Machine learning uncovers the most robust self-report predictors of relationship quality across 43 longitudinal couples studies.

Given the powerful implications of relationship quality for health and well-being, a central mission of relationship science is explaining why some romantic relationships thrive more than others. This large-scale project used machine learning (i.e., Random Forests) to 1) quantify the extent to which relationship quality is predictable and 2) identify which constructs reliably predict relationship quality. Across 43 dyadic longitudinal datasets from 29 laboratories, the top relationship-specific predictors of relationship quality were perceived-partner commitment, appreciation, sexual satisfaction, perceived-partner satisfaction, and conflict. The top individual-difference predictors were life satisfaction, negative affect, depression, attachment avoidance, and attachment anxiety. Overall, relationship-specific variables predicted up to 45% of variance at baseline, and up to 18% of variance at the end of each study. Individual differences also performed well (21% and 12%, respectively). Actor-reported variables (i.e., own relationship-specific and individual-difference variables) predicted two to four times more variance than partner-reported variables (i.e., the partner's ratings on those variables). Importantly, individual differences and partner reports had no predictive effects beyond actor-reported relationship-specific variables alone. These findings imply that the sum of all individual differences and partner experiences exert their influence on relationship quality via a person's own relationship-specific experiences, and effects due to moderation by individual differences and moderation by partner-reports may be quite small. Finally, relationship-quality change (i.e., increases or decreases in relationship quality over the course of a study) was largely unpredictable from any combination of self-report variables. This collective effort should guide future models of relationships.

Positive illusions about dyadic perspective-taking as a moderator of the association between attachment insecurity and marital satisfaction.

Attachment insecurity (i.e., attachment anxiety or avoidance) puts people at risk for dissatisfying relationships. However, the dyadic regulation model of insecurity buffering suggests that an understanding and responsive partner may help insecure individuals to regulate emotions, thus improving couples' relationships. It may also be that perceiving partners as understanding and empathic, especially in an exaggeratedly positive way (i.e., positive illusions) will buffer insecurity. In 196 mixed-gender newlywed couples, we investigated whether spouses' positive illusions about partner's dyadic perspective-taking moderated the association between spouses' attachment insecurity and spouses' and partners' marital satisfaction over two years. Positive illusions generally predicted more satisfying relationships and attachment avoidance consistently predicted more dissatisfying relationships. There were also several instances where multilevel modeling indicated that positive illusions of dyadic perspective-taking buffered the negative effects of attachment avoidance on relationship satisfaction. However, there was also potentiation such that in two instances, positive illusions about dyadic perspective-taking strengthened the association between spouses' insecurity (husbands' attachment anxiety and wives' attachment avoidance) and subsequent marital dissatisfaction. In the moment, positive illusions about dyadic perspective-taking may allow spouses to feel happy in their relationship despite fear of emotional intimacy; however, positive illusions may not continue to buffer effects of insecurity on subsequent relationship satisfaction and may even be harmful in the face of insecurity.

Association Between Mobile App Use and Caregivers' Support System, Time Spent on Caregiving, and Perceived Well-being: Survey Study From a Large Employer.

BACKGROUND: Mobile technology to address caregiver needs has been on the rise. There is limited evidence of effectiveness of such technologies on caregiver experiences. OBJECTIVE: This study evaluates the effectiveness of ianacare, a mobile app, among employees of a large employer. ianacare mobilizes personal social circles to help with everyday tasks. Through the use of ianacare, we evaluate the associations between coordinating caregiving tasks among a caregiver's personal support network and outcomes related to the caregiver's support system, time use, perceived productivity, and perceived health and well-being. Caregiver tasks include tasks such as meal preparation, respite care, pet care, and transportation. Time use is the measure of a caregiver's time spent on caregiving tasks and how much time they had to take off from work to attend planned or unplanned caregiving tasks. METHODS: We conducted 2 surveys to assess within-participant changes in outcomes for the unpaid, employed, caregivers after 6 weeks of using the mobile app (n=176) between March 30, 2020, and May 11, 2020. The surveys contained questions in three domains: the caregiver's support system, time use and perceived productivity, and perceived health and well-being. The results of the linear probability models are presented below. RESULTS: App use was significantly associated with decreasing the probability of doing most caregiving tasks alone by 9.1% points (SE 0.04; P=.01) and increasing the probability of at least one person helping the primary caregiver by 8.0% points (SE 0.035; P=.02). App use was also associated with improving the time use of the primary caregiver who took significantly less time off work to attend to caregiving duties by 12.5% points (SE 0.04; P=.003) and decreased the probability of spending more than 30 hours weekly on caregiving by 9.1% points (SE 0.04; P=.02). Additional findings on the positive impact of the app included a decrease in the probability of reporting feeling overwhelmed by caregiving tasks by 12.5% points (SE 0.04; P=.003) and a decrease in the probability of reporting negative health effects by 6.8% points (SE 0.04; P=.07) because of caregiving. Although subjects reported that COVID-19 increased their stress attributed to caregiving and prevented them from requesting help for some caregiving tasks, using the app was still associated with improvements in receiving help and lessening of the negative effects of caregiving on the caregivers. CONCLUSIONS: App use was associated with improvements in 7 of 11 caregiver outcomes across three main categories: their support system, time spent on caregiving, and perceived health and well-being. These findings provide encouraging evidence that the mobile app can significantly reduce caregiver burden by leveraging a caregiver's support network despite the additional challenges brought by COVID-19 on caregivers.

Sexual Anxiety Mediates Dyadic Associations Between Body Satisfaction and Sexual Quality in Mixed-Sex Couples.

Body satisfaction predicts sexual quality among women and men; however, mechanisms of the association are largely unknown. We hypothesized that sexual anxiety would mediate average associations over 1 year between individuals' body satisfaction and their own and their partner's sexual quality, which is comprised of their sexual satisfaction and dissatisfaction, in 123 mixed-sex cohabiting couples. Results of Actor-Partner Interdependence Models extended to Mediation (APIMeM) and tested via multilevel modelling partially supported the hypotheses. Specifically, individuals' body satisfaction indirectly predicted their own and their partner's sexual satisfaction through individuals' sexual anxiety, and indirectly predicted their own, but not their partner's sexual dissatisfaction through individuals' sexual anxiety. Thus, when individuals are relatively less satisfied with their bodies, they may experience anxiety during sexual encounters, which then interferes with their own and their partner's sexual quality.

Body Satisfaction During Pregnancy: The Role of Health-Related Habit Strength.

Objectives Body satisfaction during pregnancy is an important determinant of maternal and fetal health outcomes. It is therefore critical to investigate factors related to changes in body satisfaction and to elucidate how body satisfaction changes over time in pregnant women. The purpose of this study was to examine the relation between two novel factors (i.e., healthy eating habit strength and physical activity habit strength) and body satisfaction during pregnancy. Methods Participants (n = 67 pregnant North American women) completed online questionnaires at the beginning of their second trimester (Time 1) and at the end of pregnancy. Maternal characteristics, relationship satisfaction, self-esteem, and psychological distress were assessed at Time 1 and habit strength, body satisfaction, and weight were assessed at both time points. Results Strength of healthy eating and physical activity habits remained stable over time and body satisfaction decreased over time. Healthy eating habit strength at Time 1 predicted increases in body satisfaction from the second trimester to the end of pregnancy, even when controlling for gestational weight gain. Conclusions This study suggests that health-related habit strength in women of reproductive age may offer protection against low levels of body satisfaction during pregnancy.

Alcohol-Attributable Medical Costs in Commercially Insured and Medicaid Populations.

Introduction: Despite its social acceptance, excessive alcohol use remains among the top causes of preventable deaths in the U.S. Although there is a recognition of alcohol-related health and social costs, there are no current studies quantifying the medical costs incurred under health plans. Methods: This study estimates the direct medical costs attributable to excessive alcohol use using claims records from a large national insurer. The sample consists of adults with commercial insurance and Medicaid between 2008 and 2019. A case-control matched study design is used to compare individuals with a condition considered 100% attributable to alcohol by the Centers for Disease Control and Prevention with similar individuals. Medical care use and costs are examined over a 12-month follow-up. Costs are broken down by healthcare setting and health conditions as defined by the Centers for Disease Control and Prevention's Alcohol-Related Disease Impact diagnoses codes. Results: We find that having a diagnosis attributable to alcohol is associated with higher annual per-person healthcare expenditures in both commercially insured and Medicaid-insured participants by $14,918 (95% CI=$14,540, $15,297) and $4,823 (95% CI=$4,489, $5,158), respectively. We find that 60%‒75% of the additional costs of excessive alcohol use are driven by heart disease and stroke; conditions of the liver, gallbladder, and pancreas; and certain cancers as well as acute conditions that may be attributable to alcohol. Conclusions: The findings suggest that public and private initiatives to target people vulnerable to the harms of excessive alcohol use may potentially help to cut down significant costs on the already strained healthcare system in the U.S.

Trends in Medically Integrated Dispensing Among Oncology Practices.

PURPOSE: The integration of pharmacies with oncology practices-known as medically integrated dispensing or in-office dispensing-could improve care coordination but may incentivize overprescribing or inappropriate prescribing. Because little is known about this emerging phenomenon, we analyzed historical trends in medically integrated dispensing. METHODS: Annual IQVIA data on oncologists were linked to 2010-2019 National Council for Prescription Drug Programs pharmacy data; data on commercially insured patients diagnosed with any of six common cancer types; and summary data on providers' Medicare billing. We calculated the national prevalence of medically integrated dispensing among community and hospital-based oncologists. We also analyzed the characteristics of the oncologists and patients affected by this care model. RESULTS: Between 2010 and 2019, the percentage of oncologists in practices with medically integrated dispensing increased from 12.8% to 32.1%. The share of community oncologists in dispensing practices increased from 7.6% to 28.3%, whereas the share of hospital-based oncologists in dispensing practices increased from 18.3% to 33.4%. Rates of medically integrated dispensing varied considerably across states. Oncologists who dispensed had higher patient volumes (P < .001) and a smaller share of Medicare beneficiaries (P < .001) than physicians who did not dispense. Patients treated by dispensing oncologists had higher risk and comorbidity scores (P < .001) and lived in areas with a higher % Black population (P < .001) than patients treated by nondispensing oncologists. CONCLUSION: Medically integrated dispensing has increased significantly among oncology practices over the past 10 years. The reach, clinical impact, and economic implications of medically integrated dispensing should be evaluated on an ongoing basis.

Prophylactic intranasal administration of a TLR2/6 agonist reduces upper respiratory tract viral shedding in a SARS-CoV-2 challenge ferret model.

BACKGROUND: The novel human coronavirus SARS-CoV-2 is a major ongoing global threat with huge economic burden. Like all respiratory viruses, SARS-CoV-2 initiates infection in the upper respiratory tract (URT). Infected individuals are often asymptomatic, yet highly infectious and readily transmit virus. A therapy that restricts initial replication in the URT has the potential to prevent progression of severe lower respiratory tract disease as well as limiting person-to-person transmission. METHODS: SARS-CoV-2 Victoria/01/2020 was passaged in Vero/hSLAM cells and virus titre determined by plaque assay. Challenge virus was delivered by intranasal instillation to female ferrets at 5.0 × 106 pfu/ml. Treatment groups received intranasal INNA-051, developed by Ena Respiratory. SARS-CoV-2 RNA was detected using the 2019-nCoV CDC RUO Kit and QuantStudio™ 7 Flex Real-Time PCR System. Histopathological analysis was performed using cut tissues stained with haematoxylin and eosin (H&E). FINDINGS: We show that prophylactic intra-nasal administration of the TLR2/6 agonist INNA-051 in a SARS-CoV-2 ferret infection model effectively reduces levels of viral RNA in the nose and throat. After 5 days post-exposure to SARS-CoV-2, INNA-051 significantly reduced virus in throat swabs (p=<0.0001) by up to a 24 fold (96% reduction) and in nasal wash (p=0.0107) up to a 15 fold (93% reduction) in comparison to untreated animals. INTERPRETATION: The results of our study support clinical development of a therapy based on prophylactic TLR2/6 innate immune activation in the URT, to reduce SARS-CoV-2 transmission and provide protection against COVID-19. FUNDING: This work was funded by Ena Respiratory, Melbourne, Australia.

Dose-dependent response to infection with SARS-CoV-2 in the ferret model and evidence of protective immunity.

There is a vital need for authentic COVID-19 animal models to enable the pre-clinical evaluation of candidate vaccines and therapeutics. Here we report a dose titration study of SARS-CoV-2 in the ferret model. After a high (5 × 106 pfu) and medium (5 × 104 pfu) dose of virus is delivered, intranasally, viral RNA shedding in the upper respiratory tract (URT) is observed in 6/6 animals, however, only 1/6 ferrets show similar signs after low dose (5 × 102 pfu) challenge. Following sequential culls pathological signs of mild multifocal bronchopneumonia in approximately 5-15% of the lung is seen on day 3, in high and medium dosed groups. Ferrets re-challenged, after virus shedding ceased, are fully protected from acute lung pathology. The endpoints of URT viral RNA replication & distinct lung pathology are observed most consistently in the high dose group. This ferret model of SARS-CoV-2 infection presents a mild clinical disease.

ChAdOx1 nCoV-19 protection against SARS-CoV-2 in rhesus macaque and ferret challenge models.

Vaccines against SARS-CoV-2 are urgently required, but early development of vaccines against SARS-CoV-1 resulted in enhanced disease after vaccination. Careful assessment of this phenomena is warranted for vaccine development against SARS CoV-2. Here we report detailed immune profiling after ChAdOx1 nCoV-19 (AZD1222) and subsequent high dose challenge in two animal models of SARS-CoV-2 mediated disease. We demonstrate in rhesus macaques the lung pathology caused by SARS-CoV-2 mediated pneumonia is reduced by prior vaccination with ChAdOx1 nCoV-19 which induced neutralising antibody responses after a single intramuscular administration. In a second animal model, ferrets, ChAdOx1 nCoV-19 reduced both virus shedding and lung pathology. Antibody titre were boosted by a second dose. Data from these challenge models on the absence of enhanced disease and the detailed immune profiling, support the continued clinical evaluation of ChAdOx1 nCoV-19.

Immunological and pathological outcomes of SARS-CoV-2 challenge following formalin-inactivated vaccine in ferrets and rhesus macaques.

There is an urgent requirement for safe and effective vaccines to prevent COVID-19. A concern for the development of new viral vaccines is the potential to induce vaccine-enhanced disease (VED). This was reported in several preclinical studies with both SARS-CoV-1 and MERS vaccines but has not been reported with SARS-CoV-2 vaccines. We have used ferrets and rhesus macaques challenged with SARS-CoV-2 to assess the potential for VED in animals vaccinated with formaldehyde-inactivated SARS-CoV-2 (FIV) formulated with Alhydrogel, compared to a negative control vaccine. We showed no evidence of enhanced disease in ferrets or rhesus macaques given FIV except for mild transient enhanced disease seen 7 days after infection in ferrets. This increased lung pathology was observed at day 7 but was resolved by day 15. We also demonstrate that formaldehyde treatment of SARS-CoV-2 reduces exposure of the spike receptor binding domain providing a mechanistic explanation for suboptimal immunity.

Comparison of rhesus and cynomolgus macaques as an infection model for COVID-19.

A novel coronavirus, SARS-CoV-2, has been identified as the causative agent of the current COVID-19 pandemic. Animal models, and in particular non-human primates, are essential to understand the pathogenesis of emerging diseases and to assess the safety and efficacy of novel vaccines and therapeutics. Here, we show that SARS-CoV-2 replicates in the upper and lower respiratory tract and causes pulmonary lesions in both rhesus and cynomolgus macaques. Immune responses against SARS-CoV-2 are also similar in both species and equivalent to those reported in milder infections and convalescent human patients. This finding is reiterated by our transcriptional analysis of respiratory samples revealing the global response to infection. We describe a new method for lung histopathology scoring that will provide a metric to enable clearer decision making for this key endpoint. In contrast to prior publications, in which rhesus are accepted to be the preferred study species, we provide convincing evidence that both macaque species authentically represent mild to moderate forms of COVID-19 observed in the majority of the human population and both species should be used to evaluate the safety and efficacy of interventions against SARS-CoV-2. Importantly, accessing cynomolgus macaques will greatly alleviate the pressures on current rhesus stocks.

Marital satisfaction across the transition to parenthood.

The purpose of the present study was to discriminate between the 2 dominant perspectives governing research on the nature of marital change over the transition to parenthood. Progress can be made in understanding this transition by recognizing the role of uncontrolled sources of variability in research designs, defining and using control groups, and timing of data collection around the child's arrival, and the authors conducted a study incorporating these methodological refinements. Growth curve analyses were conducted on marital satisfaction data collected twice before and twice after the birth of the 1st child and at corresponding points for voluntarily childless couples (N = 156 couples). Spouses who were more satisfied prior to pregnancy had children relatively early in marriage, and parents experienced greater declines in marital satisfaction compared to nonparents. Couples with planned pregnancies had higher prepregnancy satisfaction scores, and planning slowed husbands' (but not wives') postpartum declines. In sum, parenthood hastens marital decline--even among relatively satisfied couples who select themselves into this transition--but planning status and prepregnancy marital satisfaction generally protect marriages from these declines.

Reciprocal Effects of Life Satisfaction and Depressive Symptoms Within Long-Wed Couples Over Time.

Objectives: This study was undertaken to examine bidirectional effects of well-being over time in long-wed couples. Method: We recruited 125 couples 50+ years of age who had been married 20+ years. Both spouses reported life satisfaction and depressive symptoms independently at three annual points over 2 years. We computed actor-partner interdependence models (APIMs) to identify concomitant and longitudinal bidirectional effects between long-wed spouses. Where parallel associations were found between models of life satisfaction and depressive symptoms, we undertook invariance analyses to compare the relative strength of associations. Results: We observed a significant association between wives' and their husbands' life satisfaction at baseline; a concomitant crossover effect was also evident from wives to husbands at 1- and 2-year follow-up, such that wives' life satisfaction predicted changes in their husbands' life satisfaction beyond that previously and concomitantly reported. Discussion: Our findings suggest that older wives influence their husbands after decades of marriage; the relative effect of this crossover on older husbands is comparatively equivalent for life satisfaction and depressive symptoms. These findings stand in contrast to prior research with younger couples suggesting that long-wed couples may be a distinct subset of the population of all married couples (i.e., those who have not divorced).

Prenatal expectations and marital satisfaction over the transition to parenthood.

Associations among prenatal expectations, the extent to which expectations were confirmed or disconfirmed, and trajectories of marital satisfaction over the transition to parenthood were assessed 7-11 times in a sample of newlywed couples. Piecewise growth curve analyses were conducted to examine levels of marital satisfaction at the beginning of marriage and rates of change over 2 periods: from the beginning of marriage through the 3rd trimester of pregnancy and from the 3rd trimester of pregnancy through 18 months postpartum. Postpartum marital decline was greater than decline from marriage through pregnancy. Spouses who were more satisfied at the beginning of marriage reported higher expectations. There was marked variability in the extent to which prenatal expectations were confirmed; some expectations were unfulfilled, others were met, and still others were surpassed. Associations between the extent to which expectations were confirmed and rates of change in marital decline differed as a function of the specific type of expectation. Implications for understanding vulnerability and resiliency in couples negotiating the transition to parenthood are discussed.

Recruitment and selection of couples for intervention research: achieving developmental homogeneity at the cost of demographic diversity.

Demographic and relationship quality data were collected from 704 individuals recruited to participate in a randomized study of relationship enhancing interventions. Recruiting at bridal shows produced partners who were more satisfied, earlier in their relationships, and less likely to be parents, with a marginally higher proportion of Latino couples. Radio and television coverage produced more established couples with higher levels of relationship discord. Self-selection effects revealed that couples from demographic groups at greater risk for divorce (those who had not completed high school, those with children at marriage, and African American couples) were more likely to agree to participate. In contrast, imposing a set of common selection criteria served to exclude couples from demographic risk groups and selected for couples with higher marital quality. Implications for recruiting couples to participate in preventive interventions are outlined.

The role of interpersonal conflict and perceived social support in nonsuicidal self-injury in daily life.

Although accumulating microlongitudinal research has examined emotion regulatory models of nonsuicidal self-injury (NSSI), few studies have examined how interpersonal contingencies influence daily NSSI behavior. Participants with repeated NSSI (N = 60) provided daily ratings of perceived social support, interpersonal conflict, and NSSI urges and behaviors for 14 days. Consistent with interpersonal models of NSSI, we hypothesized that participants would be more likely to engage in NSSI on days when they experienced high levels of interpersonal conflict, that NSSI acts that were revealed to others would be followed by desirable interpersonal changes (i.e., greater support, less conflict), and that these interpersonal changes would, in turn, predict stronger NSSI urges and more frequent NSSI behavior. Consistent with hypotheses, daily conflict was associated with stronger same-day NSSI urges and greater likelihood of NSSI acts. Perceived support increased following NSSI acts that had been revealed to others, but not unrevealed NSSI acts. This perceived support was, in turn, associated with a stronger NSSI urges and greater likelihood of engaging in NSSI on the following day. Moreover, participants whose NSSI was revealed to others engaged in more total NSSI acts during the diary period than those whose NSSI was not revealed to others. Inconsistent with hypotheses, interpersonal conflict did not decrease following NSSI, regardless of whether or not these acts were revealed to others. Together, these results provide preliminary support for interpersonal reinforcement models of NSSI and highlight the importance of expanding research in this area to include interpersonal contingencies that may influence this behavior. (PsycINFO Database Record

Registered Replication Report: Study 1 From Finkel, Rusbult, Kumashiro, & Hannon (2002).

Finkel, Rusbult, Kumashiro, and Hannon (2002, Study 1) demonstrated a causal link between subjective commitment to a relationship and how people responded to hypothetical betrayals of that relationship. Participants primed to think about their commitment to their partner (high commitment) reacted to the betrayals with reduced exit and neglect responses relative to those primed to think about their independence from their partner (low commitment). The priming manipulation did not affect constructive voice and loyalty responses. Although other studies have demonstrated a correlation between subjective commitment and responses to betrayal, this study provides the only experimental evidence that inducing changes to subjective commitment can causally affect forgiveness responses. This Registered Replication Report (RRR) meta-analytically combines the results of 16 new direct replications of the original study, all of which followed a standardized, vetted, and preregistered protocol. The results showed little effect of the priming manipulation on the forgiveness outcome measures, but it also did not observe an effect of priming on subjective commitment, so the manipulation did not work as it had in the original study. We discuss possible explanations for the discrepancy between the findings from this RRR and the original study.

Relationship education and marital satisfaction in newlywed couples: A propensity score analysis.

The purpose of this study was to investigate whether premarital relationship education and characteristics of relationship education in a community sample of newlywed couples predicted marital trajectories over 27 months. Newlywed couples (N = 191) completed measures of marital satisfaction 9 times over 27 months, and prior to marriage they provided information about relationship education and demographic, personal, and relationship risk factors for marital distress. Propensity scores (i.e., the probability of receiving relationship education) were estimated using the marital distress risk factors, and used to derive a matched sample of 72 couples who participated in relationship education and 86 couples who did not. Multilevel analyses of the propensity score matched sample (n = 158) indicated that wives who participated in relationship education had declines in marital satisfaction while wives who did not receive relationship education maintained satisfaction over time. Furthermore, the more hours of relationship education the couple participated in, the less steeply their marital satisfaction declined. Findings indicate that participation in community-based relationship education may not prevent declines in marital satisfaction for newlywed couples. A possible explanation is that the quality of relationship education available to couples is generally poor and could be greatly improved by inclusion of empirically based relationship information and skills training that are known to lead to stronger marriages.

Risk moderates the outcome of relationship education: a randomized controlled trial.

OBJECTIVE: To test whether the effects of relationship education programs generalize across couples regardless of their baseline levels of risk for relationship distress, or whether intervention effects vary systematically as a function of risk. The former result would support primary prevention models; the latter result would support a shift toward secondary prevention strategies. METHOD: Engaged and newlywed couples (N = 130) were randomized into 1 of 3 relationship education programs. Individual and relational risk factors assessed at baseline were tested as moderators of 3-year changes in relationship satisfaction, overall and in each of the 3 treatment conditions. RESULTS: Treatment effects varied as a function of risk, and more so with variables capturing relational risk factors than individual risk factors. High-risk couples (e.g., couples with lower levels of baseline commitment and satisfaction) tended to decline less rapidly in satisfaction than low-risk couples following treatment. Couples with acute concerns at baseline, including higher levels of physical aggression and alcohol use, benefitted less from intervention than couples without these concerns. Comparisons across treatment conditions indicate that couples with relatively high baseline satisfaction and commitment scores declined faster in satisfaction when assigned to an intensive skill-based intervention, as compared with a low-intensity intervention. CONCLUSIONS: Outcomes of skill-based relationship education differ depending on premarital risk factors. Efficient identification of couples at risk for adverse relationship outcomes is needed to refine future prevention efforts, and deploying prevention resources specifically to at-risk populations may be the most effective strategy for strengthening couples and families.