| 1. |
- Huber, Malin, 1979-
(författare)
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To tear and to heal : pelvic floor dysfunction and childbirth
- 2023
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Up to 80% of women are affected by a perineal laceration after their first vaginal birth. An estimated 40–50% of lacerations involve the perineal muscles, and up to 7% are obstetric anal sphincter injuries (OASI). There is a lack of knowledge about the extent of short-term complications such as pelvic floor dysfunction (PFD) following spontaneous or iatrogenic pelvic floor trauma. Women’s experiences of daily life after childbirth complicated by OASI is poorly understood. Three-dimensional endoanal ultrasonography (3D-EAUS) is a welldocumented method for evaluating damage to the anal sphincter in other contexts. Adding ultrasonography to standard clinical examination has revealed injuries previously missed, and research evaluating diagnostic methods for the routine screening of OASI has been called for.Aim: This thesis aims to evaluate the diagnostics of OASI, determine if the degree of perineal injury or anal sphincter defects after childbirth are associated with pelvic dysfunction, and explore women’s experiences of OASI.Methods Studies I and IV were prospective cohort-studies to evaluate any association between perineal tear or sphincter defect to PFD. Study II was an interview study addressing women’s experiences of OASI by qualitative content analysis. Study III was a cross-sectional study designed to examine the utility of endoanal ultrasound to detect OASI. Participants were clinically examined after birth and 3D-EAUS was performed immediately after giving birth and 3 months postpartum. PFD was evaluated using a web-based questionnaire one year after delivery.Results: A total of 511 women completed the one-year questionnaire (Study I) and a purposive sample of 11 women were invited to take part in Study II. In Study III, 680 women underwent a clinical examination and 3D-EAUS recording immediately after birth. In Study IV, 239 women who attended all follow-ups were included. PFD was experienced by women with a perineal laceration of any grade, but also those with an intact perineum. Dyspareunia and urinary incontinence were the most common problems. Women with OASI had a higher risk for developing vi symptoms of prolapse, urinary urge incontinence, dyspareunia, and pain as well as experiencing a negative impact on their daily life. Elements that negatively influenced women’s experiences of OASI were pain and symptoms of PFD, normalisation of symptoms by healthcare providers, and unrealistic expectations about this period in life. 3D-EAUS immediately after delivery had poor sensitivity and specificity in detecting clinically diagnosed OASI. Postpartum anal sphincter defects were associated with genital pain and dyspareunia.Conclusions: OASI is an evident risk factor for pelvic floor dysfunction after childbirth, but symptoms of pelvic floor disorder were found to be common, even in women with mild to moderate perineal laceration. OASI has a negative impact on how a woman experiences relationships, social contact, and sexuality. Using 3D-EAUS in a maternity ward to diagnose OASI is demanding. Staff generally have little experience in 3D-EAUS. There are also difficulties in obtaining good image quality, due to local oedema, bleeding, positioning of the woman, and unintentional movements. These factors all complicate the interpretation of images.
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| 2. |
- Ax, Anna-Karin, 1980-
(författare)
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Exercise in patients with cancer : Effects on health-related quality of life, costs, and cost-effectiveness during oncological treatment
- 2023
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Short and long-term side effects of oncological treatment negatively affect daily living and health-related quality of life (HRQoL) in patient with cancer. Exercise during treatment is beneficial for HRQoL, however evidence as to what exercise intensity is most optimal for improving HRQoL and cost-effectiveness is lacking. Cost-effectiveness is important information for decisionmakers when implementing healthcare interventions, such as exercise programmes. The overall aim of this thesis was to study functioning in daily life, HRQoL, costs, and cost-effectiveness of an exercise intervention of different exercise intensities in patients with cancer receiving oncological treatment. Method: Study I was qualitative and explored how individuals with cancer receiving curative treatment and participating in an exercise intervention experienced their functioning in daily life. Semi-structured individual interviews (n =21) were performed and analysed with thematic analysis. Studies II–IV were quantitative and used data from a randomised controlled trial (RCT) of high-intensity (HI) and low-to-moderate-intensity (LMI) exercise of combined resistance and endurance training with or without self-regulatory behaviour change support. The RCT was preceded by a descriptive longitudinal study with usual care (UC). Participants were diagnosed with breast, prostate, or colon cancer and received (neo)adjuvant oncological treatment. Study II evaluated the effects on HRQoL of exercising at HI (n =288) and LMI (n =289) versus UC (n =89) up to 18 months after start of oncological treatment, using the EORTC QLQ-C30 questionnaire. Data were analysed using descriptive and multivariate statistics. Study III evaluated resource utilisation and societal costs of the exercise intervention in the RCT (n =534) versus UC (n =85), and of HI (n =269) versus LMI (n =265) exercise 18 months after start of oncological treatment. Societal costs included costs of healthcare resource utilisation (healthcare visits, hospitalisation, prescribed medication), productivity loss (disability pensions and sick leave), and the exercise intervention. Study IV evaluated the cost-effectiveness of the exercise intensities in the RCT (HI: n =99 and LMI: n =90) at 1-year follow-up post intervention. Cost data were retrieved from Study III and health outcome were collected using the EQ-5D-5L questionnaire and calculated for quality-adjusted life-years. Cost-effectiveness was evaluated as the incremental cost-effectiveness ratio (ICER). Results: Participants experienced impairments from oncological treatment but strove to maintain function in daily life. The exercise programme improved physical and psychological wellbeing during treatment (Study I). There were no significant differences in HRQoL between exercise intensities up to 1 year after the exercise intervention. The exercise groups scored significant better HRQoL compared to UC over time (Study II). There was no significant difference in mean societal costs between the exercise intervention and UC, nor between the exercise intensities (Study III). There was no significant difference in cost or in effect between the exercise intensities. Although the mean ICER indicated that HI was cost-effective compared to LMI, the uncertainty was large (Study IV). Conclusion: Participating in an exercise programme during oncological treatment was a positive and supportive experience that contributed to increase physical and psychological wellbeing. Exercise of HI and LMI during oncological treatment had similar effect on HRQoL and societal costs. In addition, the exercise group had beneficial effects on HRQoL and no significant difference in societal costs compared to UC, meaning the exercise programme did not save or add societal cost. Thus, based on cost-effectiveness we suggest decisionmakers and clinicians implement exercise programmes including both HI and LMI in cancer care and recommend exercise regardless of intensity according to the patient’s preferences to improve or to maintain aspects of HRQoL during oncological treatment.
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| 3. |
- Mazzoni, Anne-Sophie
(författare)
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Promoting physical activity during and after curative cancer treatment : Assessment, experiences and effect of behaviour change support
- 2021
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Aims:The overall aim of this thesis was to increase knowledge about the promotion of physical activity (PA) in patients during and after curative cancer treatment. Methods: Study I investigated agreement between a 7-day diary and the SenseWear Armband mini (SWA) when assessing PA and sedentary time in 65 participants with breast cancer. Agreement was examined with Bland-Altman plots. Studies II-IV used data from an RCT, where participants about to start curative treatment for breast, prostate or colorectal cancer, were randomised to six months of high or low-to-moderate intensity exercise (supervised group-based resistance- and home-based endurance training), with or without self-regulatory behaviour change techniques (BCTs; e.g. goal-setting and action planning). In study II, participants randomised to the groups with self-regulatory BCTs answered a questionnaire (n=229) and took part in semi-structured interviews (n=18) after exercise programme completion. The interviews were analysed with thematic analysis. In Study III, all participants (n=577) randomised were included. Exercise adherence during the intervention was assessed with attendance records, training logs and heart rate monitors. Regression analyses were performed to determine the effect of self-regulatory BCTs on exercise adherence. In Study IV, participants (n=301) who provided data about their PA level at 12-month follow-up were included. Regression analyses were performed to determine the effect of self-regulatory BCTs on PA maintenance and potential baseline predictors. Results: There were mean differences and wide limits of agreement between the 7-day diary and the SWA when assessing PA and sedentary time. Participants described different incentives to exercise, which fostered feelings of autonomy, competence and relatedness and helped them find motivation to exercise during cancer treatment. Social support from coaches, feedback, self-registration of exercise and scheduled sessions at a public gym were useful for exercising. There was no effect of the self-regulatory BCTs on exercise adherence during the intervention; however, a positive effect was found on PA maintenance at 12-month follow-up. Baseline predictors of PA maintenance at 12-month follow-up were health-related quality of life, exercise motivation, expectations of exercise and being a former or current smoker/snus user. Conclusions: A 7-day diary and the SWA have limited agreement and cannot be used interchangeably in patients with breast cancer. Individual incentives and a positive and supportive environment are crucial to increase exercise motivation in patients undergoing curative cancer treatment, and can be promoted using specific support (i.e. social support, feedback, self-registration of exercise and scheduled exercise sessions). The addition of self-regulatory BCTs is not likely to improve exercise adherence in patients undergoing curative treatment for breast, prostate or colorectal cancer and participating in structured, well-controlled exercise interventions, but may improve long-term PA maintenance in this population. Patients with low health-related quality of life, low exercise motivation, high expectations of exercise or with a history of tobacco use at the start of their cancer treatment may be those most in need of such support to maintain PA.
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| 4. |
- Hayat Roshanai, Afsaneh
(författare)
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Psychological and Behavioral Aspects of Receiving Genetic Counseling for Hereditary Cancer
- 2010
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The overall aims of this thesis were to investigate psychological and behavioral effects of receiving cancer genetic counseling for breast, ovarian and colorectal cancer and/or with a family history of these cancer types and to determine whether counselees’ informational needs were met. Study I was performed 3-7 years post-counseling. Participants (n=214) reported a relatively high level of anxiety but a low level of depression compared to cancer patients in general. However, there was no indication that the distress experienced was due to the counseling. Moderate changes in life and family relations, high level of adherence to recommended controls and satisfaction was reported. Study II was a randomized control trial (RCT) intervention study which involved 147 counselees. An increase in the level of knowledge and correct estimation of personal risk was reported in both the intervention and control groups, although this increase declined at later follow-up. Enhanced information led to significantly greater satisfaction with the given information, and the way of informing relatives. Most counselees had shared information with their at-risk relatives. Study III focused on sharing information with at-risk relatives among participants in study II and their relatives (n=81). Counselees were interviewed and answered a questionnaire, whilst their relatives only answered the questionnaire. Counselees reported positive/neutral feelings about communicating genetic information and mostly interpreted their relatives’ reactions as positive/ neutral. Also, approximately 50% of relatives reported positive/neutral reactions and were generally satisfied with the received information. Study IV was conducted in Sweden and Norway based on 235 counselees. Counselees expected counselors to be skillful and thoughtful, take them seriously and provide risk estimations and medical information. Most important issues to counselees were satisfactorily addressed by the counselors. Analyzing importance rankings resulted in five categories of needs: a need for facts, caring communication and medical information, need for understanding and support in sharing genetic information, practical care and medical/practical information. In conclusion, no adverse psychological or behavioral effect on counselees was observed. Apparently, genetic counseling is managed properly and counselors successfully address counselees’ needs. Providing extended information does not seem necessary, however, tailoring information to individual counselees needs may create a more effective counseling.
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| 5. |
- Henriksson, Anna
(författare)
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Physical activity and exercise during curative oncological treatment : exploring the effects of exercise intensity and behaviour change support, safety, and patients’ and exercise professionals’ experiences
- 2020
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Aims: This thesis aimed to explore the effects of exercise intensity and behaviour change support (BCS), the safety of exercise, and experiences of exercise for both patients and exercise professionals during oncological treatment (e.g. neo/adjuvant chemotherapy, endocrine treatment, radiotherapy). This thesis is based on data from the Phys-Can (Physical training and Cancer) multicentre research program, consisting of a feasibility study, an observation study, and a randomised controlled trial (RCT). Methods: Paper I and II were quantitative studies. Paper I was a RCT with a 2x2 factorial design. Patients newly diagnosed with breast, prostate, or colorectal cancer about to start oncological treatment were randomised to six months of high intensity (HI) or low-moderate intensity (LMI) supervised group based resistance- and home-based endurance training, with or without additional BCS. The primary outcome, cancer related fatigue (CRF), was assessed by the Multidimensional Fatigue Inventory. Multiple linear regression and additional responder analysis for primary outcomes were performed. Paper II was a descriptive and comparative study based on secondary data from the observation study and RCT. Data were presented descriptively, and related factors to adverse events (AEs) were analysed with logistic regressions. Paper III and IV were qualitative studies. Participants were patients with breast, prostate, or colorectal cancer undergoing oncological treatment (Paper III) or coaches supervising exercise for participants in the RCT (Paper IV). Data were collected through semi-structured individual- (Paper III and IV) and focus group interviews (Paper III) and analysed with qualitative content analysis (Paper III) and thematic analysis (Paper IV). Main results and conclusions: The results from this thesis indicate that exercise at HI may not improve CRF in comparison with exercise at LMI in patients undergoing treatment, thus patients can be advised to exercise at either preferred intensity. Also, additional BCS did not improve CRF in relatively motivated patients receiving supervised exercise (Paper I). Furthermore, exercise-related AEs in persons undergoing oncological treatment are minor, of musculoskeletal origin, and with a similar incidence as in healthy populations. However, a higher risk of minor exercise-related AEs was reported in HI groups than in LMI groups. More serious AEs were rare, thus it seems safe to exercise even at HI for these patient groups (Paper II). The results also indicated that patients could experience side effects and concerns regarding the safety of exercising during oncological treatment as barriers to engage in physical activity. Therefore, engaging in physical activity before the onset of side effects from treatment and providing information regarding physical activity to patients could be beneficial (Paper III). Professionals supervising exercise for patients may find it highly rewarding, which is promising for implementation in cancer rehabilitation. However, patients may still receive contradictory information regarding the safety of exercise from health care staff, which can be difficult for exercise professionals to counteract (Paper IV).
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| 6. |
- Lundh, Marie Høyer, 1982-
(författare)
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Health-Related Quality of Life and Return to Work following Breast Cancer
- 2014
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Aim: The overall aim of this thesis was to study health-related quality of life (HRQoL) and return to work in the first 3 years following a breast cancer diagnosis, and to identify clinical and contextual factors associated with these outcomes.Method: The four studies were part of a population-based cohort study including women identified in the Breast Cancer Quality Register in central Sweden. Of 1,573 women asked to participate, 69% (n=1,093) responded to a baseline questionnaire, 62% (n=977) responded at the 1st follow-up and 54% (n=856) participated at the 2nd follow-up (mean time 4, 16 and 38 months post-diagnosis, respectively). Studies II and IV only included women aged <63 years at diagnosis. In Study IV, each woman was individually matched to five breast-cancer-free controls. Questionnaire data on HRQoL, socio-demographics and work-related variables were combined with clinical register, normative and social insurance data.Main findings: Study I: Women with breast cancer, particularly women aged <50 years, experienced poorer HRQoL at baseline than normative data. Chemotherapy, lack of social support, sick leave and a poor financial situation were associated with poorer HRQoL. Study II: Compared with pre-diagnosis working time, 72% of participating women reported no change, 2% had increased their working time, 15% reported a decrease in working time and 11% did not work at the 1st follow-up. Chemotherapy, cancer-related work limitations and less value attached to work increased the odds of job discontinuation/decreased working time. Study III: During the 3 years post-diagnosis, HRQoL generally improved. Less consistent improvements were found among women on sick leave/disability pension pre-diagnosis and women reporting job discontinuation/decreased working time post-diagnosis. Study IV: The proportion of women with breast cancer on sick leave steadily decreased during the 3 years post-diagnosis, but they were more likely to be on sick leave than the controls. Chemotherapy, fatigue and pre-diagnosis sick days predicted sickness absence during the 2nd and 3rd year post-diagnosis.Conclusions: Most women with breast cancer gradually recover, but there are subgroups of women who may be particularly vulnerable. In a clinical setting, increased attention should be directed towards women undergoing chemotherapy, young women, women on sick leave/disability pension pre-diagnosis and women who do not return to work to the same extent as pre-diagnosis.
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| 7. |
- Nordin, Teresa, 1987-
(författare)
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Computational Models in Deep Brain Stimulation : Patient‐Specific Simulations, Tractography, and Group Analysis
- 2023
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Deep brain stimulation (DBS) is an established method for symptom relief in movement disorders like Parkinson’s disease, essential tremor (ET), and dystonia. The therapy is based on implanting an electrode with four contacts in the deep brain structures where it provides electrical stimulation, mainly impacting the nerve tracts. Despite the evidence of DBS effectiveness, there are still questions regarding the optimal position of stimulation. With new technology, the possibility to customize the stimulation increases, which makes the programming session for each patient more complicated and tedious.Different computational models have been developed to estimate the anatomical impact of stimulation. Patient‐specific electric field simulations can be used to estimate the spatial extent of the stimulation and superimpose on patient magnetic resonance imaging (MRI) for anatomical analysis. MRI weighted with water diffusion can be used for reconstructions of nerve tracts, a process called tractography. Tractography utilizes the fact that water can move unrestricted along the nerve trajectories, but the diffusion is restricted in the perpendicular direction, i.e., the diffusion is anisotropic. For tremor, the dentato‐rubro‐thalamic tract (DRT) has gained interest.The electric conductivity has corresponding anisotropic characteristics as water diffusion in white brain tissue (nerve tracts). Diffusion MRI can therefore also be used to improve patientspecific simulations by including structure information, i.e., anisotropy. In this thesis, both a workflow for combining patient‐specific simulations with tractography of the DRT and a method for expanding the simulations with anisotropy were developed (Paper I). This was done using four patients with ET. The results show that including anisotropy will impact the simulation result in regions of dense nerve tracts (Paper I‐II). For the tractography, all patients’ estimated stimulation region intersected with the reconstructed DRT.To analyze the optimal location for stimulation, group analysis is required. This can be achieved by combining the electric field simulations with the clinical effect to create probabilistic stimulation maps (PSM). Different methods of creating these maps have been presented in the literature, and this thesis includes developing a workflow for PSM computation and evaluating the effect of different method variations (Paper III‐V). The result shows that the number of simulations (Paper V), type of input data, and choice of clustering method for defining the stimulation effect influence the PSMs the most (Paper III‐IV). Other possible improvements include weighting functions and computing at a high spatial resolution but results in a small to negligible impact on the PSM (Paper IV).In summary, two different workflows were developed in this thesis. One for anisotropic patient‐specific electric field simulations in combination with tractography reconstruction and one for group analysis using PSMs. The first part shows the feasibility of combining patientspecific simulations and tractography reconstruction of DRT. It also concludes that anisotropy impacts the electric field simulations if the DBS lead is implanted close to a larger nerve tract. The second part highlights the impact of different parameters when creating PSMs, where the number of patients, type of input data, and choice of clustering method should be carefully evaluated when designing a new study. In the future, these results can be used to develop models for predicting the effect of DBS in new patients. Predictive models can be a useful tool to aid the programming session and thereby ease the burden on both patients and healthcare.
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| 8. |
- Star, Kristina, 1963-
(författare)
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Safety of Medication in Paediatrics
- 2013
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: In paediatrics, the limited documentation to guide medication, the lack of suitable dosage forms, and the continuous development in childhood present a scenario where safety of medication is a particular challenge.Aim: To explore reported adverse drug reactions (ADRs) and the challenges in prescribing and administering medicines in paediatrics, in order to identify and suggest areas needing international surveillance within medication safety and improvement in the clinical setting.Methods: Four exploratory studies were conducted. Worldwide reporting of suspected ADRs (individual case safety reports, ICSR) with ages 0-17 years were examined overall. Twenty published case reports and ICSRs for adolescents, who developed a rare and incompletely documented ADR (rhabdomyolysis) during antipsychotic medicine use, were analysed in-depth. Prescribed doses of anti-inflammatory medicines were studied in a UK electronic health record database. Transcribed focus group interviews with 20 registered nurses from four paediatric wards in Sweden were analysed for factors that may promote or hinder safe medication practices. Descriptive statistics, multiple regression, and content analyses were used.Results: Although, skin reactions and anti-infective medicines were most frequently reported, and more reported in paediatric patients than in adults, medication errors and adverse reactions related to psychostimulant medicines were reported with increased frequency during 2005 to February 2010. The in-depth case analysis emphasised the need for increased vigilance following changes in patients’ medicine regimens, and indicated that ICSRs could contribute with clinically valuable information. Prescribed dose variations were associated with type of dosage form. Tablets and capsules were prescribed with a higher dose than liquid dosage forms. Six themes emerged from the interviews: preparation and administration was complex; medication errors caused considerable psychological burden; support from nurse colleagues was highly valued; unfamiliar medication was challenging; clear dose instructions were important; nurses handling medications needed to be accorded higher priority.Conclusions: Age-specific screening of ICSRs and the use of ICSRs to enhance knowledge of ADRs and medication errors need to be developed. Access to age-appropriate dosage forms is important when prescribing medicines to children. To improve medication safety practices in paediatric care, interdisciplinary collaborations across hospitals on national or even global levels are needed.
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| 9. |
- Downing, Charlotte
(författare)
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Early specialising aesthetic performers : An investigation of conceptualisation, motivation, and context
- 2023
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- This doctoral research project is situated within the wider debate of talent development in so-called early sports, where early specialisation is often normalised. The overarching aim is to investigate early specialisation within the context of Swedish aesthetic activities. Two research questions guided this research: 1) what characterises early specialisation, and 2) in what ways are aspects of early specialisation related to motivation?This doctoral research project includes four individual papers. The first paper is a systematic review that investigated the contextual underpinnings of recommendations regarding early specialisation and psychological aspects (e.g., motivation, burnout). The second paper outlines the development of a measurement tool for capturing degrees of early specialisation within the context of Swedish aesthetic activities. The third paper is a cross-sectional questionnaire-based study which used this measurement tool to explore the relationship between degrees of early specialisation and motivation (autonomous motivation, controlled motivation, and dropout intentions), and explored perceptions of parental influence as a moderator. The fourth paper is a qualitative interview-based study that investigated reflections on motivation throughout the training history of high-level gymnasts and figure skaters who specialised early. Additional data regarding perfectionism and parental participation in sport, collected in relation to this research but not included within the four papers, is also outlined and discussed in this thesis. Results highlight the complexity of early specialisation in terms of how it is defined, measured, and conceptualised, as well as the possible relationship to psychological aspects (e.g., motivation, perfectionism). Overall, the results do not align with the notion that early specialisation leads to lower quality motivation and an increased risk of dropout. While this research has made methodological, theoretical and empirical contributions to this research area, it is also clear that more research is needed to better understand and explain the possible outcomes often associated with early specialisation.
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| 10. |
- Jakobsson Larsson, Birgitta, 1965-
(författare)
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Quality of life, Coping and need for Support during the ALS disease trajectory
- 2016
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The overall aim of this thesis was to investigate quality of life, coping and emotional distress (i.e. anxiety and depression) among newly diagnosed ALS patients. An additional aim was also to investigate relatives’ experiences of the care for the patient and the support they received for themselves during the disease progression.The most nominated areas of importance for the patient’s overall QoL were family, friends and own physical health. Most patients rated their QoL as good, which did not change at subsequent measurement, despite their physical function having changed for the worse during disease progression. Some patients had symptoms of clinical anxiety and depression during the first year after diagnosis. The total quality of life score did not correlate with physical function but with depression early on after diagnosis. Most patients used support and independence as strategies to cope with the disease during the first six months after diagnosis. There were few changes early on after the diagnosis, and the patients used several different strategies. The results show that the use of coping strategies remained stable over time. Both physical function and emotional distress correlated significant with different coping strategies, with some variation during the disease progression. Relatives experienced the care of their loved one as positive and based on the patient’s needs and desires. The treatment, knowledge, support and help from the staff were important for the relatives’ feeling of security. Different factors influence the use of support for themselves. The relatives did not think of their own needs, but their focus was rather on the patient.The results of the thesis highlight the importance of providing support both to patients and their relatives during the disease progression. With early and regular evaluation on quality of life, coping and emotional well-being among the patients, the health professionals may be able to support the patients based on their specific needs, which probably will increase their quality of life.
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