Abstract
Diabetes mellitus and its complications carry broad financial misfortune to the diabetic patients and their family, to the well-being frameworks, and to the public economies through direct clinical expenses and decreased work efficiency. The present study systematically reviewed the possible factors that are influencing self-care behavior of disadvantaged diabetic patients that contribute heavily to the management of this chronic illness. Structured searches were conducted on PubMed, ScienceDirect, and manual searches on Google Scholar for articles published between the years 2000 and 2020. The review was limited to a particular time frame due to the change in WHO criteria for diagnosis and classification of abnormal glucose tolerance. Initially, 96858 articles were identified, and following the screening and full-text reading, 10 studies that met the inclusion criteria were chosen for systematic review. Seven studies had reported the factors influencing self-care behavior among disadvantaged diabetic population. Three studies had reported the importance of intervention strategies and its impact on self-care behavior among them. Findings show that self-care management of socio-economically disadvantaged people entails dimensions including diabetes knowledge, lack of physical activities, social support, lack of access to services, life disruptions, denial of illness, societal attitudes, responsibilities, and treatment costs. It was additionally discovered that diabetes self-management support mediations are successful in drawing in lower economy patients, tending to contending life needs and hindrances to self-care, and encouraging behavior change. Taken together, future methodologically efficacious studies that establish health promoting behaviors and explorations of the factors influencing self-care behaviors of disadvantaged diabetic patients are needed.
Introduction
Diabetic mellitus (DM) is a metabolic disorder having multiple causes like impairment in insulin secretion and/or insulin action and with symptoms like chronic hyperglycemia with defects in carbohydrate, fat, and protein metabolism (Chali et al., 2018). Inefficient treatment of diabetes can result in serious defects in the circulatory and nervous systems, kidneys, eyes, and feet, and thus diabetes takes the seventh position in leading causes of death (Reyes et al., 2017). As diabetes mellitus causes high clinical cost and furthermore lessens work efficiency, this medical issue and its intricacies bring about broad financial misfortune to the patients, their families, the medical service frameworks, and the general public economy (Mariye et al., 2018).
The International Diabetes Federation (IDF) (2017) explains that there are in excess of 425 million diabetic patients worldwide and almost 80% of them belong to low- and middle-income nations. Around the globe, there are in excess of 212 million individuals with diabetes who do not know about their disease and more than 352 million individuals live with impaired glucose tolerance (IGT), consequently making them inclined to creating diabetes and other complications (Chali et al., 2018).
Dealing with diabetes requires an intensive arrangement of self-care rehearses. These incorporate reliable checking of blood glucose levels, offsetting insulin assessments with food admission and exercise, and assumption or treatment of hypoglycemia. Following and keeping up an especially complicated well-being routine is challenging, particularly for monetarily more vulnerable patients (Vissenberg et al., 2016).
An individual adhering to a diabetes self-care framework intended to keep up glycemic control including that of diet, maintaining exercise, every day analysis of blood glucose level, holding fast to drug treatment, and foot care is said to be self-care (Getie et al., 2020). Diabetes self-management (DSM) is the essential method to bring down the danger of early morbidity and mortality related with being a diabetic patient (Fritz, 2017). The American Association of Diabetes Educator perceived seven self-care exercises vital for exact diabetes self-care. It incorporates eating healthy food, staying active, analyzing blood glucose levels, taking necessary medication, critical thinking, adapting successfully, and lowering risks (Kurnia et al., 2017). The ideal self-management practice in diabetes is related to improved glycemic control, the anticipation of cardiovascular danger factors, a decline in superfluous medical services usage, and improved explicit personal satisfaction. The ability of the patient to deal with their family, and their community, with or without the help of health care providers to improve health, to adopt preventive strategies against illness, to maintain health, and to effectively deal with disease and disability, is called “self-care” (Amelia, 2018). In any case, numerous patients face difficulties in actualizing the suggested diabetes self-care practices (Gurmu et al., 2018). Helpless self-care practice expands the rate and commonness of complexities bringing about expanded morbidity and mortality (Getie et al., 2020).
Financial hindrance “is an intricate, multidimensional issue” that is hard to characterize. The financial drawback is firmly identified with the comparative and undeniably more ordinarily utilized term “poverty”. People, families, and communities can be supposed to be in poverty when they come up short on the resources to gain such sorts of diet, partake in the activities, and have the everyday environments and conveniences which are standard, or are at any rate commonly enabled or affirmed, in the social norms to which they live in (Mukhtar and Butt, 2016). Primary disparities between individuals from more advantaged and more distraught communities are a focal component when all things are considered. These imbalances are profoundly established before and have been conveyed forward into the present. The steadiness of distraught communities seriously subverts neighborhood, public, and worldwide endeavors to create advances in the personal satisfaction and prosperity of individuals at all degrees of social, political, and financial association (Estes, 2014).
Socioeconomically disadvantaged population groups in the current study are people with low socioeconomic status, low income, poor education, or from disadvantaged areas (usually characterized by low income) (Craike et al., 2018). The disadvantages can be explained in terms of unemployment, physical laborers, single parents, self-reported chronic health and disability, families without cars, overcrowded families (>1 person per room), and apartments rented by local authorities and privately leased property (Connolly et al., 2000). People's status in the social hierarchy is called socioeconomic position (SEP), which determines their exposure and susceptibility to harmful factors (Olstad et al., 2017). It is considered to be a determinant of chronic diseases (Suwannaphant et al., 2017) such as diabetes. Also, the number of patients is increasing rapidly, which has a direct and indirect impact on the economy. It is also known that certain risk factors related to the development of diabetes are related to socioeconomic conditions. Obesity, a sedentary lifestyle, smoking, and low birth weight have been described as risk factors for type-2 diabetes (Connolly et al., 2000).
The current research focuses on the factors impacting self-management behavior of disadvantaged people with diabetes. Diabetes mellitus and its entanglements have been accounted for basic financial issues for diabetic patients in their society through direct clinical expenses and loss of occupations and pay. Medication expenditures are the costliest part of diabetes care, adding over 50% to the cost of diabetes. Financial factors, for example, lodging, occupations, tutoring, family income, and so on are straightforwardly connected to the administration of self-care for diabetes. Along these lines, it is construed that diabetes is more influential in the deprived social environment.
Self-care adherence is lower among “racial and ethnic minorities” and “people of low-income status” owing fairly to monetary troubles and misinformed judgments about diabetes and self-care (Nelson et al., 2016). Diverse contending life needs, economic issues (money and housing), and familial issues (family and caretaker commitments) fill in as obstructions to diabetes self-care (Hill-Briggs et al., 2011).
A comprehension of self-care practices is expected to improve medical services in developing countries (Irwan et al., 2016). In a populous and developing nation like India where assets are restricted and treatment costs are high (Garg et al., 2017), self-care practices were discovered to be inadmissible. Indians are having a cultural and passionate connection toward their food and food propensities which represent an enormous obstruction to diabetes self-care management (Sharma and Mishra, 2019). This eating regimen is trailed by an inactive day-by-day schedule which comprises no or exceptionally less actual exercise (Sharma and Mishra, 2019). Although self-care behavior among the Western population is inefficient, mechanical advancements have given refined, helpful gadgets that empower people to deal with their well-being and diseases (Mun et al., 2016).Different governments, including those of the USA, European countries, and Australia, have shown interest in supporting self-care, because of the aids of rehearsing self-care in long haul medical services and the connected decrease in clinical consideration costs for minor illness(Mun et al., 2016).
Financial condition assumes a critical job in deciding the self-care management methods of the patient (Sharma & Mishra, 2019).The uninsured and people of lower monetary status persevere through high impermanence and distress from diabetes. The problematic impact on this populace is compounded by lacking approval to crucial and preventive clinical consideration affiliations (Reyes et al., 2017). As shown by the World Health Organization (WHO), individuals with low income bear the most noteworthy weight of diabetes. Prescription cost talks about the issue of cost in the administration of diabetes, covering half part of the diabetes costs (Sharma and Mishra, 2019). Financial components, for example, housing, career, training, and family income are straightforwardly associated with diabetes self-care. Consequently, low financial status turns into a colossal snag on diabetes care (Sharma and Mishra, 2019). Houle et al., (2016) guaranteed that diabetes self-care has a close relationship with low SES things being what they are, to be hard for the patients to bear the cost of time and different necessities which are crucial for sickness management(Houle et al., 2016).
There is a prerequisite for fruitful intercessions that improve glycemic control among socio-monetarily oppressed patients with diabetes. Interventions that target social effects influencing self-care conduct may be promising. For instance, social communications with friends and family basically sway self-care (Vissenberg et al., 2016). Cell phone-based interventions using text informing are reported to be effective for “improving prescription adherence among low-SES, or racial, and ethnic minorities with diabetes” (Nelson et al., 2016). Exactly when mediations are proposed for comprehensive networks, regardless, distraught networks may not be reached or will be not able to make the most out of the chances given to them. Aside from financial obstructions to clinical consideration, socially in reverse gatherings may encounter issues with language, social emotions, transportation, getting time off work, child care, and low health literacy. Given that these components can affect self-care practices, mediations expected to reduce health incongruities ought to be engaged around express crowds and spot extraordinary accentuation in way programs are arranged and passed on to improve admittance and use of assets and administration(Glazier et al., 2006).
From the existing literature, it was found that among adults with DM, adherence to recommended self-care activities is suboptimal, especially among people with low income (Shrivastava et al., 2013). Disadvantaged population are unaware that there is no cure for DM, with self-management strategies, a person can live a long and healthy life. Even though a lot of studies have been conducted in the area of self-care behavior among diabetic patients, still people are not aware about the importance or advantages of self-care behavior. People still have a belief that treatment can alone help them to keep the disease under control (Xie et al., 2020).In a developing country with a large population like India, where resources are scarce and treatment costs are high, compared with other countries, self-care behavior is considered unsatisfactory, because mechanical improvements provide complex and useful equipment that enables people to use in illness and well-being. Therefore, the purpose of this systematic review is to evaluate the results of existing research, to examine the factors that affect the behavior of socially and economically disadvantaged diabetic patients, and to study intervention strategies to improve health-promoting self-care behaviors.
Method
Strategies and results were set up as indicated by the “Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines”.
Search strategy
Systematic searches on PubMed, ScienceDirect, and manual searches on Google Scholar were carried out for articles published between 2000 and 2020 by the principal investigator. The review was limited to a particular time frame due to the changes in WHO criteria for diagnosis and classification of abnormal glucose tolerance. The search terms used were: (Self-care OR Self-care Belief OR Self-care Health Belief) and (Diabetes OR Diabetic). The searches were limited to journal articles, research articles, and studies conducted among humans. All terms were searched for in the title, abstract, or keywords and were limited to English language publications. Results were uploaded to and managed by the Zotero software.
Eligibility criteria
Studies included in this review include those that discuss the following: (1) the factors influencing self-care behavior among diabetic patients, (2) self-care belief/behaviors / personal care/self-help/self-aid, (3) diabetes/DM, and (4) people with diabetes among disadvantaged population. On the other hand, commentary and opinion articles, systematic review, studies that describe the usage or effect of certain drugs, and studies related to chemistry were excluded. Also, the publications before 2000 were excluded from the current review.
Study selection and data extraction
All abstracts from the database search were independently evaluated dependent on the inclusion and exclusion criteria, and discrepancies were checked by the principal investigator. Further, randomly chosen 50% of the chosen articles were verified by second, third, and fourth authors independently. The full-texts of potentially relevant studies were retrieved for an independent assessment by all of the authors. Any disagreements were resolved by discussion till consensus was made among all.
The factors affecting self-care behavior and interventions used in diabetic patients with low income
Data analysis
A systematic narrative synthesis was conducted because of the heterogeneity of the studies. In introducing the aspects and conclusions of studies, tables and narrative synopses are used.
Results
Search results
A total of 96858 distributions were distinguished. Of those, 4303 were ignored after because of duplication. 92526 articles were taken out dependent on the underlying screening of understanding titles and modified works. 29 full-text articles were assessed for qualification. Articles were omitted because of the incorrect patient population, for being a review study, because they did not meet the inclusion requirements, and as the full-texts were not available. Finally, 10 studies met the incorporation rules after the full-text screening.
Study characteristics
Study characteristics and essential investigation conclusions are summarized in Table 1. The sample size of the 10 examinations went from 25 to 44181 individuals, with a total of 44917 individuals. Most of the study members were 18 or more years old. The examinations followed subjective investigation configuration, cross-sectional examination configuration, contextual analysis approach, and interventional/experimental design. The 10 investigations were led in five unique nations, including the US (n = 7), India (n = 1), Europe (n = 1), and Australia (n = 1).The primary findings identified in the included studies differ. The characteristics of the studies, as well as the factors influencing self-care behavior and interventions, are provided in Table 1.
Factors affecting self-care behavior among disadvantaged population
Factors affecting diabetes self-care were assessed in seven out of the 10 studies. Diabetes self-care is critical to monitor the disease. Factors such as awareness of diabetes-related information, absence of physical exercise, social support, and expenses can influence self-care practices (Chali et al., 2018). Creating diabetes self-care skills is a prolonged and challenging technique. Creating self-management abilities inside disadvantaged life settings included arranging admittance to health care systems, arranging interruptions to diabetes self-management designs, and arranging self-care information (Fritz, 2017).For lower-income patients, lack of medical insurance, transportations, scheduling, and lack of staff to provide comprehensive diabetic self-management (DSM) training limited the access to diabetics’ resources and the opportunity to choose among services and providers (Fritz, 2017). Life interruptions, for example, changing work routines, returning to class, taking on an unexpected parental figure job, encountering a relationship change, an abrupt diagnosis or injury reduce the capacity to manage diabetes effectively. Taking advice from others in the social network was not completely informative about DSM. Poor patient-provider communication and goal setting restricts the opportunity to consistently engage in DSM. (Fritz, 2017).
Many factors were identified as influencing self-care among the disadvantaged diabetic population. As the treatment costs are on the rise, due to limited resources and lack of awareness, disadvantaged diabetic population are inclined to follow unhealthy lifestyles like absence of exercise, over consumption of carbohydrates and increased BMI, and lack of access to a balanced diet (Sharma & Mishra, 2019).Diabetes information and perceived well-being status were having a huge relationship with glycemic control while health education appears to apply its effect through diabetes knowledge (Bains & Egede, 2011).
Self-management tasks involve food regulation, physical activities, medications, defining self-management goals, and making an interpretation of information from suppliers into action. The self-care encounters of low income racially and ethnically assorted grown-ups with diabetics included dietary limitations for the social association, food desires, depression and absence of admittance to psychological wellness providers, formal and casual help, dread about having the option to control diabetes, disarray about self-management, family responsibilities, and increase in social influences (Reyes et al., 2017; Vissenberg et al., 2016; Nelson et al., 2016).
Different predictive factors affecting self-care behavior include refusal of disease, motivation, skills, absence of time, stress, admittance to transport, health experts, exercise alternatives, commitment, cultural perspectives (Jones et al., 2014), and lack of informal caregiver (Bouldin et al., 2017).“Self-monitoring of blood glucose (SMBG)” is a foundation of diabetes care. Decreased SMBG was found among ethnic minorities and people with lower educational level. The obstructions included higher out-of-pocket expenditures for strips, smoking, unnecessary liquor utilizations, trouble in conveying in English, longer time since analysis, less concentrated treatment, and so forth (Karter et al., 2000).
Effect of the interventions
Agreeing to the American Diabetes Association, individuals with diabetes should think often about the treatment training they are going through, and for successful and suitable treatment, the patients ought to receive changes in their way of life to forestall the disease or postpone its significant complications (Zareban et al., 2014).Vissenberg et al., (2016) had coordinated an investigation on the social network-based intercession (“Powerful together with diabetics and Know your sugar”) (Vissenberg et al., 2016). A sum of 131 patients participated in the examination. Powerful together with diabetes proceeded for quite a while and included 24 group get-togethers for the individuals and six gatherings for their close others (loved ones). They directed two casual local area treatment gatherings at home in which people and their close others were accessible. The mediation objectives were to get the individuals to help and determinedly sway each other to more promptly manage their diabetes, to feasibly manage social effects that impede self-management, and to build the responsibility and support of relatives and associates in self-management. Know your sugar continued going a month and a half and included six gatherings for individuals. It is intended to give the individuals the data they expected to manage their diabetes. A group-based intercession pointed toward making trust, practicing together, and including family members can build social assistance and decrease social impacts preventing DSM in monetarily denied patients with diabetes (Vissenberg et al., 2016).
“Mobile phone-based mediations” using text messages are a utilitarian procedure for “improving medicine adherence among low-SES, racial, and ethnic minorities with diabetes” (Nelson et al., 2016). The goal of the assessment was to make “Rapid Education/Encouragement and Communications for Health (REACH),” an altered, text informing intervention to help self-care adherence of denied patients with T2DM. 36 adults with type-2 DM were picked. Research associates met with interested patients to portray the examination and affirm capability. They controlled a short-learned screening instrument and sent content to each understanding to outline whether the individual could see, read, and acceptably respond to the message. For around 14 days, individuals got step-by-step instant messages studying and propelling self-care, including specially designed messages tending to clients' specific checks to adherence, and step-by-step texts with adherence input. Texts gave excited/social help, reminded people to take part in self-care work out, and made them keep their self-care routine on track. REACH’s instant message commitment was higher than SMS-DM's care commitment, which may be a result of REACH's customized content and also altered adherence input (Nelson et al., 2016).
Problem-solving is a cognitive-behavioral process by which individual endeavors to distinguish compelling and versatile answers for explicit issues experienced in day-to-day living (Fitzpatrick et al., 2013). Hill-Briggs et al., (2011) focused on the Problem-Solving-Based Diabetes Self-Management Training. 56 metropolitan African American patients with type-2 diabetes and flawed glucose, circulatory strain, or cholesterol control were chosen. A group, problem-based diabetes self-management preparing expected for development in a broad and a dense program design were utilized. During the preliminary, three broad and three dense gatherings were performed. Appraisals were performed at three-time centers: standard, one-week post-intercession for chosen conduct measures, and three months after the completion of every mediation (three-month post-intercession follow-up) for social and clinical results. The three-month post-intercession resulting evaluation was related to six–nine months following baseline.
Both the intensive design and the condensed format covered the important parts of problem-solving therapy (PST) as a change in behavior intervention. In any case, at 3 months post-mediation, simply the escalated intervention was convincing in improving information, critical thinking aptitudes, self-care, and A1C (Hill-Briggs et al., 2011).
Discussion
The main objective of this systematic review was to explore the factors influencing self-care behavior among the disadvantaged diabetic population and to explore the intervention strategies to enhance health promotive self-care behavior. Overall, 10 studies were identified that met the inclusion criteria. Seven studies reported the factors influencing self-care behavior among disadvantaged diabetic population. Factors such as diabetes-related information, exercise, social support, lack of access to services, life disruptions, denial of illness, societal attitudes, responsibilities, and costs can influence the self-care practice. Three studies reported the intervention strategies used. Social Network-Based Intervention, “REACH - A Tailored Theory-Based Text Messaging Intervention,” and Problem-Solving-Based Diabetes Self-Care Training were the distinguished mediation procedures that are applied among the disadvantaged population.
Factors affecting self-care behavior among disadvantaged diabetic population
Self-care in diabetes is very important to deal with the disease effectively. Self-care management encounter of socio-monetarily denied patients incorporates different factors, for example, diabetes knowledge, absence of proactive tasks, social support, lack of access to services, life interruptions, denial of illness, societal attitudes, responsibilities, costs, etc. Bains and Egede (2011) uncovered that limited health literacy is needed to influence its effect through diabetes information and is not directly associated with diabetes self-care or medication adherence (Bains and Egede, 2011). In general, a large number of the elements in a single report may resound with other finished investigations of distraught adults with diabetes. Boundaries identified with medical care, absence of actual work, undesirable way of life, costs, social support, and absence of access to self-care services were the most widely recognized components found in each seven investigations (Bains and Egede, 2011; Bouldin et al., 2017; Fritz, 2017; Jones et al., 2014; Karter et al., 2000; Reyes et al., 2017; Sharma and Mishra, 2019).This recommends that the burdened populace fights with comparative issues as others with diabetes and necessities similar kind of emotionally supportive networks and interventions to succeed. Impeded people with diabetes face various inconveniences to diabetes self-care including persuading emotional responses and melancholy, instigating a translation of provider course into strong self-management tasks, the effect of diabetes on friendly coordinated efforts, comorbidities, and regulating family obligations and self-care(Reyes et al., 2017).
The studies demonstrate how disadvantaged social situations impose barriers to self-care practices. Barriers related to health care, lack of physical activity, unhealthy lifestyle, costs, social support, and lack of access to self-care services were the most common factors influencing the self-care behavior of the disadvantaged diabetic population.
From the discoveries, it is delineated that there is a critical requirement for more interdisciplinary and collective services, especially in rural regions (Jones et al., 2014). Medical care experts and interventional staff additionally should be extremely fixed about the best approach to regulate and keep up self-management undertakings and show patients the techniques for diabetes control to social and other significant life occurrences (Reyes et al., 2017). It ought to be recalled that while presenting data and direction on management, potential boundaries novel to a patient's experience ought to be considered (Jones et al., 2014). This review just glances at factors influencing self-care behavior among disadvantaged diabetic populace. Despite the fact that we had discovered a few investigations depicting self-care behavior among diabetic patients, we have discovered extremely restricted examinations portraying self-care behavior among disadvantaged diabetic patients. The sample size of the chosen studies was limited and mostly conducted among female participants, which shows that the results of the studies might be biased.
Effect of interventions
Lower economic status is related to more disease inconvenience from diabetes. Diabetes self-care support interventions are required that are productive in participating in lower-pay patients, tending challenging life needs and impediments to self-management, and empowering behavioral change (Hill-Briggs et al., 2011). Out of 10 investigations, three were exclusively focusing on intervention frameworks and their impact on self-care behavior among disadvantaged diabetic patients. Social Network-Based Intervention, “REACH-A Tailored Theory-Based Text Messaging Intervention,” and Problem-Solving-Based Diabetes Self-Management Training were the perceived intervention procedures.
Social network-based intervention
In financially burdened patients with diabetes, a group-based intervention pointed at building trust, practicing together, and including relatives can expand social support and lessening social impacts that obstruct DSM. Promising parts of the intervention were abilities training and feedback utilizing activities like role playing in inpatient group meetings, just as the cooperation of significant others of patients in self-care obligations, and their dynamic inclusion in the improvement of a self-care activity plan (Vissenberg et al., 2016).
REACH-A tailored theory-based text messaging intervention
Text messaging interventions give an ideal stage to broadening the conveyance of custom-fitted diabetes education and support .REACH intervention expected to defeat client explicit medication adherence boundaries and backing other self-care practices. Instant messages gave “emotional/social help, reminded individuals to partake in self-management activities, and made them keep their self-management routine on target” (Nelson et al., 2016).
Problem-solving-based diabetes self-management training
An education adapted, escalated, “critical thinking-based diabetes self-care training” was compelling for key clinical and behavioral results in a low economic population (Hill-Briggs et al., 2011).
These intervention strategies were developed to improve health status among individuals with diabetes. These interventions were proved to be successful in its administration as well as in the impact that had made. These researches, however, only report on intervention techniques that have led to improvements in particular factors influencing the behavior of self-care among disadvantaged diabetic patients. Therefore, as the intervention methods were successful, there may be a potential for biases.
Limitations
There are some certain limitations in this review. First and foremost, the over-portrayal of specific group demonstrates that most investigations may not be illustrative of the true populace. The results need to be interpreted with caution due to the risk of bias in the studies as the majority of the study focuses on the disadvantaged female participants and heterogeneity of the samples, interventions, and measures Figure 1. ■■■.
Conclusion
Managing diabetes is a complex process because it depends on a set of activities and behaviors the patient with diabetes should do. The present systematic review highlights potential barriers and the effect of intervention strategies on the self-care behavior of disadvantaged diabetic patients. Self-care experiences of disadvantaged patients include factors such as diabetes knowledge, lack of exercise, social support, lack of access to services, life disruptions, denial of illness, societal attitudes, responsibilities, and costs. It was also found that diabetes self-care support interventions are successful in engaging low-economic patients, addressing challenging life needs and obstructions to self-management, and encouraging changes in behavior. There is a need for further methodologically rigorous studies to address the limitations discussed in this systematic review, to establish the health-promoting behavior among disadvantaged diabetic people, and to explore the factors influencing self-care behavior of disadvantaged diabetic patients.
Footnotes
Acknowledgment
We thank Dr John Abraham, St. John’s Medical College, Bangalore, Karnataka, India, for his timely suggestions and support for the completion of this study.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
