Alcohol policy changes during the first three-months of the COVID-19 pandemic: Development and application of a classification scheme.

BACKGROUND: Policy changes in response to the COVID-19 pandemic have impacted on alcohol control. This study describes the development and application of a classification scheme to map alcohol policy changes during the first three-months of the COVID-19 pandemic in five countries and/or subnational jurisdictions. METHOD: A pre-registered systematic review of policy decisions from March to May 2020, in Australia/New South Wales, Canada/Ontario, Chile, Italy and the United Kingdom. One author extracted the data for each jurisdiction using a country-specific search strategy of government documents. We coded policy changes using an adapted WHO classification scheme, whether the policy was expected to tighten or loosen alcohol control, have mainly immediate or delayed impact on consumption and harm and impact the general population versus specific populations. We present descriptive statistics of policy change. RESULTS: We developed a classification scheme with four levels. Existing policy options were insufficient to capture policy changes in alcohol availability, thus we added seventeen new sub-categories. We found 114 alcohol control policies introduced across the five jurisdictions, covering five (out of ten) WHO action areas. The majority aimed to change alcohol availability, by regulating the operation of alcohol outlets. All countries introduced closures to on-premise alcohol outlets and, except Chile, allowed off-sales via take away or home delivery. We also observed several pricing policies introducing subsidies to support the alcohol industry. Seventy-four percent of policy changes were expected to tighten alcohol control and 12.3 % to weaken control. Weakening policy changes were mostly related to retail mode switching or expansion (allowing take away or home delivery). CONCLUSION: Alcohol control policies during the first three months of the COVID-19 pandemic were targeted primarily at alcohol availability and about one tenth might weaken alcohol control. Temporary changes to alcohol retail during the COVID-19 pandemic, if made permanent, could significantly expand alcohol availability.

Process Evaluation of Food Game: A Gamified School-Based Intervention to Promote Healthier and More Sustainable Dietary Choices.

Food Game is a gamified school-based intervention that aims to promote healthier dietary choices (i.e., adherence to the Mediterranean diet) and more sustainable behaviors among high school students in an urban area in Northern Italy. The program consists of an offline and online competition in which groups of students participate in peer-led activities to design and communicate products promoting health and sustainability. This study aimed to examine how the program works in practice, understand its mechanisms of change and assess any variation in student outcomes. A mixed methods process evaluation was conducted. Students completed a three-wave longitudinal survey and participated in focus groups. Program staff and teachers were also interviewed. Qualitative and quantitative data analyses indicate that Food Game?s gamification strategy was successful in engaging students, who felt stimulated by the game, its embedded competition and the self-organized group work. Although no significant change in adherence to the Mediterranean diet was found, pro-environmental behaviors, attitudes and perceived peer approval on healthy eating increased over time. Findings provide preliminary support for Food Game as an acceptable and engaging intervention though there is yet not sufficient evidence that it is also promotes healthier and more sustainable behaviors. The results contribute to the limited evidence base for offline gamified school-based interventions and offer insight into the applicability of the gamification approach as a key motivational strategy in other prevention settings and contexts. Suggestions on how to strengthen the program include dosage increase and addition of activities to promote change on relevant school and community factors.

Variations in acceptability of heavy alcohol use and gender double standards across drinking cultures. A U.S.A. - Italy study.

Focus group data from 92 youths from Italy and the U.S.A. indicate that Italians and Americans differ in perceived threshold of acceptability of drinking to excess. Youth from the U.S.A. were more accepting of intoxication than Italian youth, reflecting features of each respective dominant drinking culture. Alcohol gender double standards existed in both countries and were conceptually connected to sexuality. However, the social construction behind such connections differed across the two groups: focusing on harms to the woman in the U.S.A. and the respectability of her social group in Italy.

The selective effect of lockdown experience on citizens' perspectives: A multilevel, multiple informant approach to personal and community resilience during COVID-19 pandemic.

In the face of the first wave of COVID-19 contagion, citizens all over the world experienced concerns for their safety and health, as well as prolonged lockdowns - which brought about limitations but also unforeseen opportunities for personal growth. Broad variability in these psychological responses to such unprecedented experiences emerged. This study addresses this variability by investigating the role of personal and community resilience. Personal resilience, collective resilience, community disaster management ability, provided information by local authorities, and citizens' focus on COVID-19-related personal concerns and lockdown-related opportunities for personal growth were detected through an online questionnaire. Multilevel modelling was run with data from 3,745 Italian citizens. The potential of personal resilience as a driver for individuals to overcome adverse situations with positive outcomes was confirmed. Differently, the components of community resilience showed more complex paths, highlighting the need to pay more attention to its role in the face of far-reaching adverse events which hardly test individuals' as well as communities' adaptability and agency skills. The complexities linked to the multi-component and system-specific nature of resilience, as well as potential paths towards making the most out of citizens' and communities' ones, emerge. The theoretical and practical implications are discussed.

Patterns of Alcohol Use Among Italian Young Adults Before and During a COVID-19 Lockdown: A Latent Class Analysis Study.

Two not mutually exclusive theories explain the effects of the COVID-19 pandemic on alcohol use. The Availability hypothesis contends that reduced opportunities to drink due to the closure of outlets and consumption sites should lead to decreases in alcohol use, whereas the Stress and Coping hypothesis argues that those exposed to stressful situations may increase drinking. The primary aim of this study was to examine changes-separately by gender-in the prevalence of drinking patterns among Italian young adults (18-34 years) before and during a COVID-19 lockdown. Study design was a repeated cross-sectional study, whereby data collected in 2015 and 2020 from nationally representative samples were analyzed. Latent class analysis identified five, fully invariant for women and partially invariant for men, drinking pattern classes among both cohorts: current non-drinkers (CND), weekend risky (WRD) and weekend non-risky drinkers (WnRD), daily non-risky (DnRD) and daily risky drinkers (DRD). In support of the Availability hypothesis, increases in abstaining and moderate drinking women and men were observed from 2015 to 2020. Concomitantly, among men only there were also increases in the prevalence of patterns characterized by risky drinking, coping drinking motives and related harm (Stress and Coping hypothesis). The pandemic and the three-tier lockdown imposed by the Italian government likely reduced overall alcohol use in the general population who drink moderately. However, there was a substantial increase in the prevalence of a small but significant group of men who drank daily and heavily to cope. Outreach and prevention efforts should target primarily this group, but also consider the opportunities that the exceptional circumstances of a quarantine offer to any individuals to reshape their lifestyle and health-related behaviors.

An Integrated Model of Compliance with COVID-19 Prescriptions: Instrumental, Normative, and Affective Factors Associated with Health-Protective Behaviors.

BACKGROUND: The efficacy of public measures for reducing the transmission of the COVID-19 infection relies on citizens' voluntary adherence with prescribed actions. Drawing on prior literature about compliant behavior, this study aimed to identify factors associated with people engagement in health-protective behaviors by including a conjoint complement of instrumental/self-oriented, normative/community-based, and affective variables. METHOD: A cross-sectional study involving a non-representative sample of 4045 Italian citizens was carried out during the first stage of the pandemic (April-May 2020). Variables associated with health-protective behaviors were perceived personal and societal concerns and perceived effectiveness of the institutional response to the outbreak (instrumental dimensions), and family and friends perceived norms and sense of community responsibility (normative dimensions). Two negative emotions (anxiety and fear) were included as mediators between personal and societal concerns and outcome behaviors. RESULTS: Results showed the importance of both self-interest and community-based factors. Indeed, self-interest concerns, family perceived norms, and sense of community responsibility were significant predictors of people's decisions to engage in health-protective behaviors. CONCLUSIONS: The research findings show that compliance with public health prescriptions is a multimodal phenomenon and integrating self-interest and community-based factors can offer a better understanding of people's decision to engage in health-protective behaviors. Further, this study unveils that a shared sense of community is effective in encouraging adherence to recommended behaviors so as behavioral changes can be sustained by targeting the recommendations not only on risk minimization for oneself but also on the allocation of personal responsibility toward the belonging community.

Emergency online school learning during COVID-19 lockdown: A qualitative study of adolescents' experiences in Italy.

The COVID-19 pandemic caused abrupt and profound changes to teaching and learning. The present study seeks to understand adolescents' experiences of the emergency adoption of online school learning (OSL) during the first national lockdown in Italy. Sixty-four students in their final two years of high school were interviewed and content analysis was performed. The findings describe students' views of the changes related to OSL according to structural, individual and relational dimensions. Schools' lack of organization, overwhelming demands, as well as experience of difficulties in concentration, stress and inhibited relationships with teachers and classmates were among the challenges evidenced in the transition. OSL, however, has also made it possible to experience a new flexibility and autonomy in the organization of learning. The study stresses the importance of fostering adaptation of teacher-student relationships and collaborative learning in order to improve schools' preparedness for digital transitions in and out of emergencies.

Prosocial behaviours under collective quarantine conditions. A latent class analysis study during the 2020 COVID-19 lockdown in Italy.

We aimed to identify the patterns of prosocial behaviours under collective quarantine conditions. Survey data were collected from a sample of Italian adults during the March May 2020 COVID-19 lockdown in Italy. Participants reported on offline and online prosocial behaviours, sense of community responsibility (SoC-R) and perceptions of community resilience. Latent class analysis (LCA) was used for data analysis. A total of 4,045 participants completed the survey, and 2,562 were eligible (72% female; mean age 38.7 years). LCA revealed four classes of prosocial behaviours: Money donors (7%), Online and offline helpers (59%), Online health information sharers (21%) and Neighbour helpers (13%). The classes were partially invariant across age groups (18-35 and 35-65 years). Being a man, having achieved a higher educational level and higher SoC-R scores were associated with belonging to the Online and offline helper class. The members of this class also reported the greatest perceptions of community resilience. The results provide insight on the multidimensionality of prosociality under collective quarantine conditions. Online and offline helpers could be targeted for promoting sustained altruism and involvement in community organisations. For the other groups, programmes should aim at eliminating barriers to help others in multiple ways. Please refer to the Supplementary Material section to find this article's Community and Social Impact Statement.

COVID-19 in our lives: Sense of community, sense of community responsibility, and reflexivity in present concerns and perception of the future.

The aim of this study is to examine the association between citizens' perceptions of the effectiveness of the institutional response, their connection and responsibility to their community (Sense of Community-SoC; Sense of Community Responsibility-SoC-R), and their personal and social concerns about the current emergency and their perceptions of a postpandemic future during the first COVID-19 pandemic lockdown. Another variable considered was the personal reflexivity about the COVID-19 pandemic. 3925 Italian adults completed an online questionnaire during the first COVID-19 lockdown. A structural equation model with mediation was tested. Institutional effectiveness was associated with SoC, SoC-R, current social concerns, and perceptions of a postpandemic future. SoC and SoC-R were associated with current personal and social concerns, and perceptions of a postpandemic future. Reflexivity was negatively associated with SoC and positively associated with SoC-R, mediating the relationships between SoC, SoC-R and current personal and social concerns and perceptions of a postpandemic future. Findings indicate the need to adopt a perspective that considers individual and socio-political levels and their interaction to better understand the impact of the pandemic during a national lockdown.

The health behaviours of European study abroad students sampled from forty-two countries: Data from a three-wave longitudinal study.

Research on travelling populations indicates that geographic mobility is associated with changes in health behaviours. However, there is currently little longitudinal data recording study abroad students' health behaviours other than alcohol use [1], [2], and that includes a variety of risk and protective factors related to students' demographics and their experiences abroad. The present dataset contains the original longitudinal data from a study of European study abroad students' and includes information on participants health-related behaviour: including physical exercise, diet, alcohol and drug use, and unprotected casual sex. Self-reported data were collected across three waves: on arrival in the host country, to assess pre-departure behaviour (T1), four months through the period abroad (T2), and four months after returning home (T3). Data on factors related to participants' demographics and their abroad experience, including motivations to study abroad, acculturation orientation and adjustment to the host environment, and perceptions regarding different referent peers' drinking behaviour were also collected. Data were collected in the 2015-2016 academic year. At T1 students in 200 cities from more than 40 European countries were approached by representatives from an international student association. Participants who completed at least two surveys were included (N = 908). The T1 survey was completed by 899 students (nine students provided an e-mail address but did not complete the survey at T1), 785 (86.5%) completed T2 survey, and 438 (48.2%) the T3 survey. The data article presents tables charting variables measured by survey wave and participants' socio-demographic and study abroad experience characteristics. With an acceptable drop-out across the three waves, these data may be of interest to researchers who wish to understand factors related to changes in health behaviours in this population and develop targeted health promotion interventions. Other stakeholders such as policy makers, international offices, health professionals in counselling service, student associations may also use these data to develop communication campaigns and intervene with reference to relevant risk and protective factors.

Post-traumatic Growth Dimensions Differently Mediate the Relationship Between National Identity and Interpersonal Trust Among Young Adults: A Study on COVID-19 Crisis in Italy.

BACKGROUND: In Italy, the COVID-19 pandemic has caused a collective trauma. Post-traumatic growth (PTG) has been defined as the subjective experience of positive psychological changes as a result of a traumatic event. PTG can involve changes in five psychological main dimensions: relating to others, new possibilities, personal strength, spiritual change, and appreciation of life. In the context of national emergencies, those PTG dimensions encompassing changes at the social level (e.g., relating to others) can play a role in coping strategies that involve a renewed sense of self and one's social identities, including national identities, and in turn, foster a stronger sense of trust and connection to others. AIM: To investigate how each of the five PTG dimensions mediates the association between the salience of national identity and interpersonal trust in a sample of Italian young adults. Trust in national and European institutions were expected to positively predict the strength of the Italian national identity which in turn was expected to be positively associated with interpersonal trust, and the PTG relating to others dimension to mediate this association. METHOD: This study involves the secondary analysis of data from a representative sample of 2,000 Italian young adults (age range 18-34 years). Participants completed a web survey during the peak of the COVID-19 crisis in Italy with measures of trust in EU and national institutions, national identity, interpersonal trust, and the PTG Inventory. Structural equation modeling procedures were employed for key hypotheses tests. RESULTS: Trust in national institutions positively predicted national identity, which in turn was positively associated with interpersonal trust. Evidence of a full mediation effect of the PTG relating to others dimension on the association between national identity and interpersonal trust was found. DISCUSSION: Findings contribute to clarify the psychological responses to collective traumas. In the context of Italy's COVID-19 crisis, trust in national institutions reinforced Italian national identity, which was in turn associated with greater interpersonal trust, but only when psychological responses to the trauma involved changes in how individuals perceived and related to others, and not merely a focus on the self. Theoretical and practical implications are discussed.

A Mixed Methods Cross-Cultural Study to Compare Youth Drinking Cultures in Italy and the USA.

AIMS: To compare the drinking cultures of youth in the USA and in Italy. METHOD: Sequential explanatory mixed method design. Phase 1: Multigroup latent class analysis was used to identify subgroups of drinkers from samples of 424 (61.3% female) Italian and 323 American college students (57.3% female). Phase 2: Focus group interviews with 41 Italian and 47 American youth were used to collect narratives on features of the two drinking cultures. RESULTS: Four partially invariant subgroups of drinkers were found. Most participants (>75%) in both countries concentrated drinking during weekends. Overall, US drinkers displayed greater probabilities to report risky drinking behaviors and experience negative consequences as compared to comparable subgroups of Italian drinkers. Discrepancies in terms of socialisation processes during childhood (i.e. permissiveness) and underlying cultural assumptions with regard to alcohol consumption (i.e. purposes of alcohol use) may explain differences in how alcohol is used in the two countries. CONCLUSIONS: Findings suggest that there are crucial differences in societal schema of beliefs, informal social norms, practices, and values attached to alcoholic beverages across the USA and Italy. These results demonstrate the need for culturally tailored alcohol preventive interventions and clinical practice targeted to young people that capitalise on such differences.

General practitioners' accounts of negotiating antibiotic prescribing decisions with patients: a qualitative study on what influences antibiotic prescribing in low, medium and high prescribing practices.

BACKGROUND: Antimicrobial resistance (AMR) is high on the UK public health policy agenda, and poses challenges to patient safety and the provision of health services. Widespread prescribing of antibiotics is thought to increase AMR, and mostly takes place in primary medical care. However, prescribing rates vary substantially between general practices. The aim of this study was to understand contextual factors related to general practitioners' (GPs) antibiotic prescribing behaviour in low, high, and around the mean (medium) prescribing primary care practices. METHODS: Qualitative semi-structured interviews were conducted with 41 GPs working in North-West England. Participants were purposively sampled from practices with low, medium, and high antibiotic prescribing rates adjusted for the number and characteristics of patients registered in a practice. The interviews were analysed thematically. RESULTS: This study found that optimizing antibiotic prescribing creates tensions for GPs, particularly in doctor-patient communication during a consultation. GPs balanced patient expectations and their own decision-making in their communication. When not prescribing antibiotics, GPs reported the need for supportive mechanisms, such as regular practice meetings, within the practice, and in the wider healthcare system (e.g. longer consultation times). In low prescribing practices, GPs reported that increasing dialogue with colleagues, having consistent patterns of prescribing within the practice, supportive practice policies, and enough resources such as consultation time were important supports when not prescribing antibiotics. CONCLUSIONS: Insight into GPs' negotiations with patient and public health demands, and consistent and supportive practice-level policies can help support prudent antibiotic prescribing among primary care practices.

Reasons for Underreporting of Uremic Pruritus in People With Chronic Kidney Disease: A Qualitative Study.

CONTEXT: Uremic pruritus, or itch, is common in people with chronic kidney disease (CKD) and has a negative impact on their lives and well-being. However, for reasons currently unknown, itch often remains unreported and therefore untreated. OBJECTIVES: To explore reasons for underreporting of itch to provide pointers for improving itch reporting and management in people with CKD. METHODS: We interviewed adult patients with CKD who self-reported experiencing itching in the last three years (n = 25), nephrologists (n = 10), and nurses (n = 12) from three kidney services in the U.K. Topic guides were informed by previous studies and a theoretical model of self-regulation. We conducted a thematic analysis of verbatim transcripts using framework analysis. RESULTS: We identified the following three main themes reflecting factors that may influence whether itch is reported: knowledge on causes and treatment of itch (lack of awareness of the relationship between itch and CKD, and lack of knowledge of treatment options); attitudes toward importance of itch as a health issue (patients' and clinicians' attitudes); and prompts for itch assessment during consultations (routine practice, itch as a marker, and itch severity). CONCLUSION: Underreporting of itch is related to patients being unaware of its causes, accepting it as something to live with, prioritizing other health issues, and the length and timing of consultations. Health care professionals' assessment and management of itch vary widely and are not necessarily evidence-based. Better patient information, development of clinical practice guidelines, and incorporation of routine symptom assessments into care may improve itch reporting and management in people with CKD.

A Longitudinal Study of European Students' Alcohol Use and Related Behaviors as They Travel Abroad to Study.

BACKGROUND: Travelling away from home can be associated with fewer limits on behavior, particularly for students who participate in exchange programs. AIMS: To examine the effects of eight moderators on change in alcohol use and related negative outcomes, drug use and unprotected sexual behavior in European study abroad students before, during, and after their time abroad. METHODS: A three wave (before departure, while abroad, and after their return) longitudinal design collecting data on the frequency and volume of alcohol consumed, heavy episodic drinking, alcohol-related outcomes, drug use, and unprotected casual sex. RESULTS: The baseline survey was completed by 1145 students participating in one or two semester exchange programs (67.5% spent up to a semester abroad), of which 906 participated in two or more waves, representing 42 and 33 countries of origin and destination, respectively. Mean age was 22.2 years (SD = 2.28) and 72.7% were female. Students increased the amount of alcohol consumed by 35% (B = 0.32; 95% CI 0.287-0.349) and experienced more alcohol-related consequences (B = 0.15; 95% CI 0.089-0.219) during the study abroad experience, though levels fell below pre-departure levels when they returned home. Factors related to greater alcohol use while abroad include pre-departure expectations about alcohol use during the study abroad experience, psychological adjustment to the host country, academic involvement, and host country living costs. No statistically meaningful change in drug use and unprotected sexual behavior was observed. CONCLUSIONS: Studying abroad exposes European students to additional time-limited alcohol-related health risks.

Alcohol use, psychological distress, and subjective well-being among young adult university students: A cross-national study between Serbia and Italy.

Few studies have cross-nationally tested the mediators of the relationship between alcohol use and subjective well-being among university students. This study examined how self-reported psychological distress symptoms mediate the association between alcohol use (drinking frequency and binge-drinking frequency) and subjective well-being among 637 Serbian and 705 Italian university students. Psychological distress mediated the negative relationship between binge-drinking frequency and subjective well-being among Serbians (partial mediation) and Italians (full mediation). Drinking frequency was not associated with psychological distress or subjective well-being. Binge drinking may negatively affect subjective well-being among university students by enhancing symptoms of psychological distress.

I am going to make the most out of it! Italian university Credit Mobility Students' social representations of alcohol use during study abroad experiences.

The aim was to explore shared representations of alcohol use in students who were to travel abroad to study. Focus group data from Italian students ( N = 69) were collected. Analyses used Grounded Theory Methodology and were informed by the four key components of Social Representation Theory (cognition, emotion, attitude and behavioural intentions). The study abroad experience was described as one that would involve an increase in alcohol consumption compared to pre-departure levels. Reasons given included greater social and leisure opportunities involving alcohol, reduced social control and features of the host country environment. Opportunities to intervene and address risky alcohol use in this group are discussed.

Patterns of Alcohol Use in Italian Emerging Adults: A Latent Class Analysis Study.

AIMS: The goals of the current study were to identify latent classes of alcohol users among Italian emerging adults (18-33 years), examine differences in the class solution based on socio-demographic characteristics, and examine whether differences exist across classes in experiencing different types of alcohol-related negative consequences. METHODS: Participants (N = 5955; 62.72% female; mean age 27.19 years) were drawn from a pre-recruited Web panel designed to be representative of the Italian young adults (18-33 years) population. Latent class analysis (LCA) was used to identify common patterns of alcohol use. RESULTS: Four classes of drinking patterns were identified: (a) Current Nondrinkers (15%); (b) Weekend Non-Risky Drinkers (51%); (c) Weekend Risky Drinkers (20%); and (d) Daily Drinkers (13%). The number and type of classes did not differ across several demographic variables, although proportions within classes varied by sex, age, occupation status and geographic area. Weekend Risky Drinkers experienced the greatest number of alcohol-related negative consequences. CONCLUSIONS: The great majority of the sample displayed drinking patterns with relatively infrequent involvement in risky drinking. Preventive interventions should, instead, target those who drink alcohol on weekends only, but show the greatest negative consequences. SHORT SUMMARY: Four classes of drinking patterns were identified in a large representative sample of Italian young adults. The great majority of the sample displayed drinking patterns with relatively little involvement in risky drinking, though those misusing alcohol at weekends were at greatest risk to experience alcohol-related negative consequences.

Incorporating patient-reported symptom assessments into routine care for people with chronic kidney disease.

In this issue of Clinical Kidney Journal, Brown and colleagues show that symptom burden is high across all stages of chronic kidney disease (CKD). Still, management of symptoms in kidney patients leaves room for improvement, which may partly stem from symptoms being underreported. The use of patient-reported questionnaires may facilitate a more systematic approach to symptom assessment, but to date, the majority of these instruments have been used only in the context of research studies. In this editorial, we review how systematic patient-reported symptom assessments can be incorporated in CKD care. We show examples from an initiative in the UK where 14 renal units explored how to collect and use symptom burden assessments as part of their routine ways of working. We also discuss how to move from paper-based questionnaires towards digital collection of patient-reported symptom data. Lastly, we introduce wearable and smartphone sensors as novel methods for collecting information to support and enrich symptom assessments while minimizing data collection burden.

"Just" blood donors? A study on the multi-affiliations of blood donors.

BACKGROUND: The present work proposes to explore a phenomenon well known in the world of blood donation, but little explored by literature: multi-affiliations. By that term, in this paper we mean blood donors' engagement in multiple associations of various natures (donation, recreation, sports, etc.) simultaneously. The first objective proposes to explore the phenomenon of multi-affiliations in descriptive terms; the second is to look into the differences-in terms of motivations, family-work-volunteerism reconciliation, life satisfaction, and membership satisfaction-between those who "only" carry out blood donation activity and those who instead participate in multiple associative realities concurrently. METHOD: Participating in the research were 2674 donors from the Italian Association of Blood Donors (AVIS) (age range 18-65; 66.6% male) to which a self-report questionnaire was administered in the waiting rooms of numerous blood donation centers. RESULTS: Regarding the first objective, it emerged that only 35.9% of the participants "only" donate blood, while a good 64.1% is engaged also in other associations. Regarding the second objective, statistically significant differences emerge regarding many of the variables considered: social, values, ego-protection, and career motivation; capacity to reconcile family-volunteering and work-volunteering; life satisfaction; and membership satisfaction. CONCLUSIONS: The study offers precious information to the agencies that handle recruiting and retaining of donors. The agencies in fact can take away information on how to improve the multi-affiliations of their donors, an aspect that can facilitate their long-term retention.