Health-related quality of life scores of metastatic pancreatic cancer patients responsive to first line chemotherapy compared to newly derived EORTC QLQ-C30 reference values.

BACKGROUND: Metastatic pancreatic cancer (mPC) and its treatments significantly impact health-related quality of life (HRQoL). POLO, a randomized, double-blind, placebo-controlled phase 3 trial evaluated the efficacy of olaparib as maintenance therapy in germline BRCA mutated mPC patients who had not progressed during ≥16 weeks of first-line platinum-based chemotherapy. HRQoL was assessed using the EORTC QLQ-C30. To enhance score interpretation, we derived reference values for treatment-naïve mPC patients from the literature. METHODS: A targeted literature review identified EORTC QLQ-C30 baseline values in treatment-naïve mPC patients. Reference values were calculated by deriving means from studies meeting inclusion criteria, with scores from 0 to 100 (higher scores indicate better QoL/functioning but worse symptoms). For POLO patients, means were calculated using pooled baseline data across study arms. RESULTS: Four studies met inclusion criteria. Depending on the specific scale, sample sizes ranged from n = 466 to n = 639. Compared to newly derived reference values, POLO patients reported markedly better HRQoL scores at baseline across most scales, with eight scales showing differences of ≥10 points. POLO patients' HRQoL scores were often close to or better than general population norm data. CONCLUSIONS: This is the first study to systematically derive EORTC QLQ-C30 reference values for mPC. POLO patients had better HRQoL scores than those in the literature and similar to general population data. Comparatively high HRQoL of POLO patients are likely due to effects of prior first-line treatment and resolution of chemotherapy-related symptoms, response shift, or a combination. Newly derived reference values can enhance interpretation of mPC patients' HRQoL. TRIAL REGISTRATION: The POLO trial was registered on 9 July 2014 with ClinicalTrials.gov as NCT02184195.

Assessing Individuals' Exposure to Environmental Conditions Using Residence-based Measures, Activity Location-based Measures, and Activity Path-based Measures.

BACKGROUND: Many approaches are available to researchers who wish to measure individuals' exposure to environmental conditions. Different approaches may yield different estimates of associations with health outcomes. Taking adolescents' exposure to alcohol outlets as an example, we aimed to (1) compare exposure measures and (2) assess whether exposure measures were differentially associated with alcohol consumption. METHODS: We tracked 231 adolescents 14-16 years of age from the San Francisco Bay Area for 4 weeks in 2015/2016 using global positioning systems (GPS). Participants were texted ecologic momentary assessment surveys six times per week, including assessment of alcohol consumption. We used GPS data to calculate exposure to alcohol outlets using three approach types: residence-based (e.g., within the home census tract), activity location-based (e.g., within buffer distances of frequently attended places), and activity path-based (e.g., average outlets per hour within buffer distances of GPS route lines). Spearman correlations compared exposure measures, and separate Tobit models assessed associations with the proportion of ecologic momentary assessment responses positive for alcohol consumption. RESULTS: Measures were mostly strongly correlated within approach types (ρ ≥ 0.7), but weakly (ρ < 0.3) to moderately (0.3 ≤ ρ < 0.7) correlated between approach types. Associations with alcohol consumption were mostly inconsistent within and between approach types. Some of the residence-based measures (e.g., census tract: ß = 8.3, 95% CI = 2.8, 13.8), none of the activity location-based approaches, and most of the activity path-based approaches (e.g., outlet-hours per hour, 100 m buffer: ß = 8.3, 95% CI = 3.3, 13.3) were associated with alcohol consumption. CONCLUSIONS: Methodologic decisions regarding measurement of exposure to environmental conditions may affect study results.

Impact of Group Cohesion Among Drinking Groups at Nightclubs on Risk From Alcohol and Other Drug Use.

Although protective strategies are implemented within drinking groups, alcohol and other drugs (AOD) use may increase when protective strategies are in place. Being in a cohesive group could lead to a false sense of security, leading to more risk taking. This study examines whether club patrons perceiving greater group cohesion implement fewer protective strategies and use more AOD. The sample includes 815 club patrons (44.2% female; M age = 27.7, SD = 6.0 years) arriving in 324 groups, from seven clubs hosting electronic music dance events, across 30 evenings. Anonymous surveys, biological measures of alcohol (entry and exit) and drugs (exit only), were used. Results show that group cohesion relates to fewer strategies to keep themselves and their group safe and fewer actions responding to group AOD problems. Group cohesion was unrelated to AOD use. Findings suggest that prevention strategies should incorporate influences of group cohesion in engaging patrons in group safety strategies at clubs.

Brief report: Using global positioning system (GPS) enabled cell phones to examine adolescent travel patterns and time in proximity to alcohol outlets.

As adolescents gain freedom to explore new environments unsupervised, more time in proximity to alcohol outlets may increase risks for alcohol and marijuana use. This pilot study: 1) Describes variations in adolescents' proximity to outlets by time of day and day of the week, 2) Examines variations in outlet proximity by drinking and marijuana use status, and 3) Tests feasibility of obtaining real-time data to study adolescent proximity to outlets. U.S. adolescents (N = 18) aged 16-17 (50% female) carried GPS-enabled smartphones for one week with their locations tracked. The geographic areas where adolescents spend time, activity spaces, were created by connecting GPS points sequentially and adding spatial buffers around routes. Proximity to outlets was greater during after school and evening hours. Drinkers and marijuana users were in proximity to outlets 1½ to 2 times more than non-users. Findings provide information about where adolescents spend time and times of greatest risk, informing prevention efforts.

Indicators of club management practices and biological measurements of patrons' drug and alcohol use.

BACKGROUND: Electronic music and dance events in nightclubs attract patrons with heavy alcohol/drug use. Public health concerns are raised from risks related to these behaviors. Practices associated with increased risk in these club settings need to be identified. OBJECTIVES: The relationship between club management practices and biological measures of patrons' alcohol/drug use is examined. METHODS: Observational data from 25 events across six urban clubs were integrated with survey data (N = 738 patrons, 42.8% female) from patrons exiting these events, 2010-2012. Five indicators of club management practices were examined using mixed model regressions: club security, bar crowding, safety signs, serving intoxicated patrons, and isolation. RESULTS: Analyses revealed that serving intoxicated patrons and safety signs were related to substance use. Specifically, serving intoxicated patrons was related to heavy alcohol and drug use at exit, while safety signs were marginally related to less exit drug use. CONCLUSIONS/IMPORTANCE: Findings indicate observable measures in nightclubs provide important indicators for alcohol/drug use, suggesting practices to target. Study strengths include the use of biological measures of substance use on a relatively large scale. Limitations and future directions are discussed.

The impact of Thai family matters on parent-adolescent sexual risk communication attitudes and behaviors.

This article reports on a combined family-based substance abuse and HIV-prevention intervention targeting families with 13-14-year-old children in Bangkok, Thailand. Families (n = 340) were randomly and proportionally selected from 7 districts in Bangkok with half randomly assigned to an experimental or control condition. Families in the intervention condition were exposed to 5 interactive booklets about adolescent substance use and risky sexual behavior. Trained health educators followed up by phone to encourage completion of each booklet. Primary outcomes reported in this article include whether the intervention increased the frequency of parent-child communication in general or about sexual risk taking in particular as well as whether the intervention reduced discomfort discussing sexual issues. The authors also tested to see whether booklet completion was associated with communication outcomes at the 6-month follow-up. Multivariate findings indicate that the intervention had a significant impact on the frequency of general parent-child communication on the basis of child reports. The intervention had a marginal impact on the frequency of parent-child communication about sexual issues on the basis of parent reports. Booklet completion was associated with reduced discomfort discussing sex and was marginally associated with frequency of parent-child discussion of sex on the basis of parent reports only. These findings indicate that a family-based program can influence communication patterns.

Intergenerational transmission of religious beliefs and practices and the reduction of adolescent delinquency in urban Thailand.

This study examines the intergenerational transmission of family religion as measured by parent's and adolescent's beliefs and practices in Buddhism, and its relation to delinquent behaviors among early adolescents in Thailand. The data set is from the Thai Family Matters Project 2007, a representative sample of 420 pairs of parents and teens in Bangkok. A structural equation model is employed for the analysis. The intergenerational transmission and the direct and indirect association between parents' and adolescents' beliefs and practices in Buddhism and adolescents' minor and serious delinquent behaviors are revealed to be significant, controlling for secular parental monitoring. Spirituality within the family can play an important role in preventing delinquency among early adolescents. Policies in the areas related to family empowerment and delinquency prevention may need to consider integrating both secular and non-secular program inputs in their implementation design.

The Roles of Perceived Neighborhood Disorganization, Social Cohesion, and Social Control in Urban Thai Adolescents' Substance Use and Delinquency.

Substance use and delinquency in Thai adolescents are growing public health concerns. Research has linked neighborhood characteristics to these outcomes, with explanations focused on neighborhood disorganization, social cohesion, and social control. This study examines the independent associations of these neighborhood constructs with Thai adolescents' substance use and delinquency, through peer deviance, to determine which neighborhood aspects are particularly important. Families (N=420) with adolescents aged 13-14 were randomly selected from 7 districts in Bangkok, Thailand. Structural equation modeling showed that adolescents', but not parents', perceptions of greater disorganization were related to increased rates of both minor and serious delinquency. Surprisingly, greater neighborhood cohesion was related to greater minor delinquency. Peer deviance was unrelated to neighborhood variables. Findings can inform prevention strategies for Thai adolescents, as results suggest that neighborhoods are important for adolescent behaviors regardless of culture. Further work should help communities make use of social cohesion to benefit residents.

Psychometric Validation of the Perception of Injection (PIN) Questionnaire Using Data From Two Phase III, Open-Label, Active-Controlled, Non-Inferiority Studies in People Living With HIV.

INTRODUCTION: Currently, there are no patient-reported outcome tools specifically validated for use in people living with human immunodeficiency virus (PLHIV) to measure treatment injection acceptance and experience. The Perception of Injection (PIN) questionnaire was modified with consent from the Vaccinees' Perception of Injection (VAPI), a validated instrument developed by Sanofi Pasteur. The objective of developing the PIN was to provide information on participant experience with injectable therapies, including acceptance of pain, injection-site reactions, and tolerability following injections in PLHIV. METHODS: This post hoc analysis used data from participants who received the long-acting intramuscular cabotegravir plus rilpivirine combination treatment every 4 weeks, as part of the ATLAS (NCT02951052) and FLAIR (NCT02938520) studies, to evaluate the psychometric properties of the PIN questionnaire. RESULTS: These findings support the reliability, validity, and responsiveness to change for the PIN questionnaire in PLHIV. CONCLUSION: As a clinical trial endpoint, the PIN questionnaire could provide valuable evidence around the acceptance and experience of injections in PLHIV which could have implications for treatment adherence in this population. TRIAL REGISTRATION: ATLAS (NCT02951052); 1 November, 2016. FLAIR (NCT02938520); 19 October, 2016.

A Survey of Patient Experience in CML: American and Canadian Perspectives.

Purpose: With treatment, chronic myeloid leukemia (CML) has a favorable prognosis, however, individuals with CML experience impairment to their quality of life (QoL). The aim of this study was to examine the perspectives and experiences of individuals with CML and to understand their challenges communicating with their CML physician. Patients and Methods: An online survey in adults with CML (n=100) in the US and Canada assessed QoL, patient-provider relationships, treatment satisfaction, and understanding of CML and treatment goals via the MD Anderson Symptom Inventory, the Cancer Therapy Satisfaction Questionnaire and de novo survey questions. Participants were recruited via an external patient recruiter and CML Patient Groups. Results: Many participants reported hardships due to CML and its treatment. The main impacts were on the ability to work (21%), engage in personal activities (e.g., hobbies, 28%), and to enjoy sexual relations (median=2.00, IQR=8.50). A substantial proportion (21-39%) wished to discuss additional topics with their providers (e.g., management of CML and/or its impacts). While participants reported satisfaction with therapy overall (median=85.71, IQR=17.86), they indicated low to moderate treatment satisfaction with specific components, including concerns regarding side effects (median=43.75, IQR=43.75). Participants generally had a good understanding of CML (97%) and its treatment goals (92%). Conclusion: These findings advance our understanding of issues that need improvement to support QoL for individuals living with CML. Future work is needed to improve patient-provider relationships, address treatment-related side effects, and provide clinical information that is easier for patients to understand.

Parent and child characteristics related to chosen adolescent alcohol and drug prevention program.

Mothers were allowed to choose between two different family-based adolescent alcohol-drug prevention strategies and the choice was examined in relation to parent and teen characteristics. Under real world conditions, parents are making choices regarding health promotion strategies for their adolescents and little is known about how parent and teen characteristics interact with programs chosen. The two programs were: Family Matters (FM) (Bauman KE, Foshee VA, Ennett ST et al. Family Matters: a family-directed program designed to prevent adolescent tobacco and alcohol use. Health Promot Pract 2001; 2: 81-96) and Strengthening Families Program (SFP) 10-14 (Spoth R, Redmond C, Lepper H. Alcohol initiation outcomes of universal family-focused preventive interventions: one- and two-year follow-ups of a controlled study. J Stud Alcohol Suppl 1999; 13: 103-11). A total of 272 families with an 11-12 years old enrolled in health care centers were in the choice condition of the larger study. SFP requires group meetings at specified times and thus demanded more specific time commitments from families. In contrast, FM is self-directed through booklets and is delivered in the home at a time chosen by the families. Mothers were significantly more likely to choose SFP when the adolescent had more problem behaviors. Mothers with greater education were more likely to choose FM. Findings may provide more real-world understanding of how some families are more likely to engage in one type of intervention over another. This understanding offers practical information for developing health promotion systems to service the diversity of families in the community.

Parent-teen communication about sex in urban Thai families.

This study describes sexual communication among Thai parents and their teens and identifies variables related to communication about sex in urban Thai families. Data were derived from 420 families whose teenage children ages 13-14 years were randomly selected using the probability proportional to size technique. Interviews were conducted with 1 parent and 1 teenage child in each family. In-depth interviews were also conducted in 30 parents and teens drawn from the same 420 families. Results showed that parents were most likely to talk with their teens about body changes and dating; however, less discussion about sex-related issues, birth control, and HIV/AIDS occurred. More daughters than sons reported frequent discussions with their parents about sex. Parents who believed their teens had been involved in sexual activity were more likely to talk about HIV/AIDS and the difficulty of teenagers having babies, instead of talking about sexual intercourse or when to start having sex. Multiple regression analysis indicated that gender of the child (female), parental religiosity, and parental perception of teen sexual activity were significant predictors of increased sexual communication in Thai families. The findings suggest a need for approaches designed to facilitate communication skills about sex-related issues among Thai parents.

Successful implementation of Thai Family Matters: strategies and implications.

This article discusses the successful process used to assess the feasibility of implementing the Family Matters program in Bangkok, Thailand. This is important work since adopting and adapting evidence-based programs is a strategy currently endorsed by leading prevention funding sources, particularly in the United States. The original Family Matters consists of four booklets designed to increase parental communication with their adolescent children in order to delay onset of or decrease alcohol, tobacco, and other drug use. As part of the program, health educators contact parents by telephone to support them in the adoption of the program. Each booklet addresses a key aspect of strengthening families and protecting young people from unhealthy behaviors related to alcohol and other drug use. Adaptation of the program for Bangkok focused on cultural relevance and the addition of a unit targeting adolescent dating and sexual behavior. A total of 170 families entered the program, with the majority (85.3%) completing all five booklets. On average, the program took 16 weeks to complete, with families reporting high satisfaction with the program. This article provides greater detail about the implementation process and what was learned from this feasibility trial.

Do Thai parents really know about the sexual risk taking of their children? A qualitative study in Bangkok.

This qualitative study explores the perceptions of parents and adolescents toward sexual risk-taking behaviors. In-depth interviews were conducted with 30 parents and 30 adolescents (aged 13-14 years) in Bangkok, and were analyzed by using coding and thematic analysis. The results showed that although parents generally believed that Thai teens begin to have sex at an early age and engage in sexual risk-taking behaviors, they trusted that their teens would follow parental guidance and rules and not engage in sexual activity at this age. Most of the Thai teens reported that their parents were not really aware of their sexual behaviors because of their tendency to keep their sexual stories secret for fear of being scolded, blamed, and punished. The teens also reported that they wanted their parents to listen, give them warmth and more freedom, and be more in touch with their activities. Parents expressed their need for knowledge and skills so that they could help guide their adolescent children to avoid sexual risk-taking behaviors. A family intervention specifically aimed at empowering Thai urban parents is needed.

The Relationship between Neighborhood Characteristics and Effective Parenting Behaviors: The Role of Social Support.

Neighborhood characteristics have been linked to healthy behavior, including effective parenting behaviors. This may be partially explained through the neighborhood's relation to parents' access to social support from friends and family. The current study examined associations of neighborhood characteristics with parenting behaviors indirectly through social support. The sample included 614 mothers of 11-12 year old youths enrolled in a health care system in the San Francisco area. Structural equations modeling shows that neighborhood perceptions were related to parenting behaviors, indirectly through social support, while archival census neighborhood indicators were unrelated to social support and parenting. Perceived neighborhood social cohesion and control were related to greater social support, which was related to more effective parenting style, parent-child communication, and monitoring. Perceived neighborhood disorganization was unrelated to social support. Prevention strategies should focus on helping parents build a social support network that can act as a resource in times of need.

Implementation of adolescent family-based substance use prevention programs in health care settings: Comparisons across conditions and programs.

BACKGROUND: The majority of knowledge related to implementation of family-based substance use prevention programs is based on programs delivered in school and community settings. The aim of this study is to examine procedures related to implementation effectiveness and quality of two family-based universal substance use prevention programs delivered in health care settings, the Strengthening Families Program: For Parents and Youth 10-14 (SFP) and Family Matters (FM). These evidence-based programs were delivered as part of a larger random control intervention study designed to assess the influence of program choice vs. assignment on study participation and adolescent substance use outcomes. We also assess the effects of program choice (vs. assignment to program) on program delivery. METHODS: A mixed method case study was conducted to assess procedures used to maximize implementation quality and fidelity of family-based prevention programs delivered in health care settings. Families with an 11 year old child were randomly selected for study participation from health plan membership databases of 4 large urban medical centers in the San Francisco Bay Area. Eligible families were initially randomized to a Choice study condition (families choose SFP or FM) or Assigned study condition (assigned to FM, SFP or control group); 494 ethnically diverse families were selected for participation in study programs. RESULTS: Successful implementation of family prevention programs in health care settings required knowledge of the health care environment and familiarity with established procedures for developing ongoing support and collaboration. Ongoing training of program deliverers utilizing data from fidelity assessment appeared to contribute to improved program fidelity over the course of the study. Families who chose FM completed the program in a shorter period (p<.0001) and spent more time implementing program activities (p=0.02) compared to families assigned to FM. SFP "choice" families attended more sessions than those assigned to SFP (3.5 vs. 2.8), (p=0.07). CONCLUSION: Program choice appeared to increase family engagement in programs. The goals and approach of universal family-based substance use prevention programs are congruent with the aims and protocols of adolescent preventive health care services. Future effectiveness trials should assess approaches to integrate evidence-based family prevention programs with adolescent health services.

The roles of mothers' neighborhood perceptions and specific monitoring strategies in youths' problem behavior.

The neighborhood context can interfere with parents' abilities to effectively monitor their children, but may be related to specific monitoring strategies in different ways. The present study examines the importance of mothers' perceptions of neighborhood disorganization for the specific monitoring strategies they use and how each of these strategies are related to youths' alcohol use and delinquency. The sample consists of 415 mother-child dyads recruited from urban and suburban communities in Western New York state. Youths were between 10 and 16 years of age (56% female), and were mostly Non-Hispanic White and African American (45.3 and 36.5%, respectively). Structural equation modeling shows that mothers who perceive greater neighborhood problems use more rule-setting strategies, but report lower levels of knowledge of their children's whereabouts. Knowledge of whereabouts is related to less youth alcohol use and delinquency through its association with lowered peer substance use, whereas rule-setting is unrelated to these outcomes. Thus, mothers who perceive greater problems in their neighborhoods use less effective monitoring strategies. Prevention programs could address parental monitoring needs based upon neighborhood differences, tailoring programs for different neighborhoods. Further, parents could be apprised of the limitations of rule-setting, particularly in the absence of monitoring their child's whereabouts.

Efficacy of a Web-Based Intervention (Smart Choices 4 Teens) for Facilitating Parent-Adolescent Communication About Relationships and Sexuality: Randomized Controlled Trial.

BACKGROUND: There is a need for interventions that promote healthy decision making among adolescents and leverage the ongoing impact of parental relationships through older adolescence and young adulthood. These interventions should maximize adolescent engagement and be easily accessible to families in terms of cost, duration, and logistics related to participation. OBJECTIVE: This study aims to test the efficacy of the healthy relationships and sexual decision-making component of a web-based intervention for older adolescents and their parents, ascertain whether the efficacy varies by gender, and assess its efficacy over time. METHODS: A randomized controlled trial was conducted for the web-based, self-paced intervention Smart Choices 4 Teens from 2014 to 2015. Families (N=411) with adolescents aged 16-17 years were randomly assigned to the intervention or control condition. Surveys assessing aspects of sexual communication were administered at baseline and at 6, 12, and 18 months. Generalized estimating equations were used to determine the impact of exposure to the relationships component of the intervention on sexual communication by parents, as reported by adolescents. RESULTS: Less than half (88/206, 42.7%) of the intervention group participated in the third and final intervention component, which was focused on relationships and sexual decision making. Participation in the relationships component increased the frequency of parental sexual communication and increased the number of dating rules after accounting for other significant adolescent characteristics. The impact of the intervention varied little by gender, although it did demonstrate an impact on communication reports over the follow-up survey administrations. CONCLUSIONS: Smart Choices 4 Teens demonstrated efficacy in increasing the frequency of sexual communication between parents and adolescents in the long term. TRIAL REGISTRATION: ClinicalTrials.gov NCT03521115; https://clinicaltrials.gov/ct2/show/NCT03521115.

Implementation fidelity in adolescent family-based prevention programs: relationship to family engagement.

Reliability and validity of intervention studies are impossible without adequate program fidelity, as it ensures that the intervention was implemented as designed and allows for accurate conclusions about effectiveness (Bellg AJ, Borrelli B, Resnick B et al. Enhancing treatment fidelity in health behavior change studies: best practices and recommendations from the NIH behavior change consortium. Health Psychol 2004; 23: 443-51). This study examines the relation between program fidelity with family engagement (i.e. satisfaction and participation) in family-based prevention programs for adolescent alcohol, tobacco or other drug use. Families (n = 381) were those with an 11- to 12-year-old child enrolled in Kaiser Permanente in the San Francisco area. Families participated in one of two programs: Strengthening Families Program: For Parents and Youth 10-14 (SFP) (Spoth R, Redmond C, Lepper H. Alcohol initiation outcomes of universal family-focused preventive interventions: one- and two-year follow-ups of a controlled study. J Stud Alcohol Suppl 1999; 13: 103-11) or Family Matters (FM) (Bauman KE, Ennett ST. On the importance of peer influence for adolescent drug use: commonly neglected considerations. Addiction 1996; 91: 185-98). Fidelity was assessed by: (i) adherence to the program manual and (ii) quality of implementation. No relationships were found for FM, a self-directed program. For SFP, higher quality scores were related to higher parent satisfaction. Higher adherence scores were related to higher satisfaction for youth, yet surprisingly to lower satisfaction for parents. Parent sessions involve much discussion, and to obtain high adherence scores, health educators were often required to limit this to implement all program activities. Findings highlight a delivery challenge in covering all activities while allowing parents to engage in mutually supportive behavior.

Alcohol Outlet Density, Parental Monitoring, and Adolescent Deviance: A Multilevel Analysis.

Lower levels of parental monitoring are associated with youth problem behaviors, including substance use and delinquency. Recent studies employing routine activities theory have hypothesized that greater densities of alcohol outlets, particularly bars, may provide parents more opportunities to socialize outside the home. This, in turn, may decrease a parent's ability to effectively monitor the activities of his or her child, resulting in more deviant behaviors by the adolescent. Using hierarchical linear modeling (HLM), the current study assesses whether or not greater densities of alcohol outlets in zip code areas (n = 50) interact with levels of parental monitoring to affect levels of deviance among adolescents aged 14 to 16 (n = 1,541). The study finds that adolescents who have higher grade point averages and have not used alcohol report the lowest levels of deviant behaviors. Furthermore, the density of bars interacts with reports of parental monitoring such that adolescents in areas with more bars per roadway mile report lower levels of parental monitoring behaviors, which is associated with higher levels of deviance. These findings suggest that in those areas with greater densities of bars parents may be spending more time away from home, making monitoring of their adolescents more difficult, or parents may be drinking more frequently, thus impairing their ability to adequately monitor their children. Policies and practices that limit the number of bars in neighborhood areas with large populations of adolescents may reduce deviant behaviors.