• Posted on September 14, 2022
• Karan

A Global Health Perspective Assignment Sample

 A Global Health Perspective In Fighting Tuberculosis

Introduction

Tuberculosis is one of the most common diseases which are responsible for the death of millions globally every year and it may be clearly mentioned that it kills more people than any other pathogenic disease. In this essay, a detailed discussion will be done on the various aspects of tuberculosis and the ways to successfully prevent it by overcoming the challenges.

1. Identifying and describing four factors of globalization responsible for influencing global prevalence of tuberculosis

It may be asserted that among all the factors responsible for tuberculosis the factors of malnutrition, diabetes, alcohol and active smoking are regarded as some of the most crucial factors (Refer to Appendix-1). All the four factors responsible for the global spread of tuberculosis are discussed below in detail.

Malnutrition

Malnutrition is undoubtedly one of the major factors responsible for the spread of tuberculosis in the global context and it may be added that malnutrition is closely related to poverty which is a major cause of concern for many countries. The nutritional factor is a major factor which may negatively impact the treatment of tuberculosis due to malabsorption of necessary drugs required for the treatment of the disease (Ter Beek, 2019). On the other hand, it has to be mentioned that both micro and macro deficiency may lead to increased risk of getting affected by tuberculosis due to an imbalanced immune system (NCBI, 2021). Furthermore, it may be stated that malnutrition is caused due to poverty which is a socioeconomic issue and needs to be dealt with utmost attention and care for mitigating the risk of tuberculosis. On a broader note, it may be implied that the spread of tuberculosis is directly associated with social conditions where hunger and poverty play a dominant role.

However, it needs to be opined that tuberculosis may create certain changes in the human body such as loss of appetite which may cause changes in the entire metabolic system ultimately leading to malnutrition. Moreover, it may be argued that tuberculosis may occur due to any complications present in the immune system which may trigger latent tuberculosis into active tuberculosis (Martin, 2019). Additionally, it may be asserted that the problem of increasing global poverty has made it a challenging issue to control the spread of tuberculosis where increasing population is causing imbalance in the society to a great extent. In addition to this, it needs to be implied that the relationship between tuberculosis and malnutrition is extremely clear and transparent as malnourished children are always at higher risk of getting infected by the disease. Tuberculosis has existed in the world for millions of years and has been regarded as one of the major threats to public health all over the world as the disease gets easily transmitted through coughing and sneezing (Chandrasekaran, 2017). In a concluding remark, it may be stated that malnutrition is one of the most common causes for the global spread of tuberculosis.

Diabetes

Among all the factors responsible for the global prevalence of tuberculosis, diabetes is considered to be an essential factor and patients with diabetes are always at higher risk suffering from tuberculosis. In other words, diabetes is dangerous as it is responsible for causing immunosuppression which ultimately increases the chance of getting affected by diseases such as tuberculosis (Yorke, 2017). On the other hand, it may be implied that almost 70% of the patients with diabetes belong to low income countries and the number of patients are increasing at a steady rate where tuberculosis is endemic (NCBI, 2021). On a broader note, it may be asserted that patients with diabetes are more at high risk of getting affected by tuberculosis as diabetes increases the risk of treatment failure of tuberculosis. However, it needs to be mentioned that the countries belonging to the South Asian region such as Afghanistan, Bangladesh, Sri Lanka, Pakistan, Bhutan, Nepal, Maldives and India have 44% of the world’s total tuberculosis cases (Refer to Appendix-2). In a more specific way, it may be stated that tuberculosis and diabetes have emerged as the two prime factors affecting the global population in a profound way (Workneh, 2017).

On a contradictory note, it may be implied that tuberculosis gets worse if the patient is suffering from diabetes which again increases the rate of death among global patients and also impacts the overall treatment in a negative way. Along with this, it may be added that tuberculosis gets worse in the presence of diabetes where patients suffer from poor glycemic control (Ruslami, 2021). Furthermore, lack of awareness of the common people about diabetes and the ways to fight with tuberculosis also becomes an important factor which may be overcome through spreading awareness among masses. Tuberculosis has become a major problem for many countries and finding the reasons for comorbidity is an extremely vital aspect to confront the situation in an effective way (Silva, 2018). Additionally, it may be stated that people suffering from diabetes are at higher risk of triggering latent tuberculosis which is a cause of threat to their lives.

Alcohol

Tuberculosis is caused by several factors and alcohol is one of the global factors responsible for the prevalence of the disease and needs to be dealt with utmost care and attention. Apart from this, it may be opined that almost 10% deaths occurring due to tuberculosis are related to issues of alcohol consumption which is a global cause of concern (Myers, 2018). On the other hand, it needs to be mentioned that consumption of alcohol creates certain changes in the immune system which increases the risk factor of getting the infection of tuberculosis (NCBI, 2021). However, it may be stated that consumption of alcohol is a major factor which is significantly impacting the prevalence of tuberculosis all over the world and it has to be tackled in a strategic way. In a more specific way, it may be opined that heavy consumption of alcohol of more than 40 gram of ethanol every day increases the risk factor of getting affected by tuberculosis to a great extent (Imtiaz, 2017).

On a broader note, it needs to be implied that the amount of consumption of alcohol becomes a major factor which ultimately impacts the health condition of patients and is also responsible for increasing the burden of the disease throughout the world. Moreover, it may be clearly concluded that with the increase in the amount of alcohol intake the risk factors also gets increased and in order to avoid any major issue the amount of alcohol consumption to be reduced at any cost (Simou, 2018). In other words, lack of awareness about the ill effects of alcohol consumption is another prime issue which needs to be mitigated for dealing with the problem in a successful way. Additionally, it may be argued that alcohol consumption impacts the treatment of tuberculosis in a profound way where the essential drugs fail to improve the health conditions of the patients ultimately resulting in an increase in the number of deaths occurring due to tuberculosis. In a concluding remark, it may be asserted that the patients are to be made aware about the harmful impacts of alcohol consumption on a daily basis for controlling the number of deaths.

Active smoking

Among all the important factors responsible for the global prevalence of tuberculosis, smoking is regarded as one of the major factors which deserve special mention. Apart from this, it may be implied that smokers are always at higher risk of getting affected by tuberculosis which also increases indoor air pollution (NCBI, 2021). Along with this, it needs to be opined that the habit of smoking impacts the overall health of the patients suffering from tuberculosis by reducing the effects of effective drugs and medicines essential for treating tuberculosis. In a more specific way, it may be mentioned that smoking is responsible for doubling the risk of getting affected by tuberculosis and also increases the mortality rate significantly (Amere, 2018). However, it may be stated that despite knowing the harmful impacts of smoking, people all over the world continue to smoke and due to this reason tuberculosis is also spreading. On a contradictory note, it needs to be stated that smoking causes damage to the lungs which ultimately impacts the health of the patients suffering from tuberculosis in a profound way as the disease affects the lungs to a great extent. Furthermore, the habit of smoking impacts the treatment of tuberculosis in a direct way which lowers the rate of recovery and in some cases fails completely (Khan A. H., 2020). Moreover, smoking is directly associated with reducing the functionality of the immune system which a major factor is leading to the prevalence of tuberculosis globally. On a broader note, it needs to be mentioned that active smoking as well as passive smoking contributes to the spread of tuberculosis which may be avoided through implementing strict restrictions on smoking in public places. In a concluding remark, it may be strongly argued that people all over the world keep on smoking in spite of knowing the fact that smoking immensely affects the immune system and is considered to be an important factor for the global prevalence of tuberculosis.

2. Identification and description of the roles played by four categories of agencies involved in prevention, control and management of tuberculosis

World Health Organization 

One of the most renowned agencies that has been trying to fight against TB for a long time is the World Health Organization(who.in, 2021). and in order to keep its fight against TB ongoing, WHO has taken several initiatives for the matter as well. In order to prevent TB, treatment is extremely necessary and thereafter, WHO has been developing guidelines and informative handbooks to enhance and increase treatment for the disease in different countries. In addition to that, WHO also supports different countries to prevent the spread and also help in eradicating the root cause of TB providing guidance and also by implementing different means of control measures as well. Furthermore, WHO also gives advice to different research and development centres that are working towards inventing TB vaccines and along with that, the organization has also developed a Multisectoral Accountability Framework for the disease. A global forum held in New Delhi, India had addressed those new vaccines for TB are in clinical trials and a new path for delivery are being examined(Atmakuri, 2018).

National Health Service

Along with WHO, another agency that has also been trying to fight against TB is the National Health Services (NHS) of the UK and similar to WHO this agency aided by the government fund has also done some significant work in eradicating TB. The NHS has collaborated with the UK Health Security Agency (UKHSA) and has developed a 5 years programme plan in order to reduce TB cases in the UK within 5 years (Refer to Appendix 3). Along with that, the NHS is also conducting thorough testing for those individuals who may have contracted TB and advising people on the importance of getting care for the disease as well. Furthermore, besides providing all the medical support, the NHS is also providing significant mental health and post care support to TB patients, since the disease may have a negative impact on the mental health of some people, as TB is still stigmatized in our society. Therefore, intervention to prevent TB stigma needs to be developed as stigma may maximize initial losses in TB cases and as stigma is derived from various factors, intervention programmes need to be adopted to eliminate them as well(Bresenham, 2020). The NHS is also providing free healthcare to all the citizens of the UK so that no individual is deprived of treatment for any disease, including TB and to urge people to get the medical care needed without any hesitation.

The Global Fund

The Global Fund is an organization that has been created to ensure the end of TB and other epidemics and this organization was founded in collaboration with the government, civil society, and various private sectors with people affected by the diseases. The organization is basically an institution for financing and providing support to nations for the purpose of ending these diseases completely(theglobalfund, 2021). The Global Fund has developed a strategic initiative for TB and also funded it and also has been working with several national programmes for TB to ensure that the spread of the disease is stopped globally.

The funding will give fuel to take further efforts for finding and successfully curing people with TB who are facing difficulties to get the right treatment required for curing the disease. Several countries, such as India, have increased funding for TB and also trying to discover new drugs for the disease and along with that, increased health facilities have given new hope to find treatment for the disease (Sachdeva, 2020). One of the main factors that may be beneficial to further stop the spread of TB is people’s commitment to adhere to TB medication as it is a crucial aspect of the clinical trials in the treatment for TB(Vernon, 2019). The TB strategic programmes funded by the Global fund had helped to enhance the findings of many TB cases across different countries, which have further resulted in those people acquiring the treatment one may have needed.

National Centre for Biotechnology Information

The National Centre for Biotechnology Information (NCBI) is also an organization that has been trying to fight against TB by providing valuable information in favour of TB care to make people aware of its severity. Evidence has shown that increased awareness about the disease has led to more improved outcomes regarding the treatment and more control over the spread of the disease (Khan A. S., 2020). The information provided by NCBI has been extremely helpful for people across several countries to understand the necessity of TB care (NCBI, 2021). It has helped many people who were initially reluctant to get medical attention, finally coming to terms with the fact that TB is a deadly disease and it requires significant medical care. Most of the time the transmission of the disease happens as a reason for the patient’s irrelevant behaviour towards the illness and this behaviour is encouraged by the patient’s lack of knowledge about the disease (Sukartini, 2020).

3. Identification of challenges faced by agencies in performing their role more effectively to reduce the global burden of tuberculosis

Challenges faced by NCBI in reducing the global burden of TB

It may be opined that global agencies have faced many challenges in reducing the global burden of tuberculosis while if the challenges and difficulties of the agencies may not be solved then it will be extremely critical to mitigating the global challenges of tuberculosis. It has been observed that the private health sectors are not focused on maintaining the role to reduce the global prevalence of TB and lack of funding is one of the main issues which these agencies have experienced (Sakamoto, 2019). It needs to be implied that the people who live in rural areas are not totally aware of the deadliest impact of TB and due to this reason these NCBI have faced multiple issues in reducing the number of TB cases and providing proper TB education in rural areas and underdeveloped countries. Along with that, the global agencies mainly experienced health system-related challenges and problems as the agencies are unable to encourage and motivate the health professionals to provide TB health facilities in the rural area (ncbi, 2021). Moreover, several health agencies such as the NCBI and World Health Organization have not got proper support from the government of multiple countries while without the support of local governments it will be extremely difficult to reduce the burden of TB.

It may be implied that most of the TB cases found in rural areas and low and middle-income countries while these people did not have proper financial support for TB treatment and this reason may be considered as one of the main causes which created a negative impact on redefining the TB cases in the world. In the modern era, the cases of Multi-Drug Resistant (MDR- TB) and XDR -TB is increasing day by day as this new version of TB has more risk factors than normal TB while without proper infection control this type of TB may produce new challenges for global health agencies (Migliori G. B., 2019). In addition to that, the people of urban areas are also unaware of the severity of TB even though the challenges of NCBI have not been solved then it may also be transmitted to urban areas. Proper collaboration between the government and NCBI is required to control the burden of TB as most of the country is not showing interest to collaborate with these agencies. On the contrary, the global agencies of the world have taken several steps to improve the lung health of poor and middle-income countries as due to lack of diagnosis devices it is extremely hard to diagnose TB among the group of people(Meghji, 2021).

Challenges faced by The Global Fund in reducing the global burden of TB

A proper plan is extremely required to solve these problems which are related to tuberculosis even though most of the health agencies did not implement proper plans which created several issues in controlling the prevalence of TB. On the contrary, the Global Fund has also faced multiple difficulties in managing the TB programs during the Covid-19. Additionally, due to the Covid-19, the global health agencies were not able to take proper steps which have increased the number of TB cases worldwide. More specifically, the global fund has experienced multiple challenges in providing proper TB treatment as it is extremely lengthy and complex and it may require a minimum time of six months and a lot of antibiotics to resist the MDR-TB (theglobalfund, 2021).

It is one of the biggest diaries of the government to collaborate with health agencies and build a proper health infrastructure in the rural areas as most of the TB cases are found in rural areas in low and middle-income countries. In India, the TB control program did not succeed due to many reasons such as insufficient budget allocation is one of the main problems which created multiple obstacles in establishing improved health infrastructure for TB(Thakur, 2021). Migrated people may increase the possibilities of TB disease in a country and for that reason, the global fund has focused on multiple migrated groups which may increase the TB burden in migrated countries. Moreover, in low-income countries, there is the unavailability of TB drugs and antibiotics, however, the cost of anti-drugs are rising day by day. In addition to that, it is one of the biggest challenges of the Global Fund to raise funds in providing free medicine to the TB affected patients in those countries.

Challenges faced by WHO in reducing the global burden of TB

The governments of underdeveloped countries need to communicate with global health agencies such as WHO and the global fund which will be useful in tracking the migrated person. Due to the lack of understanding and ineffective communication, the global health agency will not be able to focus on a particular group such as women, girls, sex workers and many more. According to WHO the combination of TB and HIV is extremely dangerous and every approximately 3.6 million TB patients did not get proper medical care (who, 2021). It has been observed that the poor living status of migrant people may create a massive impact in transmitting Tuberculosis as without political influence and advocacy the transmission of TB disease may not be controlled in migrant groups (Sotgiu, 2017). It may be indicated that political commitment is extremely required which may provide proper support to the global health agencies and that may create a beneficial impact in designing a proper TB eradication program. WHO has already recommended some strategies which are extremely effective to control the prevalence of TB as the agency has provided eight prime activities such as DOTS, end TB and stop TB strategy (Matteelli, 2018). Multiple difficulties have been experienced by the WHO which has created an adverse effect in the TB control program as it has been maintained that more than 3 million tuberculosis cases have no symptoms or notification (Refer to Appendix 4).

It may be argued that social mobilization is extremely essential for the better treatment of TB as global agencies such as WHO believe in social mobilization. However, due to lack of social mobilization, most of the TB cases are not detected which create multiple problems to eradicate the TB burden. There are many challenges that are closely associated with the rising number of TB cases such as poor infection diagnosis and control methods, poor treatment, malnutrition and many more as the health agencies need to enhance the financial contribution to resolve these challenges (euro.who.int, 2021). Due to insufficient funds and government support, the health agencies are unable to detect TB patients which may create an advertisement in installing modern medical equipment in rural areas which are extremely required for the treatment of TB. Furthermore, there are huge requirements of mechanical ventilation which is immensely useful in resolving these challenges while it is extremely expensive to install and operate this medical equipment (Migliori G. B., 2020).

Challenges faced by the NHS in reducing the global burden of TB 

It has already been mentioned that the NHS of the UK has been involved in bringing significant care for TB and providing assistance to people who have been affected by the disease as well, however, these initiatives do not come without any challenges. One of the main challenges that the NHS has been facing is making people aware about the severity of the disease and the reasons for which it is of utmost importance that people seek medical care as soon as possible. Research has shown that to spread awareness about TB the health authorities need to target more male and young people for the TB awareness campaign (Zein, 2017).

Moreover, despite being told multiple times to get treated right after spotting any system of TB, people are not following that protocol and coming for treatment when it has been too long since the person has been infected. Thereafter, by then the individual has transmitted the disease to several other people and therefore, it is becoming challenging for the NHS to control the cases of TB in the UK. TB is, therefore, somewhat similar to Covid-19, since both these diseases thrive in a crowded situation and also close contact with someone who has already been ill and affected by the diseases(Wilson, 2020). Moreover, the NHS is also facing challenges in convincing people that TB is not a shameful disease and people need to seek medical attention for it as soon as the person has been detected with TB. The impact of stigma attached with the disease may be felt at home, workplace and many other places and the discrimination regarding TB cause a great deal of sufferance amongst the patients as well (George, 2020).

Therefore, the NHS has also been committed to providing mental health support to TB patients to ensure that no individual goes into depression after facing discrimination regarding TB. However, an extremely handful of people seek mental health care post being recovered from the disease and the NHS is facing multiple obstacles in bringing people in to provide such care to make sure that all patients are looked after with extreme efficiency. TB patients are recommended to isolate themselves and isolations are prone to take an emotional toll on the people who had to quarantine and also complicate any existing mental health issues as well (Huremović, 2019).

 4. Conclusion   

From the above discussion, it may be concluded that there are several issues which need to be discussed in controlling and mitigating TB cases in the world. It may be opined that better collaboration and communication framework needs to be implied by the global health agencies which may play an important role in controlling the spread of the deadliest disease. It has been mentioned that the TB cases are increasing significantly in low and middle income countries, however, the developed countries are able to control the spread of TB through effective strategies. Moreover, there are some prime factors which are the prime reasons for the spreading of TB diseases such as excessive alcohol drinking, smoking malnutrition and many more. The health professional needs to enhance the knowledge which is related to TB treatment or else the issues of TB management will not be resolved. Additionally, social and financial support is extremely required to control the spread of TB as in many countries insufficient funding creates many problems in dealing with the severe TB cases. It is one of the biggest responsibilities of the governments of underdeveloped and developing countries to improve the health infrastructure in controlling the spread of TB in an effective way.

References

Amere, G. A. (2018). Contribution of smoking to tuberculosis incidence and mortality in high-tuberculosis-burden countries. . American journal of epidemiology, 187(9), , 1846-1855.

Atmakuri, K. P.-N. (2018). Meeting report: 5th global forum on TB vaccines, 20–23 February 2018, New Delhi India. Tuberculosis, 113,, 55-64.

Bresenham, D. K.-M. (2020). Quantification and correlates of tuberculosis stigma along the tuberculosis testing and treatment cascades in South Africa: a cross-sectional study. Infectious diseases of poverty, 9(1), 1-13.

Chandrasekaran, P. S. (2017). Malnutrition: modulator of immune responses in tuberculosis. Frontiers in immunology, 8, , 1316.

england.nhs.uk. (2021, November 24). england.nhs.uk. Retrieved from england.nhs.uk: https://www.england.nhs.uk/tuberculosis-programme/

euro.who.int. (2021, Novemeber 24). euro.who.int. Retrieved from euro.who.int: https://www.euro.who.int/en/health-topics/communicable-diseases/tuberculosis/data-and-statistics/challenges-for-tuberculosis-tb-control-in-the-european-region

George, L. S. (2020). Social stigma associated with TB and HIV/AIDS among Kudumbashree members: A crosssectional study. . Journal of Family Medicine and Primary Care, 9(8),, 4062.

Huremović, D. (2019). Mental health of quarantine and isolation. In Psychiatry of pandemics , 95-118.

Imtiaz, S. S. (2017). Alcohol consumption as a risk factor for tuberculosis: meta-analyses and burden of disease. European Respiratory Journal, 50(1)., 1-20.

Khan, A. H. (2020). Effect of smoking on treatment outcome among tuberculosis patients in Malaysia; a multicenter study. BMC public health, 20, , 1-8.

Khan, A. S. (2020). Knowledge, awareness, and health-seeking behaviour regarding tuberculosis in a Rural District of Khyber Pakhtunkhwa, Pakistan. . BioMed research international, 2020.

Martin, S. J. (2019). Malnutrition and associated disorders in tuberculosis and its therapy. . Journal of dietary supplements, 16(5), , 602-610.

Matteelli, A. R.-A. (2018). Tuberculosis elimination: where are we now? European Respiratory Review, 27(148).

Meghji, J. M. (2021). Improving lung health in low-income and middle-income countries: from challenges to solutions. The Lancet.

Migliori, G. B. (2019). Reducing tuberculosis transmission: a consensus document from the World Health Organization Regional Office for Europe. European Respiratory Journal, 53(6).

Migliori, G. B. (2020). MDR/XDR-TB management of patients and contacts: Challenges facing the new decade. The 2020 clinical update by the Global Tuberculosis Network. International Journal of Infectious Diseases, 92, , S15-S25.

Myers, B. B. (2018). Impact of alcohol consumption on tuberculosis treatment outcomes: a prospective longitudinal cohort study protocol. BMC infectious diseases, 18(1),, 1-9.

ncbi. (2021, November 24). ncbi. Retrieved from ncbi: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4811263/

NCBI. (2021, November 24). NCBI. Retrieved November 24, 2021, from NCBI: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3583136/

Ruslami, R. K. (2021). The effect of a structured clinical algorithm on glycemic control in patients with combined tuberculosis and diabetes in Indonesia: A randomized trial. Diabetes Research and Clinical Practice, 173,, 108701.

Sachdeva, K. S. (2020). Paradigm shift in efforts to end TB by 2025. Indian Journal of Tuberculosis.

Sakamoto, H. L. (2019). hallenges and opportunities for eliminating tuberculosis–leveraging political momentum of the UN high-level meeting on tuberculosis. BMC public health, 19(1),, 1-7.

Silva, D. R.-T. (2018). Risk factors for tuberculosis: diabetes, smoking, alcohol use, and the use of other drugs. Jornal Brasileiro de Pneumologia, 44,, 145-152.

Simou, E. B.-B. (2018). Alcohol consumption and risk of tuberculosis: a systematic review and meta-analysis. The International Journal of Tuberculosis and Lung Disease, 22(11), , 1277-1285.

Sotgiu, G. D. (2017). Breaking the barriers: migrants and tuberculosis. La Presse Médicale, 46(2), e5-e11.

Sukartini, T. &. (2020). The effect of health education through brainstorming and booklet method on behavior in prevention of pulmonary Tb transmission. EurAsian Journal of BioSciences Eurasia J Biosci, 14,, 2697-2702.

Ter Beek, L. A. (2019). Tuberculosis-related malnutrition: public health implications. . The Journal of infectious diseases, 220(2), , 340-341.

Thakur, G. T. (2021). Status and challenges for tuberculosis control in India–Stakeholders’ perspective. Indian Journal of Tuberculosis, 68(3),, 334-339.

theglobalfund. (2021, November 24). theglobalfund. Retrieved from theglobalfund: https://www.theglobalfund.org/en/blog/2021-10-05-adapting-tb-programs-to-face-the-challenge-of-covid-19-lessons-from-the-philippines/

Vernon, A. F. (2019). The importance of adherence in tuberculosis treatment clinical trials and its relevance in explanatory and pragmatic trials. The importance of adherence in tuberculosis treatment clinical trials and its relevance in explanatory and pragmatic trials.

who. (2021, November 24). who. Retrieved from who: https://www.who.int/health-topics/tuberculosis

who.in. (2021, November 24). who.in. Retrieved from who.in: https://www.who.int/health-topics/tuberculosis

Wilson, F. A. (2020). COVID-19 and TB control in immigrant communities. Int J Tuberc Lung Dis, 24(9),, 975-977.

Workneh, M. H. (2017). Prevalence and associated factors of tuberculosis and diabetes mellitus comorbidity: a systematic review. PloS one, 12(4), , e0175925.

Yorke, E. A.-K. (2017). The bidirectional relationship between tuberculosis and diabetes. Tuberculosis research and treatment, , 1-15.

Zein, R. A. (2017). Estimating the effect of lay knowledge and prior contact with pulmonary TB patients, on health-belief model in a high-risk pulmonary TB transmission population. Psychology research and behavior management, 10, , 187.