Characteristics Associated with Relationship-Centred and Task-Focused Mealtime Practices in Older Adult Care Settings.

Purpose: To assess care home and staff characteristics associated with task-focused (TF) and relationship-centred care (RCC) mealtime practices prior to the COVID-19 pandemic.Methods: Staff working in Canadian and American care homes were invited to complete a 23-item online survey assessing their perceptions of mealtime care, with one item assessing 26 potential care practices from the Mealtime Relational Care Checklist (relationship-centred = 15; task-focused = 11) reported to occur in the home prior to the pandemic. Multivariate linear regression evaluated staff and care home characteristics associated with mealtime practices.Results: Six hundred and eighty-six respondents completed all questions used in this analysis. Mean TF and RCC mealtime practices were 4.89 ± 1.99 and 9.69 ± 2.96, respectively. Staff age was associated with TF and RCC practices with those 40-55 years reporting fewer TF and those 18-39 years reporting fewer RCC practices. Those providing direct care were more likely to report TF practices. Dissatisfaction with mealtimes was associated with more TF and fewer RCC practices. Homes that were not making changes to promote RCC pre-pandemic had more TF and fewer RCC practices. Newer care homes were associated with more RCC, while small homes (≤49 beds) had more TF practices.Conclusions: Mealtime practices are associated with staff and home factors. These factors should be considered in efforts to improve RCC practices in Canadian homes.

Resources to Support Decision-Making Regarding End-of-Life Nutrition Care in Long-Term Care: A Scoping Review.

Resources are needed to aid healthcare providers and families in making end-of-life nutrition care decisions for residents living in long-term care settings. This scoping review aimed to explore what is reported in the literature about resources to support decision-making at the end of life in long-term care. Four databases were searched for research published from 2003 to June 2023. Articles included peer-reviewed human studies published in the English language that reported resources to support decision-making about end-of-life nutrition in long-term care settings. In total, 15 articles were included. Thematic analysis of the articles generated five themes: conversations about care, evidence-based decision-making, a need for multidisciplinary perspectives, honouring residents' goals of care, and cultural considerations for adapting resources. Multidisciplinary care teams supporting residents and their families during the end of life can benefit from resources to support discussion and facilitate decision-making.

"Nobody but a family member can do it quite the same way": Understanding the meaning of mealtimes to residents and families in long-term care homes during the pandemic.

BACKGROUND AND OBJECTIVES: Meals in long term care (LTC) are essential to residents not only for nutrition and their physical well-being, but also for their social interactions supporting resident quality of life. This study aims to understand the mealtime experiences of residents and family care partners during the COVID-19 pandemic when restrictions were put in place in LTC and retirement homes. RESEARCH DESIGN AND METHODS: Interpretive description analysis of qualitative interviews in LTC and retirement homes, with 17 family care partners and 4 residents. Convenience and snowball sampling used to recruit participants for telephone interviews. RESULTS: Three themes were generated. Compromised mealtimes mean compromising community - meals were seen by participants as a key social and community-building event of the home; they reported this loss of community with pandemic restrictions. Participants noted that Family care partners are indispensable at meals for social, psychological and physical support. The dangers of eating alone spoke to the social isolation reported by participants that occurred during the pandemic and the risks they described of eating alone. DISCUSSION AND IMPLICATIONS: This study confirms the importance of mealtimes in LTC and retirement homes to community building and extends our understanding of the importance of family inclusion at meals and why eating alone, as happened during COVID-19, was so detrimental to residents. Effort needs to be made to value this communal activity for the well-being of residents.

Multi-Level Factors Associated with Relationship-Centred and Task-Focused Mealtime Practices in Long-Term Care: A Secondary Data Analysis of the Making the Most of Mealtimes Study.

Mealtimes in long-term care (LTC) can reinforce relationships between staff and residents through relationship-centred care (RCC) practices; however, meals are often task-focused (TF). This cross-sectional study explores multi-level contextual factors that contribute to RCC and TF mealtime practices. Secondary data from residents in 32 Canadian LTC homes were analyzed (n = 634; mean age 86.7 ± 7.8; 31.1% male). Data included resident health record review, standardized mealtime observation tools, and valid questionnaires. A higher average number of RCC (9.6 ± 1.4) than TF (5.6 ± 2.1) practices per meal were observed. Multi-level regression revealed that a significant proportion of variation in the RCC and TF scores was explained at the resident- (intraclass correlation coefficient [ICC]RCC = 0.736; ICCTF = 0.482), dining room- (ICCRCC = 0.210; ICCTF = 0.162), and home- (ICCRCC = 0.054; ICCTF = 0.356) levels. For-profit status and home size modified the associations between functional dependency and practices. Addressing multi-level factors can reinforce RCC practices and reduce TF practices.

Weight Loss and Weight Gain: Multi-Level Determinants Associated with Resident 3-Month Weight Change in Long-Term Care.

This study examined factors associated with weight change in 535 residents in 32 long term care homes where 3-month weight records were available. Trained researchers and standardized measures (e.g., nutrition status, food intake, home characteristics) were used to collect data; weight change was defined as ±2.5%. Just over 25% of the sample lost and 21% gained weight. Weight stability was compared to loss or gain. Weight loss was associated with being male, malnourished (MNA-SF or BMI <25), energy and protein intake and oral nutritional supplement use, while weight gain was associated with being female, and a physically (e.g., less noise) and socially supportive dining room. Weight stability was associated with better cognition. A high proportion of residents had a significant weight change in 3 months. Modifiable factors associated with weight stability or gain suggest focusing interventions that promote food intake and improve the mealtime environment.

Body Satisfaction and Associated Predictors Among Baby Boomer Women in Rural and Urban Manitoba.

Purpose: This study examines body satisfaction, weight attitudes, dieting behaviours, and aging concerns of baby boomer women (BBW; born 1946-1965) from rural and urban Manitoba.Methods: Primary data collection occurred November 2015, and 1083 participants completed the Body Image and Food Choice Survey. Four strata of BBW were represented to examine differences between older and younger BBW and location of residence. Multinomial logistic regression models were fit to determine predictors of weight and appearance satisfaction. Odds ratios and 95% confidence intervals were considered significant at p ≤ 0.05.Results: Fifty-three percent of participants were satisfied with their appearance, whereas only 34% were satisfied with their weight. Ninety-one percent desired to lose weight (29.9 ± 29.3 lbs). Aging anxiety was evident for 46% of participants and associated with appearance satisfaction (χ2 = 27.46, df = 4, p < 0.001). Body work and dieting behaviours were used to mitigate body dissatisfaction, and media influence was associated with both appearance (χ2 = 76.17, df = 6, p < 0.001) and weight satisfaction (χ2 = 67.90, df = 6, p < 0.001). Desired weight change, appearance stress, appearance importance, and self-rated health predicted both weight and appearance satisfaction.Conclusions: There is a need for greater awareness of aging women's body image concerns and the need for age-appropriate tools/resources to help dietitians support women achieve a healthy body image.

Connecting Through Conversation: A Novel Video-Feedback Intervention to Enhance Long-Term Care Aides' Person-Centred Dementia Communication.

Objective: To pilot test a novel communication intervention incorporating a video-feedback component on the person-centred dementia communication skills of long-term care aides. Methods: Effectiveness was assessed using a single group pre-test/post-test design. 11 care aide-resident dyads participated in the study. Objective outcomes included provider statements demonstrating linguistic (i.e., reciprocity, clarity/coherence, and continuity categories) and relational elements of person-centred dementia communication, measured via video-recorded observations of usual care interactions. Subjective outcomes of care aide communication confidence/competence, satisfaction with the resident relationship, relationship closeness, and self-reflection at work were measured using self-report questionnaires. Results: In respect to observed person-centred dementia communication skills, there was an increase in the use of linguistic statements in the reciprocity and continuity categories, as well as total linguistic statements overall. Relational statements and overall person-centred dementia communication (i.e., linguistic plus relational strategies) increased. Care aide-reported communication confidence and competence, relationship closeness with the resident, and self-reflection at work also increased after the communication intervention. Discussion: The communication intervention showed promise as an effective approach to enhance person-centred dementia communication behaviours in care aides. These results support undertaking a larger trial to examine the intervention's effectiveness more fulsomely.

Expanding the conversation: A Person-centred Communication Enhancement Model.

The intricacy and impact of human communication has long captured the attention of philosophers, scholars and practitioners. Within the realm of care and service provision, efforts to maximize outcomes through optimal person-provider communication have drawn research and clinical focus to this area for several decades. With the dawning of the person-centred care movement within healthcare, and in particular long-term care home and dementia care settings, improvement in care providers' use of person-centred communication strategies and enhancement of relationships between residents, their families and care providers are desired outcomes. Thus, several person-centred care and communication theoretical perspectives have been employed to ground study in this field. However, a comprehensive theoretical position to underpin person-centred communication in dementia and older adult research does not exist to our knowledge. To offer expansion to the theoretical work in this emerging field, a Person-Centred Communication Enhancement Model for long-term care and dementia care is proposed, as well as rationale for its development. This discussion will also provide an overview and critique of the extant philosophies, theories, frameworks and models that have been utilized in the study of person-centred communication within the context of long-term care and dementia care.

Qualitative analysis of a virtual research meeting summarises expert-based strategies to promote hydration in residential care during COVID-19 and beyond.

OBJECTIVES: Poor fluid intake is a complex and long-standing issue in residential care, further exacerbated by COVID-19 infection control procedures. There is no consensus on how best to prevent dehydration in residents who vary in their primary reasons for insufficient fluid intake for a variety of reasons. The objectives of this research were to determine expert and provider perspectives on: (1) how COVID-19 procedures impacted hydration in residential care and potential solutions to mitigate these challenges and (2) strategies that could target five types of residents based on an oral hydration typology focused on root causes of low fluid intake. DESIGN: Qualitative study based on virtual group discussion. The discussion was audiorecorded with supplementary field notes. Qualitative content analysis was completed. SETTING: Residential care. PARTICIPANTS: 27 invited researcher and provider experts. RESULTS: Challenges that have potentially impacted hydration of residents because of COVID-19 procedures were categorised as resident (eg, apathy), staff (eg, new staff) and home-related (eg, physical distancing in dining rooms). Potential solutions were offered, such as fun opportunities (eg, popsicle) for distanced interactions; training new staff on how to approach specific residents and encourage drinking; and automatically providing water at meals. Several strategies were mapped to the typology of five types of residents with low intake (eg, sipper) and categorised as: supplies (eg, vessels with graduated markings), timing (eg, identify best time of day for drinking), facility context (eg, identify preferred beverages), socialisation (eg, promote drinking as a social activity) and education (eg, educate cognitively well on water consumption goals). CONCLUSIONS: COVID-19 has necessitated new procedures and routines in residential care, some of which can be optimised to promote hydration. A variety of strategies to meet the hydration needs of different subgroups of residents can be compiled into multicomponent interventions for future research.

Feasibility and Acceptability Testing of Evidence-Based Hydration Strategies for Residential Care.

The current study examined stakeholder perspectives on the perceived effectiveness, feasibility, and acceptability of 20 evidence-based strategies appropriate for residential care via an online survey (N = 162). Most participants worked in long-term care (83%), were direct care providers (62%), worked in food/nutrition roles (55%), and identified as female (94%). Strategies that were rated as effective, feasible, and likely to be used in the future were social drinking events, increased drink options at meals, and pre-thickened drinks. Participants also listed their top strategies for inclusion in a multicomponent intervention. Responses to open-ended questions provided insight on implementation, compliance, and budget constraints. Participant perspectives provide insight into developing a multicomponent intervention. Strategies prioritized for such an intervention include: staff education, social drinking opportunities, drinks trolley, volunteer support, improved beverage availability, hydration reminders, offering preferred beverages, and prompting residents to drink using various cues. [Research in Gerontological Nursing, 15(1), 27-38.].

Making the Most of Mealtimes (M3): Association Between Relationship-Centered Care Practices, and Number of Staff and Residents at Mealtimes in Canadian Long-Term Care Homes.

OBJECTIVES: To determine if (1) number of staff or residents, when considering home-level factors and presence of family/volunteers, are associated with relationship-centered care practices at mealtimes in general and dementia care units in long-term care (LTC); and (2) the association between number of staff and relationship-centered care is moderated by number of residents and family/volunteers, profit status or chain affiliation. DESIGN: Secondary analysis of the Making the Most of Mealtimes (M3) cross-sectional multisite study. SETTING AND PARTICIPANTS: Thirty-two Canadian LTC homes (Alberta, Manitoba, Ontario, and New Brunswick) and 639 residents were recruited. Eighty-two units were included, with 58 being general and 24 being dementia care units. METHODS: Trained research coordinators completed the Mealtime Scan (MTS) for LTC at 4 to 6 mealtimes in each unit to determine number of staff, residents, and family or volunteers present. Relationship-centered care was assessed using the Mealtime Relational Care Checklist. The director of care or food services manager completed a home survey describing home sector and chain affiliation. Multivariable analyses were stratified by type of unit. RESULTS: In general care units, the number of residents was negatively (P = .009), and number of staff positively (P < .001) associated with relationship-centered care (F9,48 = 5.48, P < .001). For dementia care units, the associations were nonsignificant (F5,18 = 2.74, P = .05). The association between staffing and relationship-centered care was not moderated by any variables in either general or dementia care units. CONCLUSION AND IMPLICATIONS: Number of staff in general care units may increase relationship-centered care at mealtimes in LTC. Number of residents or staff did not significantly affect relationship-centered care in dementia care units, suggesting that other factors such as additional training may better explain relationship-centered care in these units. Mandating minimum staffing and additional training at the federal level should be considered to ensure that staff have the capacity to deliver relationship-centered care at mealtimes, which is considered a best practice.

Hungry for more: Low resident social engagement is indirectly associated with poor energy intake and mealtime experience in long-term care homes.

Mealtimes in long-term care (LTC) homes provide social engagement and nutritional intake to residents. Psychosocial challenges may detract from the mealtime experience, resulting in low food intake and increased risk of malnutrition. This study explores the independent effects of psychosocial factors on energy intake among LTC residents. Secondary data (Making the Most of Mealtimes [M3]) from residents in 32 Canadian LTC homes were analyzed. Data included 3-day weighed food intake, mealtime care actions taken by staff, loss of appetite, eating challenges, and other resident characteristics. Psychosocial factors (i.e., social engagement, depression, and aggressive behaviours) were measured using standardized scales. The independent effects of psychosocial factors on energy intake were tested using bivariate and linear regression analyses adjusted for loss of appetite, eating challenges, and demographic characteristics. The final sample included 604 residents (mean age = 86.8 ± 7.8 years; 31.8% male). Of the three psychosocial factors, only social engagement was associated with energy intake. Low social engagement was associated with cognitive and functional challenges, malnutrition risk, more task-focused mealtime actions by staff, and lower energy intake. Simple regression analysis revealed that individuals with low social engagement ate 59.6 kcal less per day (95% CI = -111.2, -8.0). This significant association remained when adjusting for loss of appetite, but was no longer significant when adjusting for eating challenges. Low social engagement occurs concurrently with physical and functional challenges among LTC residents, affecting both the nutritional and social aspects of mealtimes. Emphasis on socializing during mealtimes, especially for those with eating challenges (e.g., requiring assistance), may contribute to improved resident appetite and quality of life.

Family member eating assistance and food intake in long-term care: A secondary data analysis of the M3 Study.

AIM: To determine if protein and energy intake is significantly associated with a family member providing eating assistance to residents in long-term care homes as compared with staff providing this assistance, when adjusting for other covariates. BACKGROUND: Who provides eating support has the potential to improve resident food intake. Little is known about family eating assistance and if this is associated with resident food intake in long-term care. DESIGN: Cross-sectional, secondary data analysis. METHODS: Between October and January 2016, multilevel data were collected from 32 long-term care homes across four Canadian provinces. Data included 3-day weighed/observed food intake, mealtime observations, physical dining room assessments, health record review, and staff report of care needs. Residents where family provided eating assistance were compared with residents who received staff-only assistance. Regression analysis determined the association of energy and protein intake with family eating assistance versus staff assistance while adjusting for covariates. RESULTS: Of those residents who required any physical eating assistance (N = 147), 38% (N = 56) had family assistance during at least one of nine meals observed. Residents who received family assistance (N = 56) and those who did not (N = 91) were statistically different in several of their physiological eating abilities. When adjusting for covariates, family assistance was associated with significantly higher consumption of protein and energy intake. CONCLUSION: Energy and protein intake is significantly higher when family provides eating assistance. Family are encouraged to provide this direct care if it is required. IMPACT: Residents who struggle with independent eating can benefit from dedicated support during mealtimes. Findings from this study provide empirical evidence that family eating assistance is associated with improved resident food intake and provides strong justification to encourage families to be active partners in the care and well-being of their relatives. Home administrators and nursing staff should support the specialized care that families can provide at mealtimes.

Are Therapeutic Diets in Long-Term Care Affecting Resident Food Intake and Meeting their Nutritional Goals?

Purpose: To examine health characteristics of long-term care (LTC) residents prescribed therapeutic diets (promoting or restricting intake of key food components), to determine how these diets influenced intake and whether there were differences in food intake and malnutrition risk between residents with and without restrictive diets.Methods: Secondary analysis of the Making the Most of Mealtimes Study includes 435 residents with no/mild cognitive impairment in 32 LTC homes across 4 provinces. Health records were reviewed for diet prescriptions and other characteristics. Weighed and observed food and fluid consumption over 3 nonconsecutive days determined intake. Bivariate and multivariable linear regressions identified associations between therapeutic diets and intake and key nutrients.Results: Almost half (42%) of participants were prescribed a therapeutic diet. Residents receiving restrictive diets (28%) consumed absolute calories consistent with those receiving a regular diet, but kcal/kg was significantly lower (22.1 ± 5.5 vs 23.6 ± 5.3). Low sodium and weight-promoting diets were the only therapeutic diets associated with their corresponding key nutrient profiles. Restrictive therapeutic diets were not associated with energy or protein intake when adjusting for covariates.Conclusions: Restrictive therapeutic diets among those with mild to no cognitive deficits do not appear to impair food intake.

Video feedback: A novel application to enhance person-centred dementia communication.

AIM: A discussion of the use of video feedback as an effective and feasible method to promote person-centred communication approaches within dementia care and long-term care. BACKGROUND: Effective strategies to integrate person-centred approaches into health care settings have attracted global attention and research in the past two decades. Video feedback has emerged as technique to enhance reflective learning and person-centred practice change in some care settings; however, it has not been tested in the context of person-centred dementia communication in long-term care. DESIGN: Discussion paper. DATA SOURCES: Articles dating from 1995 to 2018 retrieved via searches of the SCOPUS, CINAHL, MEDLINE and Cochrane Systematic Review databases. IMPLICATIONS FOR NURSING: Inclusion of video feedback in a person-centred dementia communication intervention for nurses and other health care providers may effectively fill a gap evident in the literature. This intervention can offer feedback of enhanced quality and enduring impact on behaviour change relative to traditional training. CONCLUSION: A critical review of empirical and theoretical evidence supports video feedback as a potential means to enhance person-centred communication within the context of dementia and long-term care. The promising benefits of video feedback present a novel research opportunity to pilot its use to enhance person-centred communication between nurses/health care providers and persons with dementia in long-term care.

The association of eating challenges with energy intake is moderated by the mealtime environment in residential care homes.

OBJECTIVES: Given the increased risk of malnutrition in residential care homes, we studied how specific aspects of the mealtime environment are associated with residents' eating challenges and energy intake in general and dementia care units of these homes. DESIGN: Cross-sectional study. PARTICIPANTS: 624 residents and 82 dining rooms. SETTING: 32 residential care homes across Canada. MEASUREMENTS: Eating challenges were measured using the Edinburgh Feeding Evaluation in Dementia Questionnaire (Ed-FED-q). Energy intake was estimated over nine meals. Physical, social, person-centered, functional, and homelike aspects of the mealtime environment were scored using standardized, valid measures. Effects of interactions between dining environment scores and eating challenges on daily energy intake were assessed using linear regression. RESULTS: More eating challenges were associated with decreased energy intake on the general (ß = -36.5, 95% confidence interval [CI] = -47.8, -25.2) and dementia care units (ß = -19.9, 95% CI = -34.6, -5.2). Among residents living on general care units, the functional (ß = 48.5, 95% CI = 1.8, 95.2) and physical (ß = 56.9, 95% CI = 7.2, 106.7) environment scores were positively and directly associated with energy intake; the social and person-centered aspects of the mealtime environment moderated the relationship between eating challenges and energy intake. CONCLUSIONS: Resident eating challenges were significantly associated with energy intake on both dementia care and general care units; however on general care units, when adjusting for eating challenges, the functional and physical aspects of the environment also had a direct effect on energy intake. Furthermore, the social and person-centered aspects of the dining environment on general care units moderated the relationship between eating challenges and energy intake. Dementia care unit environments had no measurable effect on the association between resident eating challenges and energy intake.

Provincial Differences in Long-Term Care Menu Variety and Food Intake for Residents who Consume a Regular Texture.

Purpose: To determine regular-texture menu variety offered in Canadian long-term care (LTC) homes and its association with residents' food intake. Methods: Twenty-nine LTC menus from Alberta, Manitoba, New Brunswick, and Ontario were analyzed. Items offered during the regular-texture menu cycle were categorized according to Eating Well with Canada's Food Guide food groups and variety scores were calculated per day and per week. Residents' food intake was assessed by weighing and observing intake over 3 nonconsecutive days. Diet quality was determined using a mean adequacy ratio score (MAR) for regular and soft and bite-sized consumers (n = 394). Results: Average daily and weekly menu variety scores were 24 ± 5.8 and 78 ± 17.2, respectively, with significantly higher scores in Ontario (29 ± 2.7 and 102 ± 11.7). Of all the food groups, only the variety score for the "Other" food category was positively associated with protein intake. No associations were observed between variety and energy intake or MAR score. Conclusion: This study is the first in Canada to assess LTC menu variety. Although there was variability between provinces in menu variety, this was not associated with resident diet quality or intake.

Construct Validation of the Mealtime Relational Care Checklist for Individual Resident Use in Long-Term Care.

BACKGROUND AND PURPOSE: To determine the construct validity of the Mealtime Relational Care Checklist (M-RCC) when used with individual residents. METHODS: Data was collected from 639 residents from 32 long-term care homes; M-RCC was completed at three meals for each resident and averaged. Bivariate analyses determined associations between the M-RCC and other resident level and dining room level measures. RESULTS: Resident M-RCC was positively and significantly (p < .05) associated with three of five summary scales from Dining Environment Audit Protocol and Meal Time Scan as well as resident malnutrition risk (rs = 0.23). M-RCC was negatively associated with protein intake (gram per kilogram body weight; rs = -0.13) and Cognitive Performance Score (t-value = 4.48). CONCLUSIONS: The resident level M-RCC was significantly associated with other measures in expected directions demonstrating construct validity.

Prevalence of Malnutrition or Risk in Residents in Long Term Care: Comparison of Four Tools.

The ideal tool for determination of malnutrition risk or malnutrition in long term care (LTC) is elusive. This study compares prevalence, association with resident risk factors and sensitivity (SE) and specificity (SP) of malnutrition or risk categorization in 638 residents from 32 LTC homes in Canada using four tools: the Mini-Nutritional Assessment Short Form (MNA-SF); Patient-Generated Subjective Global Assessment (PG-SGA) Global Category Rating and the Pt-Global webtool; and the interRAI Long Term Care Facility undernutrition trigger. Prevalence was most common with MNA-SF (53.7%) and lowest with InterRAI (28.9%), while the PG-SGA Global Category Rating (44%) was higher than the Pt-Global webtool (33.4%). Tools were consistently associated with resident covariates with few exceptions. The PG-SGA Global Category Rating demonstrated the best sensitivity and specificity when compared to all other tools. Further work to determine the predictive validity of this tool in LTC residents is required.

Resident and Staff Mealtime Actions and Energy Intake of Long-Term Care Residents With Cognitive Impairment: Analysis of the Making the Most of Mealtimes Study.

Long-term care (LTC) residents with cognitive impairment (CI) are at increased risk of malnutrition, often explained by mealtime actions (e.g., resident eating challenges, staff actions with eating assistance). The purpose of the current study was to examine the association between mealtime actions and energy intake of LTC residents with CI. Participants with CI (N = 353) from 32 LTC in four provinces were included. Mealtime actions were assessed using the Relational Behavioural Scale, Edinburgh Feeding Evaluation in Dementia (Ed-FED), nine additional eating challenges, and the Mealtime Relational Care Checklist. Several eating challenges (e.g., refusal to eat, turning head away) were associated with poor energy intake. Adjusting for age and sex, partial eating assistance and total Ed-FED score were associated with poor intake, whereas dysphagia risk and often receiving assistance were associated with better intake. Interventions to support eating independence and address residents' eating challenges in LTC are needed to improve their intakes. [Journal of Gerontological Nursing, 45(8), 32-42.].