Developing a Measure to Assess Emotions Associated with Never Being Deployed

Much research has focused on stress related to deployments; however, a substantial proportion of soldiers never deploy. In a study of 1.3 million veterans, suicide risk was higher among veterans who had never deployed. Thus, not being deployed may have an impact on soldiers' well-being; however...

Ausführliche Beschreibung

Gespeichert in:
Bibliographische Detailangaben
Veröffentlicht in:Military medicine 2018-09, Vol.183 (9-10), p.e509-e517
Hauptverfasser: Hoopsick, Rachel A, Homish, D Lynn, Bartone, Paul T, Homish, Gregory G
Format: Artikel
Sprache:eng
Schlagworte:
Online-Zugang:Volltext
Tags: Tag hinzufügen
Keine Tags, Fügen Sie den ersten Tag hinzu!
container_end_page e517
container_issue 9-10
container_start_page e509
container_title Military medicine
container_volume 183
creator Hoopsick, Rachel A
Homish, D Lynn
Bartone, Paul T
Homish, Gregory G
description Much research has focused on stress related to deployments; however, a substantial proportion of soldiers never deploy. In a study of 1.3 million veterans, suicide risk was higher among veterans who had never deployed. Thus, not being deployed may have an impact on soldiers' well-being; however, no measures exist to assess emotions regarding non-deployment. We aimed to develop and test an original measure of non-deployment emotions. We examined the Non-Deployment Emotions (NDE) questionnaire, a novel four-item measure of guilt, unit value, unit camaraderie, and unit connectedness in a sample of never-deployed male and female US Army Reserve/National Guard (USAR/NG) soldiers (N = 174). Data are from Operation: SAFETY (Soldiers and Families Excelling Through the Years), an ongoing survey-based study examining the health of USAR/NG soldiers and their partners. The protocol was approved by the Institutional Review Board at the State University of New York at Buffalo. The relationship between each of the items was examined by calculating correlation and alpha coefficients. Latent class analyses tested for the existence of distinct levels of negative emotions related to non-deployment. Negative binomial regression models examined the cross-sectional associations between NDE summary score and each of the following outcomes, separately: anger, anxiety, depression, and post-traumatic stress. More than half of never-deployed USAR/NG soldiers expressed negative emotions for having not been deployed. "Guilt," "value," "camaraderie," and "connectedness" were each positively correlated with each other (p < 0.001) and the internal consistency reliability was high (male soldier α = 0.90, female soldier α = 0.93). Latent class analyses revealed a superior three-class model with well-delineated class membership (entropy = 0.93): "Class 1" (low NDE; 47.6%), "Class 2" (moderate NDE; 33.8%), and "Class 3" (high NDE; 18.6%). Regression models demonstrated that greater non-deployment emotions were independently associated with more severe anger (RR = 1.02, 95% CI: 1.01, 1.03, p < 0.001), anxiety (RR = 1.06, 95% CI: 1.01, 1.11, p < 0.05), depression (RR = 1.06, 95% CI: 1.01, 1.11, p < 0.05), and PTSD (RR = 1.10, 95% CI: 1.04, 1.16, p < 0.01). Findings demonstrate that negative emotions regarding non-deployment are prevalent among never-deployed USAR/NG soldiers and that these emotions are related to a mental health. The NDE provides a measure of "guilt," "value," "camaraderie," a
doi_str_mv 10.1093/milmed/usy005
format Article
fullrecord <record><control><sourceid>proquest_cross</sourceid><recordid>TN_cdi_proquest_miscellaneous_2014952375</recordid><sourceformat>XML</sourceformat><sourcesystem>PC</sourcesystem><sourcerecordid>2014952375</sourcerecordid><originalsourceid>FETCH-LOGICAL-c388t-6f7b2605c1a2d3175bbb32279e49c59f9897e416b68660d7eb4913ca920c26223</originalsourceid><addsrcrecordid>eNp9kb1Pw0AMxU8IREthZEWRWFhCfXfJXTyWtnxIBRaQ2KJ8OJAqyYVcAup_T6LQhYHJsvV7T7YfY-ccrjmgnJd5UVI67-wOwD9gU44SXMXl2yGbAgjleqD9CTuxdgvAPQz4MZsI9D2N0puyzYq-qDB1Xr07kfNIke0aclrjLKwla511adrcVHboTZJHLaXOd95-OE-9rnFuaBCuqC7MjtJTdpRFhaWz3zpjr7frl-W9u3m-e1guNm4ig6B1VaZjocBPeCRSybUfx7EUQiN5mPiYYYCaPK5iFSgFqabYQy6TCAUkQgkhZ-xq9K0b89mRbcMytwkVRVSR6WwohkN9IbXfo5d_0K3pmqrfLhSeBEDkiP9SXPXroALdU-5IJY2xtqEsrJu8jJpdyCEcwgjHMMIxjJ6_-HXt4mG8p_fflz8KGISY</addsrcrecordid><sourcetype>Aggregation Database</sourcetype><iscdi>true</iscdi><recordtype>article</recordtype><pqid>2168979607</pqid></control><display><type>article</type><title>Developing a Measure to Assess Emotions Associated with Never Being Deployed</title><source>MEDLINE</source><source>Elektronische Zeitschriftenbibliothek - Frei zugängliche E-Journals</source><source>Oxford University Press Journals All Titles (1996-Current)</source><creator>Hoopsick, Rachel A ; Homish, D Lynn ; Bartone, Paul T ; Homish, Gregory G</creator><creatorcontrib>Hoopsick, Rachel A ; Homish, D Lynn ; Bartone, Paul T ; Homish, Gregory G</creatorcontrib><description>Much research has focused on stress related to deployments; however, a substantial proportion of soldiers never deploy. In a study of 1.3 million veterans, suicide risk was higher among veterans who had never deployed. Thus, not being deployed may have an impact on soldiers' well-being; however, no measures exist to assess emotions regarding non-deployment. We aimed to develop and test an original measure of non-deployment emotions. We examined the Non-Deployment Emotions (NDE) questionnaire, a novel four-item measure of guilt, unit value, unit camaraderie, and unit connectedness in a sample of never-deployed male and female US Army Reserve/National Guard (USAR/NG) soldiers (N = 174). Data are from Operation: SAFETY (Soldiers and Families Excelling Through the Years), an ongoing survey-based study examining the health of USAR/NG soldiers and their partners. The protocol was approved by the Institutional Review Board at the State University of New York at Buffalo. The relationship between each of the items was examined by calculating correlation and alpha coefficients. Latent class analyses tested for the existence of distinct levels of negative emotions related to non-deployment. Negative binomial regression models examined the cross-sectional associations between NDE summary score and each of the following outcomes, separately: anger, anxiety, depression, and post-traumatic stress. More than half of never-deployed USAR/NG soldiers expressed negative emotions for having not been deployed. "Guilt," "value," "camaraderie," and "connectedness" were each positively correlated with each other (p &lt; 0.001) and the internal consistency reliability was high (male soldier α = 0.90, female soldier α = 0.93). Latent class analyses revealed a superior three-class model with well-delineated class membership (entropy = 0.93): "Class 1" (low NDE; 47.6%), "Class 2" (moderate NDE; 33.8%), and "Class 3" (high NDE; 18.6%). Regression models demonstrated that greater non-deployment emotions were independently associated with more severe anger (RR = 1.02, 95% CI: 1.01, 1.03, p &lt; 0.001), anxiety (RR = 1.06, 95% CI: 1.01, 1.11, p &lt; 0.05), depression (RR = 1.06, 95% CI: 1.01, 1.11, p &lt; 0.05), and PTSD (RR = 1.10, 95% CI: 1.04, 1.16, p &lt; 0.01). Findings demonstrate that negative emotions regarding non-deployment are prevalent among never-deployed USAR/NG soldiers and that these emotions are related to a mental health. The NDE provides a measure of "guilt," "value," "camaraderie," and "connectedness" specific to non-deployed soldiers and is able to well discriminate between soldiers that have low, moderately, and highly negative non-deployment emotions. These findings suggest that all military personnel, regardless of deployment status, could be at risk for negative outcomes. As with any survey-based study, there is a potential for response bias; however, given the range of responses collected with the NDE, social desirability is unlikely. Further work is needed to confirm our findings in other components of the military and to examine soldiers in the rear detachment.</description><identifier>ISSN: 0026-4075</identifier><identifier>EISSN: 1930-613X</identifier><identifier>DOI: 10.1093/milmed/usy005</identifier><identifier>PMID: 29547934</identifier><language>eng</language><publisher>England: Oxford University Press</publisher><subject>Adult ; Alcohol ; Anxiety ; Cohort Studies ; Cross-Sectional Studies ; Emotions ; Female ; Health care ; Humans ; Iraq War-2003 ; Male ; Mental depression ; Mental disorders ; Mental health ; Military deployment ; Military personnel ; Military Personnel - psychology ; Military Personnel - statistics &amp; numerical data ; Military reserves ; Military service ; Post traumatic stress disorder ; Psychiatry ; Psychometrics - instrumentation ; Psychometrics - methods ; Psychometrics - standards ; Reproducibility of Results ; Research Design - statistics &amp; numerical data ; Stress Disorders, Post-Traumatic - epidemiology ; Stress Disorders, Post-Traumatic - psychology ; Studies ; Suicides &amp; suicide attempts ; Surveys and Questionnaires ; Travel - statistics &amp; numerical data</subject><ispartof>Military medicine, 2018-09, Vol.183 (9-10), p.e509-e517</ispartof><rights>Association of Military Surgeons of the United States 2018. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.</rights><rights>Copyright Oxford University Press Sep/Oct 2018</rights><lds50>peer_reviewed</lds50><oa>free_for_read</oa><woscitedreferencessubscribed>false</woscitedreferencessubscribed><citedby>FETCH-LOGICAL-c388t-6f7b2605c1a2d3175bbb32279e49c59f9897e416b68660d7eb4913ca920c26223</citedby><cites>FETCH-LOGICAL-c388t-6f7b2605c1a2d3175bbb32279e49c59f9897e416b68660d7eb4913ca920c26223</cites></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><link.rule.ids>315,781,785,27929,27930</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/29547934$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>Hoopsick, Rachel A</creatorcontrib><creatorcontrib>Homish, D Lynn</creatorcontrib><creatorcontrib>Bartone, Paul T</creatorcontrib><creatorcontrib>Homish, Gregory G</creatorcontrib><title>Developing a Measure to Assess Emotions Associated with Never Being Deployed</title><title>Military medicine</title><addtitle>Mil Med</addtitle><description>Much research has focused on stress related to deployments; however, a substantial proportion of soldiers never deploy. In a study of 1.3 million veterans, suicide risk was higher among veterans who had never deployed. Thus, not being deployed may have an impact on soldiers' well-being; however, no measures exist to assess emotions regarding non-deployment. We aimed to develop and test an original measure of non-deployment emotions. We examined the Non-Deployment Emotions (NDE) questionnaire, a novel four-item measure of guilt, unit value, unit camaraderie, and unit connectedness in a sample of never-deployed male and female US Army Reserve/National Guard (USAR/NG) soldiers (N = 174). Data are from Operation: SAFETY (Soldiers and Families Excelling Through the Years), an ongoing survey-based study examining the health of USAR/NG soldiers and their partners. The protocol was approved by the Institutional Review Board at the State University of New York at Buffalo. The relationship between each of the items was examined by calculating correlation and alpha coefficients. Latent class analyses tested for the existence of distinct levels of negative emotions related to non-deployment. Negative binomial regression models examined the cross-sectional associations between NDE summary score and each of the following outcomes, separately: anger, anxiety, depression, and post-traumatic stress. More than half of never-deployed USAR/NG soldiers expressed negative emotions for having not been deployed. "Guilt," "value," "camaraderie," and "connectedness" were each positively correlated with each other (p &lt; 0.001) and the internal consistency reliability was high (male soldier α = 0.90, female soldier α = 0.93). Latent class analyses revealed a superior three-class model with well-delineated class membership (entropy = 0.93): "Class 1" (low NDE; 47.6%), "Class 2" (moderate NDE; 33.8%), and "Class 3" (high NDE; 18.6%). Regression models demonstrated that greater non-deployment emotions were independently associated with more severe anger (RR = 1.02, 95% CI: 1.01, 1.03, p &lt; 0.001), anxiety (RR = 1.06, 95% CI: 1.01, 1.11, p &lt; 0.05), depression (RR = 1.06, 95% CI: 1.01, 1.11, p &lt; 0.05), and PTSD (RR = 1.10, 95% CI: 1.04, 1.16, p &lt; 0.01). Findings demonstrate that negative emotions regarding non-deployment are prevalent among never-deployed USAR/NG soldiers and that these emotions are related to a mental health. The NDE provides a measure of "guilt," "value," "camaraderie," and "connectedness" specific to non-deployed soldiers and is able to well discriminate between soldiers that have low, moderately, and highly negative non-deployment emotions. These findings suggest that all military personnel, regardless of deployment status, could be at risk for negative outcomes. As with any survey-based study, there is a potential for response bias; however, given the range of responses collected with the NDE, social desirability is unlikely. Further work is needed to confirm our findings in other components of the military and to examine soldiers in the rear detachment.</description><subject>Adult</subject><subject>Alcohol</subject><subject>Anxiety</subject><subject>Cohort Studies</subject><subject>Cross-Sectional Studies</subject><subject>Emotions</subject><subject>Female</subject><subject>Health care</subject><subject>Humans</subject><subject>Iraq War-2003</subject><subject>Male</subject><subject>Mental depression</subject><subject>Mental disorders</subject><subject>Mental health</subject><subject>Military deployment</subject><subject>Military personnel</subject><subject>Military Personnel - psychology</subject><subject>Military Personnel - statistics &amp; numerical data</subject><subject>Military reserves</subject><subject>Military service</subject><subject>Post traumatic stress disorder</subject><subject>Psychiatry</subject><subject>Psychometrics - instrumentation</subject><subject>Psychometrics - methods</subject><subject>Psychometrics - standards</subject><subject>Reproducibility of Results</subject><subject>Research Design - statistics &amp; numerical data</subject><subject>Stress Disorders, Post-Traumatic - epidemiology</subject><subject>Stress Disorders, Post-Traumatic - psychology</subject><subject>Studies</subject><subject>Suicides &amp; suicide attempts</subject><subject>Surveys and Questionnaires</subject><subject>Travel - statistics &amp; numerical data</subject><issn>0026-4075</issn><issn>1930-613X</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2018</creationdate><recordtype>article</recordtype><sourceid>EIF</sourceid><recordid>eNp9kb1Pw0AMxU8IREthZEWRWFhCfXfJXTyWtnxIBRaQ2KJ8OJAqyYVcAup_T6LQhYHJsvV7T7YfY-ccrjmgnJd5UVI67-wOwD9gU44SXMXl2yGbAgjleqD9CTuxdgvAPQz4MZsI9D2N0puyzYq-qDB1Xr07kfNIke0aclrjLKwla511adrcVHboTZJHLaXOd95-OE-9rnFuaBCuqC7MjtJTdpRFhaWz3zpjr7frl-W9u3m-e1guNm4ig6B1VaZjocBPeCRSybUfx7EUQiN5mPiYYYCaPK5iFSgFqabYQy6TCAUkQgkhZ-xq9K0b89mRbcMytwkVRVSR6WwohkN9IbXfo5d_0K3pmqrfLhSeBEDkiP9SXPXroALdU-5IJY2xtqEsrJu8jJpdyCEcwgjHMMIxjJ6_-HXt4mG8p_fflz8KGISY</recordid><startdate>20180901</startdate><enddate>20180901</enddate><creator>Hoopsick, Rachel A</creator><creator>Homish, D Lynn</creator><creator>Bartone, Paul T</creator><creator>Homish, Gregory G</creator><general>Oxford University Press</general><scope>CGR</scope><scope>CUY</scope><scope>CVF</scope><scope>ECM</scope><scope>EIF</scope><scope>NPM</scope><scope>AAYXX</scope><scope>CITATION</scope><scope>4T-</scope><scope>K9.</scope><scope>NAPCQ</scope><scope>7X8</scope></search><sort><creationdate>20180901</creationdate><title>Developing a Measure to Assess Emotions Associated with Never Being Deployed</title><author>Hoopsick, Rachel A ; Homish, D Lynn ; Bartone, Paul T ; Homish, Gregory G</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-c388t-6f7b2605c1a2d3175bbb32279e49c59f9897e416b68660d7eb4913ca920c26223</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>2018</creationdate><topic>Adult</topic><topic>Alcohol</topic><topic>Anxiety</topic><topic>Cohort Studies</topic><topic>Cross-Sectional Studies</topic><topic>Emotions</topic><topic>Female</topic><topic>Health care</topic><topic>Humans</topic><topic>Iraq War-2003</topic><topic>Male</topic><topic>Mental depression</topic><topic>Mental disorders</topic><topic>Mental health</topic><topic>Military deployment</topic><topic>Military personnel</topic><topic>Military Personnel - psychology</topic><topic>Military Personnel - statistics &amp; numerical data</topic><topic>Military reserves</topic><topic>Military service</topic><topic>Post traumatic stress disorder</topic><topic>Psychiatry</topic><topic>Psychometrics - instrumentation</topic><topic>Psychometrics - methods</topic><topic>Psychometrics - standards</topic><topic>Reproducibility of Results</topic><topic>Research Design - statistics &amp; numerical data</topic><topic>Stress Disorders, Post-Traumatic - epidemiology</topic><topic>Stress Disorders, Post-Traumatic - psychology</topic><topic>Studies</topic><topic>Suicides &amp; suicide attempts</topic><topic>Surveys and Questionnaires</topic><topic>Travel - statistics &amp; numerical data</topic><toplevel>peer_reviewed</toplevel><toplevel>online_resources</toplevel><creatorcontrib>Hoopsick, Rachel A</creatorcontrib><creatorcontrib>Homish, D Lynn</creatorcontrib><creatorcontrib>Bartone, Paul T</creatorcontrib><creatorcontrib>Homish, Gregory G</creatorcontrib><collection>Medline</collection><collection>MEDLINE</collection><collection>MEDLINE (Ovid)</collection><collection>MEDLINE</collection><collection>MEDLINE</collection><collection>PubMed</collection><collection>CrossRef</collection><collection>Docstoc</collection><collection>ProQuest Health &amp; Medical Complete (Alumni)</collection><collection>Nursing &amp; Allied Health Premium</collection><collection>MEDLINE - Academic</collection><jtitle>Military medicine</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>Hoopsick, Rachel A</au><au>Homish, D Lynn</au><au>Bartone, Paul T</au><au>Homish, Gregory G</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Developing a Measure to Assess Emotions Associated with Never Being Deployed</atitle><jtitle>Military medicine</jtitle><addtitle>Mil Med</addtitle><date>2018-09-01</date><risdate>2018</risdate><volume>183</volume><issue>9-10</issue><spage>e509</spage><epage>e517</epage><pages>e509-e517</pages><issn>0026-4075</issn><eissn>1930-613X</eissn><abstract>Much research has focused on stress related to deployments; however, a substantial proportion of soldiers never deploy. In a study of 1.3 million veterans, suicide risk was higher among veterans who had never deployed. Thus, not being deployed may have an impact on soldiers' well-being; however, no measures exist to assess emotions regarding non-deployment. We aimed to develop and test an original measure of non-deployment emotions. We examined the Non-Deployment Emotions (NDE) questionnaire, a novel four-item measure of guilt, unit value, unit camaraderie, and unit connectedness in a sample of never-deployed male and female US Army Reserve/National Guard (USAR/NG) soldiers (N = 174). Data are from Operation: SAFETY (Soldiers and Families Excelling Through the Years), an ongoing survey-based study examining the health of USAR/NG soldiers and their partners. The protocol was approved by the Institutional Review Board at the State University of New York at Buffalo. The relationship between each of the items was examined by calculating correlation and alpha coefficients. Latent class analyses tested for the existence of distinct levels of negative emotions related to non-deployment. Negative binomial regression models examined the cross-sectional associations between NDE summary score and each of the following outcomes, separately: anger, anxiety, depression, and post-traumatic stress. More than half of never-deployed USAR/NG soldiers expressed negative emotions for having not been deployed. "Guilt," "value," "camaraderie," and "connectedness" were each positively correlated with each other (p &lt; 0.001) and the internal consistency reliability was high (male soldier α = 0.90, female soldier α = 0.93). Latent class analyses revealed a superior three-class model with well-delineated class membership (entropy = 0.93): "Class 1" (low NDE; 47.6%), "Class 2" (moderate NDE; 33.8%), and "Class 3" (high NDE; 18.6%). Regression models demonstrated that greater non-deployment emotions were independently associated with more severe anger (RR = 1.02, 95% CI: 1.01, 1.03, p &lt; 0.001), anxiety (RR = 1.06, 95% CI: 1.01, 1.11, p &lt; 0.05), depression (RR = 1.06, 95% CI: 1.01, 1.11, p &lt; 0.05), and PTSD (RR = 1.10, 95% CI: 1.04, 1.16, p &lt; 0.01). Findings demonstrate that negative emotions regarding non-deployment are prevalent among never-deployed USAR/NG soldiers and that these emotions are related to a mental health. The NDE provides a measure of "guilt," "value," "camaraderie," and "connectedness" specific to non-deployed soldiers and is able to well discriminate between soldiers that have low, moderately, and highly negative non-deployment emotions. These findings suggest that all military personnel, regardless of deployment status, could be at risk for negative outcomes. As with any survey-based study, there is a potential for response bias; however, given the range of responses collected with the NDE, social desirability is unlikely. Further work is needed to confirm our findings in other components of the military and to examine soldiers in the rear detachment.</abstract><cop>England</cop><pub>Oxford University Press</pub><pmid>29547934</pmid><doi>10.1093/milmed/usy005</doi><oa>free_for_read</oa></addata></record>
fulltext fulltext
identifier ISSN: 0026-4075
ispartof Military medicine, 2018-09, Vol.183 (9-10), p.e509-e517
issn 0026-4075
1930-613X
language eng
recordid cdi_proquest_miscellaneous_2014952375
source MEDLINE; Elektronische Zeitschriftenbibliothek - Frei zugängliche E-Journals; Oxford University Press Journals All Titles (1996-Current)
subjects Adult
Alcohol
Anxiety
Cohort Studies
Cross-Sectional Studies
Emotions
Female
Health care
Humans
Iraq War-2003
Male
Mental depression
Mental disorders
Mental health
Military deployment
Military personnel
Military Personnel - psychology
Military Personnel - statistics & numerical data
Military reserves
Military service
Post traumatic stress disorder
Psychiatry
Psychometrics - instrumentation
Psychometrics - methods
Psychometrics - standards
Reproducibility of Results
Research Design - statistics & numerical data
Stress Disorders, Post-Traumatic - epidemiology
Stress Disorders, Post-Traumatic - psychology
Studies
Suicides & suicide attempts
Surveys and Questionnaires
Travel - statistics & numerical data
title Developing a Measure to Assess Emotions Associated with Never Being Deployed
url https://sfx.bib-bvb.de/sfx_tum?ctx_ver=Z39.88-2004&ctx_enc=info:ofi/enc:UTF-8&ctx_tim=2024-12-14T21%3A44%3A34IST&url_ver=Z39.88-2004&url_ctx_fmt=infofi/fmt:kev:mtx:ctx&rfr_id=info:sid/primo.exlibrisgroup.com:primo3-Article-proquest_cross&rft_val_fmt=info:ofi/fmt:kev:mtx:journal&rft.genre=article&rft.atitle=Developing%20a%20Measure%20to%20Assess%20Emotions%20Associated%20with%20Never%20Being%20Deployed&rft.jtitle=Military%20medicine&rft.au=Hoopsick,%20Rachel%20A&rft.date=2018-09-01&rft.volume=183&rft.issue=9-10&rft.spage=e509&rft.epage=e517&rft.pages=e509-e517&rft.issn=0026-4075&rft.eissn=1930-613X&rft_id=info:doi/10.1093/milmed/usy005&rft_dat=%3Cproquest_cross%3E2014952375%3C/proquest_cross%3E%3Curl%3E%3C/url%3E&disable_directlink=true&sfx.directlink=off&sfx.report_link=0&rft_id=info:oai/&rft_pqid=2168979607&rft_id=info:pmid/29547934&rfr_iscdi=true