-demographic prototype and an open-ended section on alcohol-related perceptions of the students. Findings indicated that overall, 72% of the respondents perceived that alcohol is good for socializing, 68% perceived that alcohol is good in the aspect of stress reduction, 58% believed that alcohol consumption is indicative of maturity, 36% perceived that alcohol enhances their sexual performance while 39% perceived that alcohol serves to enhance alertness/concentration. Results also showed that gender (β = −. 23; p < .05), paternal alcohol use (β = .36; p < .01), parental socio-economic status (β = .33; p < .01), and residential status of university of respondents (β = .21; p < .05) significantly predicted alcohol use. The study concluded that perceptions about alcohol are very germane to understanding students’ alcohol use and should be reckoned with in designing intervention programmes. The need to adopt a ‘client-centered’ approach to the problem of student drinking behaviour was emphasized.     

Type D personality,illness perception,social support and quality of life in continuous ambulatory peritoneal dialysis patients

The previous studies reported Type D was associated with poor quality of life (QoL), increased psychological distress, and impaired health status in cardiac patients. The aim of this study is to assess the relationships among Type D personality, illness perception, social support, and investigate the impact of Type D personality on QoL in continuous ambulatory peritoneal dialysis (CAPD) patients. Type D personality was assessed by the Chinese 14-item Type D Personality Scale (DS14). Illness perceptions were assessed using the Chinese version of the Brief Illness Perception Questionnaire (B-IPQ). Social support status was assessed by the well-validated social support rating scale (SSRS). Patients’ QoL was assessed by using Medical Outcomes Short Form 36 (SF-36), respectively. The Type Ds had significantly lower objective support score (8.18 ± 2.56 vs. 9.67 ± 3.28, p = 0.0001), subjective support score (6.71 ± 2.0 vs. 7.62 ± 1.93, p = 0.0001) and utilization of social support score (6.76 ± 2.0 vs. 7.61 ± 1.94, p = 0.0001) than that of the non-type Ds. Type Ds believed their illness had much more serious consequences (7.67 ± 2.64 vs. 6.27 ± 3.45, p < 0.001), and experience much more symptoms that they attributed to their illness (6.65 ± 2.54 vs. 7.31 ± 2.36, p = 0.023). Significant differences were found between Type Ds and non-Type Ds in PCS (40.53 ± 6.42 vs. 48.54 ± 6.21 p < 0.001) and MCS (41.7 1 ± 10.20 vs. 46.35 ± 9.31, p = 0.012). The correlation analysis demonstrated that Type D was negatively associated with physical component score (PCS) (r = –0.29, p < 0.01), mental component score (MCS) (r = –0.31, p < 0.01), and social support (r = –0.24, p < 0.001). Using multiple linear regression analysis, we found that Type D personality was independently associated with PCS (β = –0.32, p < 0.001) and MCS (β = –0.24, p < 0.001). Type D personality was a predictor of poor QoL in CAPD patients. The current study is the first to identify a strong association among Type D, illness perceptions, social support and QoL in CAPD patients. The worse illness perceptions and lower social support level therefore represent possible mechanisms to explain the link between Type D and poor QoL in CAPD patients.     

Quality of Life Before and After Cataract Surgery: Research in a Sample of Polish Patients

The goal of this paper is to present possible change in quality of life (QoL) in older sample of people with vision disturbances. The patients were investigated twice: before (N = 193) and 4 month after the cataract surgery (N = 69), by means of the scale for vision functioning, and the Life Quality Questionnaire (Schalock & Keith, 1993) extend with the items measuring health related quality of life (HRQoL). Two problems were formulated: To what extent are visual defects associated with the decreased subjective QoL? What changes are observed in perceived QoL during the period of treatment of visual defects? The patients reported significant increase of HRQoL, however they did not report similar increase of a general QoL. Few reasons are considered: overlapping of the content of visual function scales and HRQoL and different indices of a general QoL and HRQoL, lack of a proper postoperative care, low socio-economic status of the participants, and too high expectation concerning better functioning after the surgery.     

Differences Between African American and White Research Volunteers in Their Attitudes,Beliefs and Knowledge Regarding Genetic Testing for Alzheimer’s Disease

Genetic susceptibility testing for common diseases is expanding, but little is known about race group differences in test perceptions. The purpose of this study was to examine differences between African Americans and Whites in knowledge, attitudes, and motivations regarding genetic susceptibility testing for Alzheimer’s disease (AD). Before enrolling in an AD genetic testing research trial, 313 first-degree relatives of AD patients (20% African American; 71% female; mean age = 58 years) were surveyed regarding: (1) knowledge about genetics and AD risk; (2) concerns about developing AD; and (3) reasons for seeking testing. In comparison to Whites, African Americans were less knowledgeable about genetics and AD risk (p < .01) and less concerned about developing AD (p < .05), with lower levels of perceived disease risk (p = .04). The results suggest that African Americans and Whites differ notably in their knowledge, beliefs, and attitudes regarding genetic testing for AD. Additional research with more representative samples is needed to better understand these differences.     

Illness Perception Mediates the Effect of Illness Course on the Quality of Life of Mexican Patients with Psychosis

Learning about possible factors influencing, positively or negatively, the Quality of Life (QoL) of patients with psychosis is an important task for both, research and treatment. The study examined the association of illness course with QoL in a sample of Mexican patients with psychosis. It was hypothesized that illness perception would mediate the relation of illness course to QoL. Sixty-one (56 % female) patients were interviewed and assessed for illness course (relapses, residual symptoms, and diagnosis), QoL, and illness perception. Mediation analyses (simple and multiple) with bootstrapping procedures were applied, including residual symptoms as the predictor of QoL, and illness perception dimensions as candidate mediators. Residual symptoms, rather than a relapsing course or a diagnosis of schizophrenia, have a diminishing effect in the subjective QoL. This effect is fully mediated by illness perception, particularly by the cognitive and the emotional representations. Results underscore the importance that patients’ beliefs have on their perceived QoL, encouraging further research and development of interventions targeting illness perceptions.     

Coronary Intervention Improves Disease Specific Health-Related Quality of Life but Not Individualised Quality of Life: A Potential Response Shift Effect?

To explore potential response shift effects with different quality of life (QoL) instruments in cardiac patients undergoing coronary intervention. Study Design and Setting: Recalibration was assessed with the disease specific health-related quality of life (HRQL) instrument MacNew in combination with a then-test approach. Reconceptualisation and reprioritisation were assessed with the individualised QoL instrument SEIQoL-DW. Significant treatment effects were seen on the MacNew (global Δ: 0.6 ± 1.1, p = 0.004) but not on the SEIQoL-DW (Δ: 3.3 ± 16, p = 0.37) 6 months after coronary intervention. No recalibration effect was found on the MacNew then-test, while with the SEIQOL-DW potential response shift effects of reconceptualisation and reprioritisation were seen. For the first time response shift effects were explored in cardiac patients undergoing coronary intervention. This study confirmed that there is a clinically significant improvement in disease specific HRQL over time following successful coronary interventions. However, no treatment effect was seen for individualised QoL with the SEIQoL-DW. This might be due to reconceptualisation and reprioritisation response effects. Future studies need to focus on exploring response shift effects, and the interrelationship between its different components, captured by different patient reported outcome instruments in larger patient groups undergoing coronary interventions.     

Anxiety and Asthma Symptoms in Urban Adolescents with Asthma: The Mediating Role of Illness Perceptions

Twenty to 40% of adolescents with asthma experience significant symptoms of anxiety. This study examined the mediational role of illness perceptions in the relationship between anxiety and asthma symptoms in adolescents. One hundred fifty-one urban adolescents (ages 11–18) with asthma completed measures of illness perceptions, and anxiety and asthma symptoms. Using the Baron and Kenny approach and Sobel tests, we examined whether illness perceptions mediated the anxiety-asthma symptom relationship. Three illness perceptions significantly mediated the relationship between anxiety and asthma symptoms, z = 1.97–2.13, p < .05; adjusted R ² = 0.42–0.51, p < .05. Greater anxiety symptoms were associated with perceptions that asthma negatively impacted one’s life and emotions and was difficult to control. These negative illness perceptions were, in turn, related to greater asthma symptoms. Illness perceptions helped explain the anxiety-asthma symptoms link in adolescents. Results suggest that targeting illness perceptions in adolescents with asthma and anxiety may help reduce asthma symptoms.     

Doctor-patient relationship and quality of life in Irritable Bowel Syndrome: an exploratory study of the potential mediating role of illness perceptions and acceptance

Irritable Bowel Syndrome (IBS) is a functional gastrointestinal disorder characterised by unpredictable bowel symptoms. These can be difficult to manage, consequently impacting quality of life (QoL). In addition, a strained doctor–patient relationship is independently reported in the qualitative literature. Given the doctor is often the first port of call for people with IBS, a difficult relationship may influence subsequent IBS management. Research suggests illness perceptions are important in determining IBS outcomes in therapy; however, their association with doctor–patient relationship and QoL is yet to be investigated. This exploratory study aimed to investigate the association between these constructs in IBS, as well as potential mediation by illness perceptions. Online questionnaires measuring doctor–patient relationship, illness perceptions, acceptance and QoL, were completed by 167 participants who reported an IBS diagnosis (144 female, mean age = 44.22 years, SD = 15.91 years). Bootstrapped pathway analysis was used to model the relationship and mediation effects. There was a significant positive correlation between patient–doctor relationship and QoL, r = .258, n = 167, p = .001. There was a significant indirect effect between doctor–patient relationship and QoL through illness coherence and acceptance (bootstrapped estimate = .058, 95%CI Lower-Upper = .02, .095, p = .002). No other indirect effects were observed in combination with good fit indices for the other illness perceptions. Findings suggest a doctor–patient relationship which fosters mutual understanding and helps patients make sense of symptoms, increases their ability to manage their IBS in a psychologically flexible manner, subsequently helping them maintain their QoL.     

Verbal Sexual Coercion and Perceived Victim Responsibility: Mediating Effects of Perceived Control

Verbal coercion involves unwanted sexual penetration compelled by psychological pressure. It was hypothesized that, to the degree that verbal coercion is seen as controllable, victims may be held more responsible. Two samples of US undergraduates rated perceptions of hypothetical sexual coercion scenarios. In Study 1, participants (N = 120) read scenarios of either verbal coercion or rape by a male dating partner. Participants perceived verbal coercion as more controllable than rape, which accounted for the greater responsibility attributed to verbal coercion victims. In Study 2, participants (N = 275) read scenarios involving either male-to-female or female-to-male verbal coercion. Participants perceived female-to-male coercion as more controllable, which accounted for the greater responsibility attributed to a verbally coerced man.     

Emotional Reaction to Fragile X Premutation Carrier Tests Among Infertile Women

Female fragile X premutation carriers are at ∼10-fold increased risk of premature ovarian failure (follicle stimulating hormone >40 mIU/mL, amenorrhea, age <40). A milder degree of premature ovarian aging (diminished ovarian reserve, where follicle stimulating hormone levels are typically 10–20 mIU/mL) results in infertility. Approximately 10% of fertility clinic patients have this diagnosis. A cohort of 20 women diagnosed with diminished ovarian reserve provided a blood specimen (confidential results), and completed structured questionnaires that assessed emotional reactions to potentially being a premutation carrier (pretest questionnaire, n = 20) and the posttest known carrier status (3 month follow-up questionnaire, n = 18 non-carriers). Responses were measured using 9-point scales, and analyzed with Fisher exact and Wilcoxon exact tests. While most participants did not view fragile X premutations as a serious medical condition, perceptions of seriousness were positively correlated with anger and regret about not knowing sooner of the potential association of these premutations with infertility. Overall, when women (pretest) imagined themselves as carriers, their self-esteem and Health Orientation Scale responses were unchanged with the exception of feeling more afraid (p = 0.004). Despite strongly wishing for negative test results, they were glad to know there might be a medical explanation for their infertility. Financial Support: This work was financially supported by a University of Virginia School of Medicine Research & Development Award.     

The Effect of Dispositional Optimism in HRQOL in Patients with Chronic Musculoskeletal Pain Conditions in Greece

The purpose of this investigation was to study the influence of optimism in the quality of life of patients with musculoskeletal problems that were referred to Amfilohia Rehabilitation Center, because of chronic pain and kinetic difficulties. The sample consisted of 96 patients. The questionnaires that were used are the short form health questionnaire (12 questions; SF12), the life orientation test-revised (LOT-R) and a VAS scale for pain measurement. According to the regression analysis performed, dispositional optimism is an independent factor affecting both the physical (β = .249, p < .005) and mental composite score (β = .414, p < .0001) in patients with musculoskeletal problems, even after controlling for the effect of pain intensity.     

A Study of the Relationship between Familial Factors and Academic Motivation and Achievement in High School Students

Educational psychologists, nowadays, are more concerned about the students who are motivated in learning and interested in achieving their academic goals. Academic motivation and achievement are considered as primary indicators of students’ learning process and outcomes. This study aimed to know the relationship between the most important familial factors (e.g., parental education, parental occupation, family type, monthly household income, sibling’s achievement) with students’ academic motivation and achievement. One hundred and eighty high school students, age ranging from 13 to 16 years (M = 14.20, SD = .960), at eighth through tenth grade, were selected from six high schools through purposive sampling method, from Chittagong, Bangladesh. A Bangla version of ‘Academic Motivation Questionnaire’ (Fatematuzzohra et al., 2010), originally developed by Vallerand et al. (Can J Behav Sci 21(3):323–349, 1989. https://doi.org/10.1037/h0079855), was used to pursue the study. The result showed that all of the familial factors except the family type had significant effects on both students’ academic motivation and achievement scores. A significant positive correlation was found between students’ academic achievement and academic motivation scores (r = .339, p < .01). All of the familial factors were significant in explaining students’ academic achievement as well as their academic motivation. These factors combinedly explained 57.5% of the variance in students’ academic achievement (R2 = .575, F(13, 166) = 17.281, p < .01) and explained 30.5% of the variance in students’ academic motivation (R2 = .305, F(13, 166) = 5.614, p < .01). Implications for understanding the relationship between familial factors and academic motivation and achievement are discussed.     

The Influence of Clinical Variables on the Psychological Adaptation of Adolescents after Solid Organ Transplantation

This study assessed the influence of clinical and socio-demographic variables on the psychological adaptation of transplanted adolescents. Twenty-six transplanted adolescents and 25 healthy adolescents, aged 13–17, and their parents participated in the study. The following domains were measured: social competence, emotional/behavioral problems, self-concept, self-esteem and subjective well-being. The findings revealed that transplanted boys presented significantly less social competence (U = 26,000, p < .05) and more externalizing problems (U = 25,000, p < .05), social problems (U = 25,000, p < .05) and attention problems (U = 17,500, p < .01) than healthy boys. In contrast, transplanted girls displayed significantly more internalizing problems (U = 47,000, p < .05) and lower physical self-concept (U = 49,500, p < .05) than healthy girls. Hierarchical regression analysis showed clinical variables, especially waiting-list time, significantly predicted attention problems (β = .364, p < .05) and negative affect (β = .632, p < .05) in transplanted adolescents. Also, male (β = −0.554, p < .01) and younger (β = −0.444, p < .01) transplanted adolescents were at risk for attention problems. Our data suggest the importance of the waiting-list time for transplanted adolescents. Efforts to reduce the pretransplant phase would help adolescents achieve better psychological adaptation at long-term posttransplant.     

Quality of Life Assessment for Physical Activity and Health Promotion

Despite the clear relationship of physical activity and quality of life (QoL), QoL measures are seldom targeted for physical activity and health promotion. The current research attempted to address that gap by developing a QoL measure based on a conceptual model that reflects positive health and is relevant for physical activity and health promotion programs. In the project, which extended over three phases, an initial 70-item QoL survey was administered to university students and community program participants (total n = 512) along with measures of satisfaction with life and physical activity. Exploratory and confirmatory factor analyses revealed clear social, emotional, cognitive, physical, spiritual and functional (ADL) QoL factors as well as integrated QoL. The resulting 32-item QoL Survey fits the conceptual model, demonstrates logical relationships with physical activity and has sufficient psychometric properties for use in related research and health promotion programs.     

Self-Esteem, Teasing and Quality of Life: African American Adolescent Girls Participating in a Family-Based Pediatric Overweight Intervention

Two studies investigated overweight in African American girls. First, African American adolescent girls (BMI was ≥ 85th percentile) and their mothers participated in focus groups addressing weight and eating. Although mothers and daughters shared some similar views on these issues, there were important discrepancies, with mothers expressing greater doubt about the potential success of a healthy weight program. The second study evaluated baseline data from 39 African American girls participating in a weight management program; mothers' reports were also analyzed. In both studies, adolescents reported significant teasing, and in the second study, teasing was inversely associated with social quality of life (β=.55, t=3.01, p=.007). Motivation to participate was positively associated with teasing (r=.50, p < .01). Self-esteem was inversely related to positive health habits (all p < .05). Mothers who viewed their daughters as having higher self-esteem were less concerned about their daughters' weight. Differences in mothers' and daughters' perceptions highlight the importance of a family approach in pediatric overweight interventions. Results provide evidence that overweight African American girls face significant weight stigmatization and suggest areas to target regarding intervention implementation.

Physical Activity, Life Satisfaction, and Self-Rated Health of Middle School Students

Little research has examined the association between life satisfaction, self-rated health (SRH), and physical activity concurrently for middle school students. A convenience sample of 245 students in grades 7 and 8 was surveyed about physical activity, life satisfaction, and SRH using the U.S. Centers for Disease Control and Prevention (CDC) 2005 Middle School Youth Risk Behavior Survey. ANOVA analyses revealed significantly reduced life satisfaction for females who reported not engaging in vigorous physical activity during the past 7 days [p < .01, effect size (ES) = .75]. Significantly reduced life satisfaction was detected for both males (p < .001, ES = .66) and females (p < .0001, ES = .80) who reported not playing on sports teams. Additionally, logistic regression analyses showed the odds of reporting fair/poor SRH increased 5.4 times for males (CI = 1.30–22.39, p < .05) and 30.9 times for females (CI = 3.74–255.43, p < .001) who reported not playing on sports teams. Preliminary findings suggest physical activity and sports participation is associated with improved life satisfaction and SRH for middle school students. In addition, although some gender differences were observed, consistent findings for sports participation suggest sports participation may carry multiple social, mental, and physical benefits for youth.