Differential Mental Health Impact of COVID-19 Lockdowns on Persons with Non-Communicable Diseases in Trinidad and Tobago.

Persons with chronic non-communicable diseases (NCDs) were identified as particularly at risk of severe morbidity and mortality during the COVID-19 pandemic. Little is written about the impact of COVID-19 on this sub-population in the Caribbean, where the prevalence of NCDs is disproportionately high. This study aimed to ascertain COVID-related concerns, and the mental health impact of the pandemic among persons with and without NCDs in Trinidad and Tobago, during the acute period of COVID-19 lockdowns early in the pandemic. An anonymous online survey collected cross-sectional data from a convenience sample nationwide. Of 1287 respondents, 219 self-identified as having an NCD. Findings suggest that the pandemic was experienced unequally by persons with NCDs, who were more likely to be concerned about health and wellbeing and to report health inequalities-unemployment, social isolation and negative effects of government restrictions. Compared to those without NCDs, they were more likely to increase use of marijuana during the lockdown period, and to report severe anxiety/depression that can result in exacerbation of NCDs. Interventions for persons with NCDs must address the mental health consequences of any pandemic, including increased drug use, and also address social inequalities to reduce sustained post-pandemic mental health impact and negative health outcomes.

Positive influences of the COVID-19 pandemic on community dwelling adults in Trinidad and Tobago: a cross sectional study.

BACKGROUND: Since the onset of the coronavirus (COVID-19) pandemic its negative effects have been highlighted globally. There is little literature that examines the positive impact on daily living. AIMS: To examine the positive influences of government-imposed COVID-19 public health restrictions on adults throughout Trinidad and Tobago (TT) and their associated factors. METHOD: A cross-sectional study, using an adapted pretested online survey instrument, was conducted amongst non-institutionalised, community-dwelling adults using convenience sampling. RESULTS: Of 1287 completed and weighted responses, the mean age (S.D.) was 39.2 (14.6) years, 49% were males, and 61% completed secondary level education. The top 5 positive experiences were more time spent with family (80%), more down-time (78%), learning new skills (68%), more time for hobbies (66%), self-care (57%), more time spent with friends (55%) and eating healthier (50%). The importance of religion, working from home, and an increase in marijuana use emerged as positive correlates for certain positive experiences, while participants with chronic illness, and a positive anxiety or depression screen, were negatively associated with most positive experiences. CONCLUSIONS: Despite the negative consequences of the COVID19 pandemic, several positives were highlighted in this study. These findings have implications for social policies toward building resilience within the community.

Child Sexual Abuse and the Complexities of Gender, Power, and Sexuality.

This article contributes to the still limited analysis of gender and sexuality in the exploration of HIV infection in the Caribbean. In Trinidad and Tobago, child sexual abuse was identified as a prevalent behavior. This motivated a gendered exploration of the sociocultural factors underlying child sexual abuse and the link with HIV. Using a qualitative action research methodology, researchers sought to understand the patterns of behavior, sociocultural and gendered meanings, and significance of child sexual abuse; to sensitize stakeholders to these issues; and to develop multidisciplinary community-based interventions and policies. This article reports on the analysis of data collected from the interventions carried out as part of the action research methodology, as well as a range of national and community-specific action research activities including ethnographic case studies, national stakeholders meetings, and a study of service providers. It provides a nuanced understanding of the meanings, underlying assumptions, perceptions, and taboos associated with child sexual abuse in Trinidad and Tobago, as well as new ways of understanding child sexual abuse in the Caribbean. Findings showed that the social and gender context for child sexual abuse involves several interconnecting factors located within a framework of gender ideologies and expressions, sexual expectations and behaviors, and social norms based on patriarchal values. These findings would be of significance for the prevention of child sexual abuse and the associated HIV risk in Trinidad and Tobago, and the management of victims and perpetrators of child sexual abuse.

Action research improves services for child sexual abuse in one Caribbean nation: An example of good practice.

BACKGROUND: Child sexual abuse (CSA) is a multi-dimensional problem. The search for best practice must consider the complexities surrounding CSA and its management in any particular society. OBJECTIVE: Data previously gathered from service providers on CSA service provision in Trinidad and Tobago identified key deficient issues in policy and practice. In this paper, researchers aimed to bridge the gaps identified, and effect changes to improve services for CSA using an action research methodology. PARTICIPANTS AND SETTING: Service providers from all sectors in governmental and non-governmental organizations in Trinidad and Tobago, who work with children at risk of CSA were involved in the process. METHODS: Researchers led the service providers into an awareness of their own practice through critical discussion of, and reflection on, the key deficient issues. The new knowledge generated, with guided input from evidenced-based best practice, led to the development of guidelines for management. Discussion of the practicability of the guidelines by service providers in multiple sectors generated more new knowledge that refined the management approach. RESULTS: The contextual knowledge obtained from service providers resulted in best practice guidelines for service providers that were culturally relevant and context-sensitive, adaptive and implementable, and allowed a seamless multidisciplinary response to CSA in Trinidad and Tobago within prevailing constraints. CONCLUSIONS: Action research offers an effective approach to improve services for CSA through mobilization of service providers and changes in policy and practice. It is applicable in any setting and likely to be effective in any socio-cultural context.

Intensity of Energy Drink Use Plus Alcohol Predict Risky Health Behaviours among University Students in the Caribbean.

The relationship between energy drink (ED) use and risky behaviours has not been explored in the Caribbean, where youth risky behaviours are prevalent. This paper examines the relationship between ED use and risky behaviours and the moderating effect of gender among 1994 undergraduate students in Trinidad and Tobago. Analyses examined the association between ED use and risky behaviours, and the significant predictors of risky behaviours. Analysis of variance determined whether there were differences in risky behaviours between those who used only alcohol or EDs, both alcohol and EDs, alcohol mixed with EDs and neither alcohol nor EDs; and the difference between those with high and low intensity of ED use. In both males and females current use of energy drinks was positively associated with harmful substance use, risky sexual behaviours, and risky non-sexual behaviours, more strongly for males. The strongest predictor of risky behaviours was gender. Males consuming both alcohol and EDs, independently or mixed, were most likely to have risky behaviours. Consistent with previous reports, harmful alcohol use and other risk taking health behaviours appear to be predicted by a combination of high intensity use of EDs and alcohol. In countries like Trinidad and Tobago where violence, alcohol use disorders, STI/HIV infection and teenaged pregnancy are prevalent, the assessment of consumption of EDs and alcohol may be an important potential predictor of health compromising behaviours.

The National Alcohol Survey of Households in Trinidad and Tobago (NASHTT): willingness to support changes in policy, laws and regulations.

BACKGROUND: Over 60% of households (HHs) in Trinidad and Tobago (T&T) consume alcohol. These HHs were more likely to report illnesses, relationship problems, and behavioral problems with children. This study set out to determine what proportion of HHs were willing to support changes in specific policies, laws and regulations in a national alcohol campaign. METHODS: A cross-sectional convenience sample of HHs were surveyed from a random sample of enumeration districts (ED) in T&T. An interviewer-applied, field pre-tested de novo questionnaire had 5 domains and was developed over 1 1/2 years after an extensive literature review and consultation. Many of the WHO 'best buys' recommendations were included. RESULTS: One thousand six hundred ninety-five HHs (from 53 ED) responded from a total of 1837 HHs approached (response rate 92%). In a national campaign the following proportions of HHs would support: setting the legal age for drinking at 21 years (82.4%); restricting or banning alcohol advertising on TV and other media (73.1% and 54.4% respectively); banning all alcohol advertising at sports and cultural events (64.8%); banning radio stations playing songs with reference to alcohol use (71.3%); holding sellers of alcohol responsible for the amount of alcohol sold (79.5%); advocating that proof of age to be shown by persons buying alcohol (87.4%); placing more prominent warning labels on products displaying alcohol content (87.2%); placing more prominent warning labels on products showing harmful effects (88.5%); increasing taxes on alcohol sales (87.7%). Less than 50% of HH supported restrictions in density of outlets and reduction in opening times for alcohol outlets. CONCLUSIONS: Many HHs in T&T are willing to support changes in policies around alcohol, including many of the policies shown by the WHO to be effective in reducing the harmful consumption of alcohol.

Alcohol and Road Traffic Injuries in Latin America and the Caribbean: A Case-Crossover Study.

BACKGROUND: This study reports dose-response estimates for the odds ratio (OR) and population attributable risk of acute alcohol use and road traffic injury (RTI). METHODS: Data were analyzed on 1,119 RTI patients arriving at 16 emergency departments (EDs) in Argentina, Brazil, Costa Rica, Dominican Republic, Guatemala, Guyana, Mexico, Nicaragua, Panama, and Trinidad and Tobago. Case-crossover analysis, pair-matching the number of standard drinks consumed within the 6 hours prior to the RTI with 2 control periods (prior d/wk), was performed using fractional polynomial analysis for dose-response. RESULTS: About 1 in 6 RTI patients in EDs were positive for self-reported alcohol 6 hours prior to the injury (country range 8.6 to 24.1%). The likelihood of an RTI with any drinking prior (compared to not drinking) was 5 times higher (country range OR 2.50 to 15.00) and the more a person drinks the higher the risk. Every drink (12.8 g alcohol) increased the risk of an RTI by 13%, even 1 to 2 drinks were associated with a sizable increase in risk of an RTI and a dose-response was found. Differences in ORs for drivers (OR = 3.51; 95% CI = 2.25 to 5.45), passengers (OR = 8.12; 95% CI = 4.22 to 15.61), and pedestrians (OR = 6.30; 95% CI = 3.14 to 12.64) and attributable fractions were noted. Acute use of alcohol was attributable to 14% of all RTIs, varying from 7% for females to 19% for being injured as a passenger. CONCLUSIONS: The finding that the presence of alcohol increases risk among drivers and nondrivers alike may further help to urge interventions targeting passengers and pedestrians. Routine screening and brief interventions in all health services could also have a beneficial impact in decreasing rates of RTIs. Higher priority should be given to alcohol as a risk factor for RTIs, particularly in Latin America and the Caribbean.

Type and Context of Alcohol-Related Injury among Patients Presenting to Emergency Departments in a Caribbean Country.

There is an association between alcohol consumption and injuries in Latin America and the Caribbean. This cross-sectional study explores the socio-contextual factors of alcohol-related injuries in Trinidad and Tobago. Data on drinking patterns, injury type, drinking context prior to injury, and demographics were collected from patients presenting with injuries to the Emergency Departments (ED) of four hospitals. Findings show that 20.6% of patients had consumed alcohol, mainly beer, in the 6 h before injury. More than half were drinking at home (27%), or someone else's home (27%). Injury most commonly occurred outdoors (36%) while in transit. Alcohol-related injuries occurred mainly because of falling or tripping (31.7%); these patients recorded the highest mean alcohol consumption prior to injury. Most persons who fell (50%) did so at home. Findings highlight the previously unreported significant risk of non-drivers sustaining injures through falling and tripping because of heavy alcohol use. Current interventions to reduce alcohol-related injury have focused on drink driving but there is a need for interventions targeting pedestrians and those who drink at home. A comprehensive multi-component approach including secondary prevention interventions in the medical setting, community educational interventions, enforcement of current legislative policies concerning the sale of alcohol, and policy initiatives surrounding road safety and alcohol outlet density should be implemented.

Participants' perception of a unique community of practice for substance abuse education in the Caribbean.

BACKGROUND: Substance abuse is a significant public health challenge in the Caribbean. It is important that health and allied professionals be adequately trained in this field. The Caribbean Institute on Alcoholism and other Drug Problems (CARIAD) was established to provide new knowledge and share successful best practices in substance abuse in the Caribbean. CARIAD brings together diverse participants from throughout the region in a structured community of practice and emphasizes local knowledge formation. This paper evaluates the acceptability and perceived impact of CARIAD to/on participants. METHODS: The authors analyzed anonymous written evaluations of 458 CARIAD participants completed immediately after the program in 2003-2012. Questionnaires collected quantitative data on the acceptability of the program in meeting the learning needs of participants. Perception of program acceptability and impact on the participant were also obtained from descriptive content analysis of qualitative data obtained through open-ended questions. A 2013 online follow-up survey collected data about the utilization and dissemination of knowledge acquired at CARIAD from 141 graduates of the same period. Data analysis employed basic descriptive statistics and qualitative content analysis. RESULTS: Participant evaluation immediately following CARIAD showed a high level of satisfaction with the organization, structure, content, and usefulness of the program. Participants valued the program's cultural relevance and the opportunity for networking and collaboration. They expressed a collective solidarity, and empowerment to address substance abuse problems. Participants reported that CARIAD had impacted positively on their professional practice and facilitated knowledge transfer to colleagues and communities. CONCLUSION: CARIAD is perceived as an effective community of practice, producing a network of graduates who use the acquired knowledge, skills, and motivation to lead in the field of substance abuse in the Caribbean. This process of learning can be recommended to countries where research is not prioritized and evidence-driven interventions are not always available.

Time for a regional alcohol policy - A literature review of the burden of normative alcohol use in the Caribbean.

Alcohol use is deeply engrained in the socio-cultural fabric of the Caribbean where heavy episodic drinking is an accepted and common drinking pattern. This article aims to create awareness of the tremendous negative impact on population health in the English-speaking Caribbean from culturally customary levels of alcohol consumption. It advocates for the urgent development and implementation of a regional alcohol policy in the English-speaking Caribbean, and emphasizes the importance of crafting and implementing the policy without cultural offence.

Energy drink usage among university students in a Caribbean country: Patterns of use and adverse effects.

OBJECTIVE: There has been little inquiry addressing whether or not concerns about adverse effects of energy drink usage are relevant in the Caribbean. This survey investigated energy drink usage and adverse consequences among tertiary level students in Trinidad and Tobago. METHODS: A cross-sectional survey of 1994 students from eight institutions was conducted using a de novo questionnaire based on findings from a focus group of students. Chi-squared analyses and logistic regression were used to assess relationships between energy drink usage, adverse effects and other factors affecting energy drink use, and to verify predictors of energy drink use. RESULTS: Prevalence of use was 86%; 38% were current users. Males were more likely to use, used more frequently and at an earlier age. Energy drinks were used most commonly to increase energy (50%), combat sleepiness (45%) and enhance academic performance (40%), and occurred during sports (23%) and mixed with alcohol (22.2%). The majority (79.6%) consumed one energy drink per sitting; 62.2% experienced adverse effects, most commonly restlessness (22%), jolt and crash (17.1%) and tachycardia (16.6%). Awareness of adverse effects was associated with no use (p=0.004), but adverse effects were not a deterrent to continued use. CONCLUSION: Energy drink usage is prevalent among students. The use is not excessive, but associated with high rates of adverse effects and occurs in potentially dangerous situations like during exercise and with alcohol. There is a need to educate students about the potential adverse effects of energy drinks.

Breaking the silence of child sexual abuse in the Caribbean: a community-based action research intervention model.

In Trinidad and Tobago, little data exists on child sexual abuse, although there are many anecdotal reports of high prevalence. The Breaking the Silence Gender and Community Empowerment Model is a multidisciplinary intervention to prevent and respond to child sexual abuse in Trinidad and Tobago. It is an innovative, gender-sensitive intervention that uses a community based action research methodology anchored in a national framework. Preliminary evaluation of the Breaking the Silence model shows increased knowledge of child sexual abuse, increased willingness to discuss child sexual abuse, and an impact that goes beyond the target communities. This model can be replicated in communities to prevent and respond to child sexual abuse and adapted to address other sensitive social issues in the Caribbean.

Alcohol, drugs, sexual behavior, and HIV in Trinidad and Tobago--the way forward.

The HIV epidemic in Trinidad and Tobago is primarily heterosexual, fueled by a high level of risky sex, gender inequality, and alcohol and drug use; however, the influence of alcohol and drugs has been neglected in the literature. Research shows that current HIV prevention approaches have failed to substantially impact sexual behavior change. This may be so because they do not incorporate a comprehensive understanding of the sociocultural factors underlying sexual behavior. There is an urgent need to understand how socially accepted patterns of alcohol and drug use contribute to sexual behaviors and HIV risk in Trinidad and Tobago. Moreover, specialized, evidence-based interventions are needed for HIV-infected substance abusers. Using an adaptation of the cognitive behavioral stress management (CBSM) protocol, this intervention project aimed to assess effectiveness in reducing relapse and risky behaviors among recovering HIV-infected substance abusers in Trinidad and Tobago.

Changes in HIV needs identified by the National AIDS Hotline of Trinidad and Tobago.

OBJECTIVES: To examine utilization of the National AIDS Hotline of Trinidad and Tobago (AIDSLINE), evaluate its validity as a reliable data source for monitoring national HIV-related needs, and identify changes in caller requests between two different time periods. METHODS: A total of 7 046 anonymous hotline calls in 1998-2002 (T1) and 2 338 calls in 2007 (T2) were analyzed for associations between caller characteristics and call content. A subsample of the data was also analyzed qualitatively. T1 findings were compared with HIV-related data collected by national policy-makers during that period, to evaluate the hotline's validity as a data source, and findings from T2, to reveal changes in call content over time. RESULTS: In T1, the hotline was well utilized for information and counseling by both the general population and those living with HIV/AIDS. Call content from T2 indicated an increase versus T1 in 1) general awareness of HIV and other sexually transmitted diseases; 2) HIV testing; and 3) knowledge of HIV symptoms and transmission. HIV-related mental health needs, and the relationship between HIV and both child sexual abuse (CSA) and intimate partner violence (IPV), were identified as emerging issues. CONCLUSIONS: AIDSLINE is a well-utilized tool for providing information and counseling on national HIV-related issues, and a valid, cost-effective, easily accessed information source for planners and policy-makers involved in HIV management. Over the two study periods, there was an increase in HIV awareness and testing and in requests related to mental health, CSA, and IPV, but no change in sexual behaviors.

Changes in HIV needs identified by theNational AIDS Hotline of Trinidad and Tobago

OBJECTIVES: To examine utilization of the National AIDS Hotline of Trinidad and Tobago (AIDSLINE), evaluate its validity as a reliable data source for monitoring national HIV-related needs, and identify changes in caller requests between two different time periods. METHODS: A total of 7 046 anonymous hotline calls in 1998–2002 (T1) and 2 338 calls in 2007 (T2) were analyzed for associations between caller characteristics and call content. A subsample of the data was also analyzed qualitatively. T1 findings were compared with HIV-related data collected by national policy-makers during that period, to evaluate the hotline's validity as a data source, and findings from T2, to reveal changes in call content over time. RESULTS: In T1, the hotline was well utilized for information and counseling by both the general population and those living with HIV/AIDS. Call content from T2 indicated an increase versus T1 in 1) general awareness of HIV and other sexually transmitted diseases; 2) HIV testing; and 3) knowledge of HIV symptoms and transmission. HIV-related mental health needs, and the relationship between HIV and both child sexual abuse (CSA) and intimate partner violence (IPV), were identified as emerging issues. CONCLUSIONS: AIDSLINE is a well-utilized tool for providing information and counseling on national HIV-related issues, and a valid, cost-effective, easily accessed information source for planners and policy-makers involved in HIV management. Over the two study periods, there was an increase in HIV awareness and testing and in requests related to mental health, CSA, and IPV, but no change in sexual behaviors.

Changes in HIV needs identified by the National AIDS Hotline of Trinidad and Tobago / Cambios en las necesidades relacionadas con el VIH identificadas por la Línea Directa Nacional de Trinidad y Tobago sobre Sida

Objectives: To examine utilization of the National AIDS Hotline of Trinidad and Tobago (AIDSLINE), evaluate its validity as a reliable data source for monitoring national HIV-related needs, and identify changes in caller requests between two different time periods. Methods: A total of 7 046 anonymous hotline calls in 1998-2002 (T1) and 2 338 calls in 2007 (T2) were analyzed for associations between caller characteristics and call content. A subsample of the data was also analyzed qualitatively. T1 findings were compared with HIV-related data collected by national policy-makers during that period, to evaluate the hotline's validity as a data source, and findings from T2, to reveal changes in call content over time. Results: In T1, the hotline was well utilized for information and counseling by both the general population and those living with HIV/AIDS. Call content from T2 indicated an increase versus T1 in 1) general awareness of HIV and other sexually transmitted diseases; 2) HIV testing; and 3) knowledge of HIV symptoms and transmission. HIV-related mental health needs, and the relationship between HIV and both child sexual abuse (CSA) and intimate partner violence (IPV), were identified as emerging issues. Conclusions: AIDSLINE is a well-utilized tool for providing information and counseling on national HIV-related issues, and a valid, cost-effective, easily accessed information source for planners and policy-makers involved in HIV management. Over the two study periods, there was an increase in HIV awareness and testing and in requests related to mental health, CSA, and IPV, but no change in sexual behaviors.

Objetivos: Evaluar la utilización de la Línea Directa Nacional de Trinidad y Tobago sobre Sida (AIDSLINE) y su validez como fuente confiable de información para monitorear las necesidades nacionales sobre el VIH, e identificar cambios en las preguntas de los usuarios en dos momentos diferentes. Métodos: Se buscaron asociaciones entre las características de los usuarios y el contenido de 7 046 llamadas anónimas recibidas entre 1998 y 2002 (T1) y 2 338 recibidas en 2007 (T2). Se tomó una submuestra para análisis cualitativo. Se compararon las características de las llamadas de T1 con: 1) los datos de la autoridad nacional sobre la infección por VIH en ese período, para evaluar la validez de AIDSLINE como fuente de información, y 2) con las de T2 para revelar los cambios en el contenido de las llamadas en el tiempo. Resultados: En T1, AIDSLINE se utilizó ampliamente para buscar información y consejería, tanto por la población general como por personas con VIH/sida. El contenido de las llamadas en T2 indicó un incremento con respecto a T1 en: 1) preocupación general sobre el VIH y otras enfermedades de transmisión sexual; 2) detección de la infección por el VIH; y 3) información sobre los síntomas de la infección y su transmisión. Se identificaron como preocupaciones emergentes las necesidades en salud mental relacionadas con el VIH y la relación entre esta infección y el abuso sexual de menores (ASM) y la violencia de pareja (VDP). Conclusiones: AIDSLINE es una herramienta ampliamente utilizada para brindar información y consejería sobre el VIH en el país y una fuente de información válida, efectiva en función del costo y de fácil acceso para los encargados de planear y elaborar políticas relacionadas con el VIH. Con respecto a T1, en T2 aumentaron la preocupación por el VIH y su detección y las preguntas sobre la salud mental, el ASM y la VDP, pero sin cambios en cuanto a la conducta sexual.

Poor educational attainment and sexually transmitted infections associated with positive HIV serostatus among female in-patient substance abusers in Trinidad and Tobago.

Female crack cocaine users are at high risk for HIV infection. Data from 121 female substance abusers admitted to an all-female rehabilitation center in Trinidad and Tobago between 1996 and 2002 were reviewed retrospectively to determine human immunodeficiency virus (HIV) seroprevalence and associated risk factors. HIV seroprevalence was 19.8%, which is six times higher than in the general population. The univariate analysis identified the following factors associated with HIV infection: poor educational attainment, history of a sexually transmitted infection (STI), and use of crack cocaine. In the multivariate analysis, only poor educational attainment and history of an STI were independently associated with HIV seroprevalence. Female substance abusers, especially female crack cocaine users, are at high risk of acquiring and transmitting the HIV virus. To reduce risk of HIV infection, rehabilitation programs should address risky sexual behaviors and screen for STIs, and they also should improve educational attainment, develop skills, and provide vocational training.

Neuroleptic-induced Tardive Tourette treated with clonazepam: a case report and literature review.

Tardive Tourette syndrome has been reported as a rare complication of neuroleptic treatment. This report describes the first case of neuroleptic-induced tardive Tourette syndrome in the Latin Americas and supports the successful treatment of this disorder with clonazepam. The syndrome developed in a female schizophrenic patient who discontinued medication after 8 years of continuous neuroleptic therapy. Symptoms were unresponsive to increased doses of typical antipsychotics and treatment with an atypical antipsychotic. Significant, sustained improvement occurred with clonazepam. In this report all cases of adult-onset tardive Tourette are reviewed.

Risk behaviours and healthcare needs of homeless drug users in Saint Lucia and Trinidad.

In the Caribbean AIDS has become the leading cause of death among those aged 15-45. The homeless are at high risk due to the nexus of mobility, psychiatric disorders and substance use, particularly crack. Seventy-four homeless, out-of-treatment drug users were recruited in Saint Lucia and Trinidad to assess risk behaviour and healthcare needs. Information was collected in several domains: medical, mental health, substance use, sexual risk, and barriers to care. Ninety-five percent of the sample reported crack cocaine use within the previous 30 days. Approximately 35% of the sample had ever been diagnosed with a sexually transmitted disease and 25% of the sample reported being HIV+. Approximately 40% had a history of trading sex for crack or money. Due to the range of needs in this population, interventions should be multimodal. A focus on the individual, community, and structural levels is warranted to improve chances of program effectiveness.