The Effect of Mindfulness-Based Stress Reduction Counseling on Blood Glucose and Perceived Stress in Women with Gestational Diabetes.

OBJECTIVE: Gestational diabetes can cause maternal and neonatal morbidity. Psychological factors, especially stress, play a meaningful role in diabetes management. Therefore, the present study aimed to investigate the effect of Mindfulness-Based Stress Reduction counseling on blood sugar and perceived stress in women with gestational diabetes. METHODS: The present quasi-experimental interventional study was performed on 78 women with gestational diabetes. In the intervention group, a Mindfulness-Based Stress Reduction counseling program was conducted by the researcher in 8 sessions of 90 minutes twice a week. The Cohen stress questionnaire was filled in both groups. Also, fasting blood sugar and 2-hour blood sugar levels were measured in both groups. Statistical analysis was performed using the independent T-Test, the paired T-Test, the Mann-Whitney and Wilcoxon Tests using IBM SPSS Statistics for Windows version 20 version (IBM Corp., Armonk, NY, USA). RESULTS: The mean age of pregnant women in the intervention group was 28.84 ± 6.20 years old and 29.03 ± 5.42 years old in the control group. There was a significant mean difference between the fasting blood sugar score (p = 0.02; - 6.01; and - 11.46) and the 2-hour fasting blood sugar score (p < 0.001;12.35; and - 5.3) and the perceived stress score (p < 0.001; 35.57; and - 49.19) existed between the intervention and control groups after the intervention. CONCLUSION: The results of the present study showed that mindfulness-based stress reduction counseling is effective in reducing blood sugar levels and reducing perceived stress in women with gestational diabetes treated with diet.

Perceptions of primiparous women diagnosed with gestational diabetes mellitus: A descriptive qualitative study.

OBJECTIVE: To understand the perceptions of primiparous women recently diagnosed with Gestational Diabetes Mellitus (GDM) in Singapore. DESIGN: A descriptive qualitative study design. SETTING: An outpatient women's health clinic in a tertiary hospital in Singapore. PARTICIPANTS: Twelve English-speaking primiparous women (aged 27-44 years old) who were diagnosed with GDM were recruited via purposive sampling to participate in this study. METHODS: Face-to-face interviews were carried out with study participants in a private room at the outpatient clinic from December 2019 to May 2021. All interviews were audio-recorded and transcribed verbatim on the same day. Data analysis was guided by Braun and Clarke's thematic analysis framework. FINDINGS: Four main themes were identified from this study's findings: (1) Life leading to GDM: A 'hint' that something was wrong, (2) Reactions to diagnosis: Shock or acceptance, (3) Learning to cope: Facing internal and external challenges, and (4) Living with GDM: A way forward. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Primiparous women with GDM require comprehensive informational, practical, and emotional support to help them manage and accept their condition. Healthcare providers are encouraged to provide individualised and holistic care to these women using a humanistic approach. Accessible online educational resources and peer support services could be considered. Public campaigns to increase the general public's awareness of GDM would also allow future women and their families to be more familiar with the condition and hence more prepared to cope with it.

Attitudes of women with gestational diabetes toward diet and exercise: a qualitative study.

OBJECTIVE: Gestational diabetes (GDM) refers to glucose intolerance of varying severity first occurring in pregnancy. Following a diagnosis of GDM, exercise and dietary modification has a positive effect on improving glycemic control. Lifestyle changes affected in pregnancies affected by GDM have beneficial effects on long-term health if continued following birth. In addition, the psychological impact of a diagnosis of GDM should not be overlooked. Reports of maternal stress, anxiety, and fear are commonly reported issues in the literature. Support, both socially and from health care professionals, is also linked with higher rates of success in GDM management. Research to date had focused on women's reaction to a diagnosis of GDM, their mood and quality of life following a diagnosis, and their knowledge or opinions on the management of GDM. This qualitative study explored the attitudes of women with GDM toward these lifestyle changes, specifically diet and exercise. Women were also asked to identify advice that would be useful for other women newly diagnosed with GDM. METHODS: With ethical approval a qualitative study was conducted using semi-structured interviews which were examined using Thematic Analysis. Patients were invited to participate and gave written consent after a discussion with a study researcher. The question plan for semi-structured interviews was designed with the advice of patient advocates. Recurrent themes were developed until the saturation of data. RESULTS: Thirty-two women took part in the study. Time, convenience, and lack of educational awareness were common barriers to healthy eating and physical activity plans. Enablers for change included meal planning and organization. Women regarded their diets pre-diagnosis as healthy, with small "tweaks" (such as portion control) required to comply with recommendations. Another significant facilitator to change was support from the woman's partner. This also set a benchmark for plans of diet maintenance within the family structure after pregnancy. Unlike dietary changes, a consistent theme was that exercise was considered a "chore" in managing GDM and was unlikely to be continued in the long term. Practical advice offered by participants for other women with GDM included organization, realistic approaches, and lack of self-blame. CONCLUSION: Women reported that changes in diet would be more achievable in the long term than changes in exercise patterns. Partners and the clinical team were significant sources of support. Women's views are crucial to providing clinicians with a comprehensive and holistic understanding of disease management. Involving women in self-care decisions and empowering women to manage their own health are key contributors to long-term behavior change as well as service provision and policy implementation.

The impact of prenatal depression and diabetes management self-efficacy on postpartum stress and depression in women with gestational diabetes mellitus.

AIMS: The study aimed to examine the impact of prenatal depression and diabetes management self-efficacy on postpartum stress and postpartum depression in women with gestational diabetes mellitus. BACKGROUND: Poor perinatal mental health is linked to various adverse pregnancy outcomes in women with gestational diabetes mellitus. DESIGNS: A predictive study design and the guidelines for the STROBE checklist were used for the study. METHODS: A total of 119 pregnant women with a positive 75 g-glucose challenge test were recruited at a medical centre. The Taiwanese depression questionnaire (TDQ), the diabetes management self-efficacy scale (DMSES) and the Hung postpartum stress scale (Hung PSS) were used for data collection at the 24th week of pregnancy and the first week after childbirth. RESULTS: Diabetes management self-efficacy was correlated with postpartum stress in women with gestational diabetes mellitus. Moreover, prenatal depression was a predictor of postpartum stress and postpartum depression, respectively, in women with gestational diabetes mellitus. CONCLUSIONS: Healthcare providers should assess those women's diabetes management self-efficacy and mood status during prenatal visits and offer the needed intervention to reduce the levels of postpartum stress and postpartum depression of those women after childbirth. RELEVANCE TO CLINICAL PRACTICE: A holistic care approach integrated diabetic care and mental health for women with gestational diabetes mellitus in a timely manner is warranted to promote perinatal mental health in women with gestational diabetes mellitus.

Breastfeeding support and barriers to women with gestational diabetes mellitus: a nationwide cross-sectional survey of hospitals in Japan.

BACKGROUND: Despite the benefits of breastfeeding for women with Gestational Diabetes Mellitus (GDM) and their infants, breastfeeding is less likely to be performed by this group. This study aimed to examine the current levels of implementation of breastfeeding support to women with GDM in Japan and to clarify barriers to promoting breastfeeding among this population. METHODS: A 25-item questionnaire was developed by the authors to investigate the current levels of implementation of breastfeeding support for women with GDM provided in hospitals, and to explore barriers for promoting breastfeeding among these women. The questionnaire was sent to all 1046 hospitals facilitating childbirth in Japan. Descriptive statistics were used to analyze the quantitative data, and content analysis was used to analyze qualitative data from the open-ended questions. RESULTS: All 296 respondents were included in this study. Regarding breastfeeding support, 95.2% of the respondents provided general information on breastfeeding to GDM women during antenatal midwife consultations. However, the benefits of breastfeeding for preventing type 2 diabetes were addressed by only 48.0%. Likewise, although follow-up services (e.g., telephone support or breastfeeding consultations) were conducted in 88.9% of hospitals, only 50.7% of hospitals informed women that breastfeeding decreases the risk of developing type 2 diabetes after GDM. Regarding barriers, seven categories and 20 subcategories about promoting breastfeeding for women with GDM were extracted and abstracted into the following three themes: Barriers associated with mother and infant, Barriers associated with health professionals, and Organizational barriers. CONCLUSIONS: In Japan, most hospitals that responded provided general breastfeeding support from the antenatal to postpartum periods. However, the benefits of breastfeeding in terms of preventing the incidence of type 2 diabetes following GDM were insufficiently communicated to women with GDM. Furthermore, there were numerous barriers to promoting breastfeeding among women with GDM.

Weight Loss Prior to Pregnancy and Early Gestational Glycemia: Prepare, a Randomized Clinical Trial.

CONTEXT: Women with elevated body mass index are encouraged to lose weight before pregnancy, but no trials have tested the effects of prepregnancy weight loss on risk of developing gestational diabetes. OBJECTIVE: This work aims to determine whether prepregnancy weight loss improved the early metabolic environment as measured by early gestational diabetes diagnosis. METHODS: This was a secondary analysis of a pragmatic randomized clinical trial conducted between May 2015 and October 2019 in an integrated health system that encouraged first-trimester gestational diabetes screening for high-risk women, including those with obesity. Women aged 18 to 40 years with a body mass index (BMI) greater than or equal to 27 who were planning pregnancy were randomly assigned to a behavioral weight loss intervention or usual care. Clinical care decisions and data collection were blind to condition assignment. We compared rates of diagnosis with gestational diabetes in early pregnancy between the groups using logistic regression. RESULTS: Of 326 participants, 168 (89 in the intervention and 79 in usual care) had singleton pregnancies during the study period. At baseline, mean age was 31.3 ±â€…3.5 years and BMI was 34.8 ±â€…5.8. Fifty-nine (66%) intervention participants and 57 (72%) usual care participants underwent early screening. Among those, intervention participants were 73% less likely to be diagnosed with gestational diabetes than usual care participants (adjusted odds ratio [aOR], 0.27; 95% CI, 0.09-0.80). There was no difference in diagnosis of gestational diabetes in later pregnancy (aOR, 1.08; 95% CI, 0.41-2.81). CONCLUSION: Participation in a prepregnancy weight loss intervention led to lower rates of gestational diabetes diagnosis in early pregnancy. This suggests positive effects of prepregnancy weight loss on the early metabolic environment, a critical factor in offspring metabolic risk.

Metformin administration during pregnancy attenuated the long-term maternal metabolic and cognitive impairments in a mouse model of gestational diabetes.

BACKGROUND: Gestational diabetes mellitus (GDM) is a metabolic disease that can have long-term adverse effects on the cognitive function of mothers. In our study, we explored the changes in metabolic health and cognitive function in mice of middle- and old- age after exposure to GDM, and whether metformin therapy during pregnancy provided long-term benefits. RESULTS: Mice with GDM demonstrated significant cognitive impairment in old age, which was associated with insulin resistance. Gestational metformin therapy was shown to increase insulin sensitivity and improve cognition. The ovarian aging rate was also accelerated in mice exposed to GDM during pregnancy, which may be related to fatty acid metabolism in the ovaries. CONCLUSION: Treatment with metformin during pregnancy was shown to improve fatty acid metabolism in ovarian tissues. METHOD: During pregnancy, mice were fed with a high-fat diet (GDM group) or a low-fat diet (Control group), and a third group received metformin while receiving a high-fat diet (Treatment group). At 12 months old, the mice completed an oral glucose tolerance test, insulin tolerance test, Morris water maze test, female sex hormones were measured, and metabolite profiles of tissue from the ovaries, hypothalamus, and pituitary glands were analysed using gas chromatography-mass spectrometry.

Perspectives and experiences of collecting antenatal colostrum in women who have had diabetes during pregnancy: a North Queensland semistructured interview study.

OBJECTIVES: To explore and describe the experiences and perspectives of collecting and storing colostrum in the antenatal period in women who have had diabetes in pregnancy. DESIGN: Face-to-face, semistructured interviews analysed with purposive sampling and thematic analysis. SETTING: A regional hospital in North Queensland with a high prevalence of diabetes in pregnancy. PARTICIPANTS: Six women with a previous pregnancy complicated by diabetes who were advised to collect and store colostrum in pregnancy. RESULTS: Six themes were identified: wariness of medicalisation (adjusting to an 'abnormal' pregnancy, seeking continuity of care, determination to reduce formula, fear of invasive intervention); underlying altruism (providing the best for baby, preparing for complications, eager for milk donation); internal pressure to succeed (coping with confronting information, disheartened by failures, constant fear of insufficient supply, overwhelming guilt, concern for future breastfeeding success); self-management and ownership (adapting to awkwardness, developing strategies for success, actively seeking education, gaining confidence to request help, accepting personal limitations); frustrated by waste (encroaching on time, squandering a precious resource, ambiguous about necessity) and building fortitude for motherhood (physically preparing for breast feeding, symbolic of the imminent infant, establishing early relationships with supports, approaching challenges with realistic optimism). CONCLUSION: Women with diabetes in pregnancy experience guilt and stress about the added risk of hypoglycaemia to their babies and strive to provide the best for their babies by collecting and storing colostrum, even if this leads to distress to themselves. It is crucial that these women be provided accurate, realistic advice about the benefits and disadvantages of collecting colostrum in the antenatal period.

Effects of a Web-Based Self-Management Program on the Behavior and Blood Glucose Levels of Women with Gestational Diabetes Mellitus.

Background:Women diagnosed with gestational diabetes mellitus suffer from anxiety and depression, which make controlling blood glucose levels difficult.Introduction:This quasi-experimental study uses a nonequivalent control group pretest-posttest design to investigate the effects of a web-based self-care program on self-care behaviors, anxiety, depression, and blood glucose in patients with gestational diabetes mellitus.Methods:The subjects of the study were outpatients being treated in the Department of Endocrinology at Hospital G, located in Seoul near University C, from July 15, 2015, to December 31, 2016. The experimental and control groups contained 22 participants each. The experimental group received a 12-week web-based program and one session of nutrition education; the control group received nutrition education. Using the SPSS program, pre-post changes in blood glucose, anxiety, depression, and self-care behaviors were examined between the two groups by a repeated-measures ANOVA.Results:After the 12 weeks intervention, self-care behaviors increased in both groups, and blood glucose monitoring increased in the experimental group (p = 0.001). Anxiety in the experimental group decreased by 5.1 points but increased by 1.0 point in the control group (p = 0.048). Depression increased in both groups. Glycated hemoglobin (HbA1C) levels decreased in the experimental group but increased in the control group (p = 0.001).Discussion:In addition to reducing HbA1C and anxiety, the web-based self-care program was effective in increasing the frequency of daily blood glucose monitoring in patients with gestational diabetes mellitus.Conclusions:This study will be helpful in informing an anxiety intervention program, blood glucose control, and healthy self-care behaviors in women with gestational diabetes mellitus.

Experiences of women, hospital clinicians and general practitioners with gestational diabetes mellitus postnatal follow-up: A mixed methods approach.

PROBLEM: Postnatal screening rates to detect type two diabetes following gestational diabetes are low. The quality of communication is an important element to consider in developing targeted strategies that support women in completing recommended follow-up care. AIMS: To explore the communication perspectives, practices and preferences of women, hospital clinicians and general practitioners, to determine strategies that may promote completion of recommended postnatal GDM follow-up, in Queensland Australia. METHOD: We used an exploratory, three-phase, mixed-methods approach, interpreted through intergroup communication theory. Phase one: convergent interviews explored perspectives of the communication experience in GDM care among new mothers (n = 13), hospital clinicians (n = 13) and general practitioners (n = 16). Phase two: a retrospective chart audit assessed current practice in postnatal discharge summaries of women (n = 86). Phase three: an online survey identified the preferences of general practitioners and hospital clinicians who provide maternity care in Queensland. Triangulation of the findings from the interviews, audit and surveys was used to clarify results and increase the robustness of the findings. RESULTS: Three themes: Seeking information, Written hospital discharge summary (discharge summary) and Clarity of follow-up requirements, provide direction for pragmatic strategies to promote follow-up. Practical recommendations include continued discussion about care with women from the point of GDM diagnosis into the postnatal period; discharge summaries that give primacy to diagnosis and ongoing treatment; and provision of explicit directions for recommended testing and timing. IMPLICATIONS: This research informs seven practical recommendations to help promote completion of recommended postnatal GDM follow-up.

The effect of dietary counselling on food intakes in pregnant women at risk for gestational diabetes: a secondary analysis of a randomised controlled trial RADIEL.

BACKGROUND/OBJECTIVES: The prevalence of gestational diabetes mellitus (GDM) is increasing worldwide. GDM may be prevented by improving the diets of pregnant women. The objective of this study was to evaluate the effect of dietary counselling on the diets of pregnant women at GDM risk. SUBJECTS/METHODS: This study was a secondary analysis of a randomised controlled trial the Finnish gestational diabetes prevention study (RADIEL) in which pre-pregnant and pregnant women with previous GDM or BMI ⩾30 kg/m(2) were allocated into two groups, namely the control and the intervention groups. The control group received standard antenatal dietary counselling according to the Finnish Nutrition Recommendations. The intervention group participated in one individual dietary counselling session and one group dietary counselling session in addition to the standard counselling. This study included women who were recruited during pregnancy. To assess changes in food intake, food-intake questionnaires were collected during the first and the second trimester of pregnancy. Bootstrap type analysis of covariance was used, and 242 participants were included in the final analysis to study changes in food intake. RESULTS: The intakes of low-fat cheese (baseline adjusted mean 0.09 times/day; 95% confidence interval (CI) 0.07, 0.24; P=0.040) and fish (baseline adjusted mean 0.28 times per week; 95% CI 0.08, 0.49; P=0.011) showed a significant increase in the intervention group compared with the control group. CONCLUSIONS: This study showed that dietary counselling in early pregnancy can lead to modest dietary improvements in pregnant women at GDM risk.

Beliefs about health and illness and health-related behavior among urban women with gestational diabetes mellitus in the south east of China.

PURPOSE: The incidence of gestational diabetes among Chinese women is 4.3%. No study has previously been conducted about beliefs and health-related behavior among urban Chinese women with this disease. This article aims to explore beliefs about health and illness and health-related behavior among women in this group in a Chinese sociocultural context. DESIGN: A qualitative exploratory study was conducted and semistructured individual interviews (n = 15) were processed by content analysis. RESULTS: Beliefs about health and illness among these women were foremost attributed to the individual, social, and natural worlds. They feared the negative influence of gestational diabetes, but some of them believed in "letting nature take its course" and "living in the present." Their care-seeking behavior varied between the professional, popular, and folk sectors. They sought a balance between following professionals' advice and avoiding practical difficulties. CONCLUSION: The beliefs and health-related behavior among them were influenced by Chinese culture, which can sometimes but not always reduce the effect of the disease.

An interpretive review of women's experiences of gestational diabetes mellitus: proposing a framework to enhance midwifery assessment.

BACKGROUND: Gestational diabetes mellitus (GDM) affects almost 5% of pregnancies in Australia, and within 15 years, 25% of affected women will go on to develop Type 2 Diabetes Mellitus (T2DM). The adoption of preventive health behaviours may be influenced by women's experiences of GDM. QUESTION: This review sought to understand women's beliefs, values, perceptions and experiences following diagnosis of GDM. METHODS: Peer reviewed and professional journals were searched for primary research, published between January 1991 and December 2011 that explored the beliefs, values, perceptions and experiences of peripartum or postpartum women with a diagnosis or history of GDM. FINDINGS: Nineteen studies met the inclusion criteria and the majority of these studies were qualitative (n=15). Each study was reviewed and synthesis revealed three emergent themes and core concepts related to each theme: Responses (initial reaction to GDM diagnosis, negative thoughts following diagnosis, struggle to manage GDM, feelings of 'loss of control', changes to identity and adapting to change), Focus of Concern (concern for baby's health, mother's concern for her own health, perceived seriousness of GDM, perceived fear of T2DM) and Influencing Factors (cultural roles and beliefs, social stigmas, social support, professional support, adequate and appropriate information, social roles and barriers to self-care). CONCLUSION: The experiences of women with GDM are unique and personal however this review highlights common experiences evident in the existing research. The proposed framework may be used by midwives in clinical assessment and care of women diagnosed with GDM.

Beliefs about health and illness in women managed for gestational diabetes in two organisations.

OBJECTIVE: to explore beliefs about health, illness and health care in women with gestational diabetes mellitus (GDM) managed in two different organisations based on diabetology or obstetrics. DESIGN: an explorative qualitative study using semi-structured interviews. SETTING: clinic A: a specialist diabetes clinic with regular contact with a diabetologist and antenatal care provided by a midwife; clinic B: a specialist maternity clinic providing regular contact with a midwife, a structured programme for self-monitoring of blood glucose and insulin treatment, and a 1-day diabetes class by an obstetrician, a diabetologist, a midwife and a dietician. The clinics were located at two different university hospitals in Sweden. PARTICIPANTS: a consecutive sample of Swedish women diagnosed with GDM; 13 managed in clinic A and 10 managed in clinic B. MEASUREMENT AND FINDINGS: women described their perceptions of as well-being, being healthy and freedom from disease. All respondents reported a delay in the provision of information about GMD and an information gap about GDM and the management of the condition, from diagnosis until the start of treatment at the specialist clinic. Respondents from clinic A expressed fear about future development of type 2 diabetes. Women from clinic B discussed different causes of GDM, and many claimed that health-care staff informed them that GDM was a transient condition during pregnancy. Respondents from clinic A reported a conflict in their treatment of pregnancy and GDM as two different conditions. KEY CONCLUSIONS: beliefs differed and were related to the health-care model chosen. Women with GDM monitored at a specialist maternity clinic believed GDM to be a transient condition during pregnancy only, whereas women monitored at a diabetes specialist clinic expressed fear about a future risk of developing type 2 diabetes. IMPLICATIONS FOR PRACTICE: relevant information about GDM should be provided without delay after initial diagnosis and thereafter repeatedly. It is important to recognise the context of information given on GDM, as it will substantially influence the beliefs and attitudes of women towards GDM as a transient condition during pregnancy or as a potential risk factor for diabetes.

Management of gestational diabetes from the patient's perspective--a comparison of Swedish and Middle-Eastern born women.

AIM: To explore patients' evaluation of a specialized diabetes clinic for management of women with gestational diabetes born in Sweden and the Middle East and its contribution to a decreased level of stress and improved coping capability to promote health in patients receiving care. BACKGROUND: No studies comparing patients' perceptions of healthcare in women of different origin with gestational diabetes have been found. A perceived clinical problem in specialized diabetes care is of lower activity level in self-care in foreign- than Swedish-born women and the question is whether the healthcare organization is optimal in meeting different individuals' needs. DESIGN: Explorative study. METHOD: Semi-structured individual interviews by external evaluators. PARTICIPANTS: Consecutive sample. Females with gestational diabetes, 13 born in Sweden and 14 born in the Middle East. RESULTS: The healthcare model was perceived as functioning well. Swedish women were problem focused and information seeking. Frustration and stress were increased due to perceived delay in information concerning gestational diabetes, limited access to telephone service and lack of confidence in staff because they lacked the expected competence. Control of gestational diabetes and pregnancy by different persons led to perceived lack of holistic care. Women from the Middle East felt cared, had been given the necessary information and claimed to follow advice. Adequate information reduced respondents' anxiety and increased their control over the situation. CONCLUSIONS: The clinic needs to be further improved by adapting programmes to persons to become problem focused by giving adequate information immediately. RELEVANCE TO CLINICAL PRACTICE: Cultural differences in coping strategies and attitudes to gestational diabetes need to be considered. Training of staff working with gestational diabetes patients is urgently needed.

Swedish and Middle-Eastern-born women's beliefs about gestational diabetes.

OBJECTIVE: to compare beliefs about health and illness between women born in Sweden and the Middle East who developed gestational diabetes (GD). DESIGN: a qualitative, explorative study using semi-structured interviews. SETTING: in-hospital diabetes specialist clinic in Sweden. PARTICIPANTS: consecutive sample of women with GD; 13 born in Sweden and 14 born in the Middle East. MEASUREMENT AND FINDINGS: all the women described health as freedom from disease, and expressed worries for the baby's health and well-being. Women from the Middle East did not know the cause of GD, discussed the influence of social factors, such as being an immigrant, and supernatural factors, tried to adapt to the disease and thought it would disappear after birth, felt they had more pregnancy-related complications but had not received any treatment. Swedish women attributed GD to inheritance, environment and hormonal change, feared developing Type 2 diabetes, found work-related stress harmful to their health, more often sought help, used medications against pregnancy-related complications, and were more often on sick-leave from work. KEY CONCLUSIONS: Swedish women initiated a battle against GD, demanded medical treatment for pregnancy-related complications because of gainful employment and viewed pregnancy as a disease. Women from the Middle East temporarily adapted to the disease and perceived pregnancy and related problems as a natural part of life. IMPLICATIONS FOR PRACTICE: it is important to assess individual beliefs, risk awareness and to meet individual needs for information.