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Psychology, Health & Medicine
ISSN: 1354-8506 (Print) 1465-3966 (Online) Journal homepage: http://www.tandfonline.com/loi/cphm20
Feasibility and effectiveness of psychosocial resilience training: A pilot study of the READY program
Nicola W. Burton , Ken I. Pakenham & Wendy J. Brown
To cite this article: Nicola W. Burton , Ken I. Pakenham & Wendy J. Brown (2010) Feasibility and effectiveness of psychosocial resilience training: A pilot study of the READY program, Psychology, Health & Medicine, 15:3, 266-277, DOI: 10.1080/13548501003758710
To link to this article: https://doi.org/10.1080/13548501003758710
Published online: 17 May 2010.
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Feasibility and effectiveness of psychosocial resilience training: A pilot
study of the READY program
Nicola W. Burton a *, Ken I. Pakenham
b and Wendy J. Brown
a
a School of Human Movement Studies, The University of Queensland, Blair Drive, St Lucia, Brisbane 4072, Australia;
b School of Psychology, The University of Queensland, Blair Drive,
St Lucia, Brisbane 4072, Australia
(Received 11 September 2009; final version received 4 February 2010)
Despite many studies on the characteristics associated with resilience, there is little research on interventions to promote resilience in adults. The aims of this study were to gather preliminary information regarding the feasibility of implementing a group psychosocial resilience training program (REsilience and Activity for every DaY, READY) in a workplace setting, and to assess if program would potentially promote well-being. The program targets five protective factors identified from empirical evidence: Positive emotions, cognitive flexibility, social support, life meaning, and active coping. Resilience enhancement strategies reflect core acceptance and commitment therapy (ACT) processes and cognitive behavior therapy strategies. Sessions involve psychoeducation, discussions, experiential exercises, and home assignments. Sixteen participants completed 11 6 two h group sessions over 13 weeks. Baseline and post-intervention assessment included self-administered questionnaires, pedometer step counts, and physical and hematological measures. Data were analyzed using standardized mean differences and paired t-tests. There was a significant improvement between baseline and post intervention scores on measures of mastery (p ¼ 0.001), positive emotions (p ¼ 0.002), personal growth (p ¼ 0.004), mindfulness (p ¼ 0.004), acceptance (p ¼ 0.012), stress (p ¼ 0.013), self acceptance (p ¼ 0.016), valued living (p ¼ 0.022), autonomy (p ¼ 0.032) and total cholesterol (p ¼ 0.025). Participants rated the program and materials very highly. These results indicate that the READY program is feasible to implement as a group training program in a workplace setting to promote psychosocial well-being.
Keywords: resilience; well-being; mental health; health promotion; ACT; depression; stress management
Background
Resilience is the capacity of people to effectively cope with, adjust, or recover from stress or adversity. When faced with adversity, people with low resilience are at risk of depression, stress, anxiety and interpersonal difficulties, and may adopt health compromising behaviors and experience somatic complaints and poor physical health. Prolonged stress and poor psychosocial functioning may negatively impact on physical health for example, via biological mechanisms such as hypertension and
*Corresponding author. Email: [email protected]
Psychology, Health & Medicine
Vol. 15, No. 3, May 2010, 266–277
ISSN 1354-8506 print/ISSN 1465-3966 online
� 2010 Taylor & Francis DOI: 10.1080/13548501003758710
http://www.informaworld.com
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blood pressure reactivity to stress, atherogenic lipid profiles, pro-inflammatory cytokines (e.g. C reactive protein), and the development of metabolic syndrome (Rozanski, Blumenthal, & Kaplan, 1999; Strike & Steptoe, 2004).
Most studies of resilience have focused on young people or individuals experiencing specific adverse circumstances, and have explored the personal characteristics associated with effective coping (Richardson & Waite, 2002). Only a few studies have focused on adults and investigated the effectiveness of resilience training. A worksite trial of the ‘‘Personal Resilience and Resilient Relationships’’ program, with 5 6 7 h modules implemented weekly over five weeks, demonstrated significantly higher levels of self esteem, locus of control, purpose in life, and interpersonal relations among program participants compared with a control group (Waite & Richardson, 2004). A modified version of this program, with 10 6 90 min modules implemented twice weekly over five weeks for people with diabetes, found no significant difference between program participants and a usual care group on the same psychological measures or glycosylated hemoglobin or waist circumference (Bradshaw et al., 2007). Participants of a worksite trial of the ‘‘Resilience Reintegration’’ program, implemented in approximately 14 days during six months for employees with illnesses attributed to work stress, demonstrated higher levels of effective coping (including seeking social support) and lower levels of depression at post- intervention compared with baseline (Steensma, Den Heijer, & Stallen, 2006). These latter two programs involved a tertiary approach to psychosocial well- being, as they targeted individuals with developed conditions so as to minimize suffering associated with poor health. Only the first program adopted a primary approach of promoting resilience in otherwise healthy adults.
We have developed a psychosocial resilience training program (READY: REsilience and Activity for every DaY) to promote resilience and psychosocial well-being in adults. The program is designed as a primary or secondary level of intervention, and targets adults at risk of stress or stress induced depressive symptoms, but otherwise generally healthy. The aim of this article is to describe a pilot study of the program that was conducted to obtain information on the feasibility of implementing the program as group-based training in a workplace setting. The study also examined the potential effectiveness of the program to promote subjective well-being, and reduce symptoms associated with depression and stress.
Method
The study protocol was approved by The University of Queensland Medical Research Ethics Committee (2007000303).
Study design
This study was a single group pre–post trial with outcome measures assessed the week immediately prior to and after the 13 week intervention period.
Setting
The program was conducted with employees of a university in a capital city.
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Participants
An invitation to participate in the program, without cost, was circulated in a weekly email communication to administrative staff at The University of Queensland (Australia). Interested respondents contacted the project staff by return email, and were then contacted by telephone by a research assistant who provided preliminary study information. Respondents were considered ineligible if they reported receiving current psychiatric/psychological treatment (pharmacological or therapy-based). Those who provided preliminary consent to participate were then asked to attend a group-based assessment session at the University. No incentives were offered for participation.
The intervention
The READY program targets five key resilience protective factors that were identified from empirical literature: (1) positive emotions; (2) cognitive flexibility (e.g. accep- tance), (3) life meaning, (4) social support, and (5) active coping strategies (including physical activity) (Southwick, Vythilingam, & Charney, 2005).
The intervention approach is based on Acceptance and Commitment Therapy (ACT), which is an empirically based third generation Cognitive Behavioral Therapy that uses acceptance and mindfulness strategies, and commitment and behavior change strategies to produce psychological flexibility and resilience through six core processes: Acceptance, cognitive defusion (changing our relationship with thoughts), being present (mindfulness), self-as-context, values and committed action (Hayes, Luoma, Bond, Masuda, & Lillis, 2006). The program also includes cognitive behavioral therapy processes of skills training for relaxation and building social support. One program module promotes participation in purposive and incidental physical activity. Physical activity has previously been identified as a potential coping resource (Southwick et al., 2005) that can provide enduring resilience to stress (Salmon, 2001), enhance well-being (Penedo & Dahn, 2005; Scully, Kremer, Meade, Graham, & Dudgeon, 1998; Stathopoulou, Powers, Berry, Smits, & Otto, 2006), and protect against incident depression symptoms (Brown, Ford, Burton, Marshall, & Dobson, 2005; Strawbridge, Deleger, Roberts, & Kaplan, 2002; van Gool et al., 2007).
The program has 11 modules, and sessions include psychoeducation, discussion, experiential exercises, and structured learning and practice activities. Session topics include an introduction to the READY resilience model, physical activity, mindfulness, defusion (two modules including self-as-context), acceptance, life values, social connectedness, relaxation and pleasant activities, and activating and trouble shooting strategies (two modules).
Participants receive a detailed workbook that includes an audio compact disc (with guided exercises), written notes, sections for critical reflection, and structured learning activities to complete. The reflection and learning activities comprise the READY Personal Plan, which is a personalized resource to help participants apply the generalized information to their specific context and individual style.
Eleven sessions each of two h duration were run weekly over 13 weeks (with 1 week off in weeks three and 10 because of public holidays) at the university. Sessions
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were held during the week after work hours (five–seven pm), and were led by two of the authors (N.B., K.P.) who are clinical and health psychologists.
Measures
Group assessment sessions were conducted at the university, in the week before and the week after the program, by three independent research assistants (one each for questionnaire, physical, and hematological measures) with the lead investigator (N.B.) in attendance.
Feasibility and acceptability
Participant attendance records were kept for each session by the interventionists, and reasons for non-attendance were recorded. The post intervention ques- tionnaire included items to obtain participant feedback on the program and materials.
Psychosocial well-being
A battery of self completed questionnaires included:
(1) Ryff’s Scales of Psychological Well-Being, including subscales of autonomy, environmental mastery, personal growth, positive relations, purpose in life, and self-acceptance (Ryff, 1989). This measure is widely used, has well established reliability and validity (Ryff & Singer, 2003), and has previously been shown to be sensitive to detecting treatment effects (Fava, Rafanelli, Grandi, Conti, & Belluardo, 1998).
(2) The Center for Epidemiological Studies Depression Scale (CES-D) (Radloff, 1977). This is one of the most commonly used self report questionnaires on depression for a general (vs. clinical) population, and has established reliability and validity (Radloff, 1977).
(3) The Short Version of the Depression Anxiety Stress Scale (DASS-21) with subscales of depression (DASS_Dep), stress (DASS_Stress), and anxiety (DASS_Anx), (Lovibond & Lovibond, 1995). Each subscale has been shown to have high internal consistency and has yielded meaningful discriminations in a variety of settings in both Australian clinical and community samples (Lovibond & Lovibond, 1995).
(4) The positive affect scale from The Positive and Negative Affect Schedule (PANAS-X), which is widely used with well established psychometric properties (Watson & Clark, 1999).
(5) The action consistency items from The Valued Living Questionnaire (Wilson & Groom, 2002). Psychometric data on this measure is not yet available.
(6) The Mindful Attention Awareness Scale, which has been shown to be reliable, valid, and sensitive to change (Brown & Ryan, 2003).
(7) The Acceptance and Action Questionnaire II (AAQII), which has acceptable levels of factorial validity, criterion validity, and reliability (Hayes et al., 2006).
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(8) The MOS Social Support Survey (Sherbourne & Stewart, 1991), which has acceptable levels of reliability and validity (Hays, Sherbourne, & Mazel, 1995).
Physical activity
Physical activity was measured via self-report using items adapted from the Active Australia surveys that ask about the total time spent during the previous week in walking (Australian Institute of Health and Welfare (AIHW), 2003). These items have acceptable levels of reliability and validity (Brown, Bauman, Chey, Trost, & Mummery, 2004; Brown, Burton, Marshall, & Miller, 2008; Brown, Trost, Bauman, Mummery, & Owen, 2004). Total time spent in activity was calculated by summing the time spent in minutes of activity across these three categories, after weighting minutes in vigorous activity by two to allow for the greater intensity [i.e. (minutes walking) þ (minutes moderate activity) þ (minutes vigorous activity 62)]. Physical activity was also assessed using pedometer step counts. Participants were asked to wear a pedometer for seven consecutive days and record the total number of steps taken each day. The pedometer and the step log were returned at the first group training session, and by mail after the program completion. Data was used to derive average daily step counts.
Physical and hematological measures
Physical measures included height and weight (used to derive body mass index [BMI]) and blood pressure (BP_Sys and BP_Dias). Hematological data involved a fasting blood sample to measure blood glucose, total cholesterol, C-reactive protein (CRP), and cortisol.
Sociodemographic measures
Questionnaire data were used to assess age, gender, country of birth, household composition, educational qualifications, employment status, occupation, ability to manage on income received, overall health status, caffeine and alcohol consumption, and tobacco cigarette consumption.
Analyses
Descriptive statistics were used to analyze attendance records, responses to questionnaire items about the program, and sociodemographic data. Outcome measure data were analyzed on an as per protocol basis. Standardized mean differences (with Hedges adjustment for a small sample size) and 95% confidence intervals were used to examine the relative size of the intervention effect across the different measures. For the following variables, scores were interpreted as positive intervention effects when the post-intervention values were lower than baseline: DASS_Stress, DASS_Dep (depression), DASS_Anx (anxiety), CES-D (depression), BP_Dias and BP_Sys (blood pressure), cholesterol, CRP (C- reactive protein), and BMI. Cohen’s standards (large [0.8], medium [0.5], and small [0.2]) were used to interpret the magnitude of intervention effects (Cohen, 1988).
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Paired t-tests were used to determine the significance of differences between baseline and post intervention scores. As this was a feasibility study with a small sample, an a of 0.05 was used initially instead of a more conservative value. However given the number of planned comparisons, results were also examined using a sequential Bonferroni adjustment of a levels.
Results
Participants
The sociodemographic characteristics of participants are presented in Table 1. The age of participants ranged from 24 to 50 years, with a mean of 36.5 (SD 8.6). The self-reported time spent in physical activity ranged from 45 to 1200 min/week, with a median of 205 minutes/week. Average daily steps ranged from 4956 to 14,249, with a mean of 9801 (SD ¼ 2784).
Feasibility
Thirty-five people responded to the study invitation and 18 people consented to participate. Two participants did not complete the program; one moved interstate, and the other discontinued because of a change in personal circumstances.
The average proportion of sessions attended by participants was 81%, with three participants attending all 11 sessions. During the program, 37% (n ¼ 6) missed one or two sessions, and 44% (n ¼ 7) missed three or four sessions. The most common reasons given for missing sessions were time conflicts with work meetings and planned recreation leave.
Participant feedback on the program was very positive. On a five-point Likert scale, the mean rating for the program overall was 4.67 (where 5 was excellent and 4 was very good), and the mean rating of personal helpfulness was 4.44 (where 5 was a lot and 4 was moderately so). On a four-point Likert scale (where 4 was very helpful and 3 was moderately helpful), the mean rating for the workbook was 3.87, and the mean rating for the READY Personal Plan was 3.5. The majority of participants agreed with the weekly frequency (75%) and the two hour session duration (87%). In terms of the overall program length, 56% agreed that it was good, and 31% thought it was too short.
Effect on psychosocial, physical activity, physical, and hematological measures
Figure 1 shows the standardized mean differences and 95% confidence intervals for each measure. There were large favorable intervention effects on measures of acceptance, environmental mastery, positive emotions, mindfulness and personal growth; moderate effects on measures of stress, self acceptance, valued living, autonomy, and depression; and a small effect on the total cholesterol measure.
The mean scores at baseline and post-intervention are shown in Table 2. Paired t-tests indicated a significant difference (p 5 0.05) between baseline and post intervention scores on measures of mastery (t[15] ¼ 4.234, p ¼ 0.001), positive emotions (t[15] ¼ 3.696, p ¼ 0.002), personal growth (t[15] ¼ 3.357, p ¼ 0.004), mindfulness (t[15] ¼ 3.362, p ¼ 0.004), acceptance (t[15] ¼ 2.847, p ¼ 0.012), stress (t[15] ¼ 72.807, p ¼ 0.013), self acceptance (t[15] ¼ 2.720, p ¼ 0.016), valued living (t[15] ¼ 2.557, p ¼ 0.022), autonomy (t[15] ¼ 2.369, p ¼ 0.032), and total
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cholesterol (t[15] ¼ 72.483, p ¼ 0.025). The difference on a measure of depression (CES-D) had borderline significance (t[15] ¼ 72.063, p ¼ 0.057). Using the sequential Bonferroni adjustment of a levels, only mastery remained significant.
Discussion
These results provide promising preliminary support for the READY program as an intervention that can be feasibly implemented as group-based training in a
Table 1. Sociodemographic characteristics of study sample.
Study sample % (n)
Gender Men 85 (15) Women 17 (3)
Age group (years) 20–30 33 (6) 31–40 33 (6) 41–50 33 (6)
Country of birth Australia 61 (11) UK/USA 17 (3) Other 22 (4)
Highest educational qualification completed School only 11 (2) Certificate/diploma 11 (2) University degree 78 (14)
Household composition Living alone 11 (2) Single and living with others 17 (3) Couple, no children 50 (9) Couple with children 22 (4)
Employment status Full time 83 (15) Part time/casual 17 (3)
Occupational group Manager or Senior Administrator 28 (5) Professional or Associate Professional 33 (6) Clerical/Other 39 (7)
Ability to manage on income received Easy 33 (6) Not too bad/Difficult sometimes 61 (11) Impossible 6 (1)
General health status Excellent/very good 17 (3) Good 33 (6) Fair/Poor 50 (9)
Body mass index 518.5–525 67 (12) 425 33 (6)
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workplace setting to improve psychosocial well-being. Our three-month implemen- tation period was twice as long as both the original and the modified Personal Resilience and Resilient Relationships program (Bradshaw et al., 2007; Waite & Richardson, 2004), but half the length of the Resilience and Reintegration program, although the majority of that was conducted in the first seven weeks (Steensma et al., 2006). READY involved 22 h of contact time, which was slightly longer than the Personal Resilience and Resilient Relationships Program (Bradshaw et al., 2007) but much shorter than the other two training programs that required 40 h (Waite & Richardson, 2004) and (approximately) 14 days (Steensma et al., 2006).
Written feedback indicated that the READY participants liked the weekly frequency of sessions, as this kept training issues ‘‘on the agenda’’ while also allowing time for reflection and skills practice. Although the 11 6 2 h sessions were seen as a significant time commitment, and less than 20% of participants attended all sessions, a shorter implementation period or shorter sessions was not favored by the majority of participants. There was some support for having a longer implementa- tion period to allow for more breaks during the program, e.g. the occasional two week break from weekly sessions, so as to consolidate learning and prevent fatigue. Consideration of this for future applications of the program would however, need to be in consultation with the employer organization; in this trial the implementation period was within one term in the university calendar.
Participants rated the program highly, and saw it as personally helpful and enjoyable. The participant workbook and READY Personal Plan were well received
Figure 1. Standardized mean difference and 95% confidence intervals for study measures.
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and seen as a useful resource both during and after the program. Specific suggestions to improve the program were to have more time in each session to review homework and activities from the previous week, more small group work, and more time to review the overall program and the READY Personal Plan.
There were large and significantly favorable intervention effects on measures of acceptance (acknowledging both positive and negative experiences), environmental mastery (effective and competent use of opportunities and external activities), positive emotions (e.g. interest, enthusiasm, determination), mindfulness (conscious attention and awareness), and personal growth (self improvement, openness to new experiences).
There were also moderate and significant favorable intervention effects on measures of stress, self acceptance (positive self attitude), valued living (actions consistent with life priorities and desires), and autonomy (self-determination, self regulation). As the READY program targeted positive emotions, problem solving, and life purpose as key protective factors, and included session modules on mindfulness and acceptance (targeting the protective factor of cognitive flexibility), improvements in these areas were particularly pleasing. Although there was a moderate favorable effect on depression, this did not reach statistical significance. This may reflect low baseline levels; the mean score for both the DASS_Depression
Table 2. Mean differences in measures between baseline and post-intervention.
Measure Mean
difference (SD) 95% confidence
interval p
Questionnaire measures Ryff_Autonomy 3.06 (5.17) 0.31–5.82 0.03 Ryff_Environmental mastery 6.25 (5.91) 3.10–9.40 0.001 Ryff_Personal growth 4.37 (5.21) 1.60–7.15 0.004 Ryff_Positive relations 1.06 (6.29) 72.29–4.41 0.509 Ryff_Life purpose 3.87 (9.82) 71.36–9.11 0.135 Ryff_Self acceptance 3.94 (5.79) 0.85–7.02 0.016 CES-D (Depression)
a 75.25 (10.18) 710.67–0.17 0.057 DASS_Depression
a 73.75 (9.46) 78.79–1.29 0.134 DASS_Stress
a 75.75 (8.19) 710.12 to 1.38 0.013 DASS_Anxiety
a 0.50 (7.17) 73.32–4.32 0.784
PANAS_positive affect 6.44 (6.97) 2.72–10.15 0.002 Valued living questionnaire 7.19 (11.24) 1.20–13.18 0.022 Mindful attention awareness scale 7.12 (8.48) 2.61–11.64 0.004 Acceptance and action questionnaire II (AAQII) 6.81 (9.57) 1.71–11.91 0.012 MOS social support survey 0.87 (2.03) 70.21 to 1.96 0.105
Physical activity Minutes/week 15.33 (289) 7144–175 0.840 Average steps/day 223.85 (2870) 71356–1823 0.757
Physical measures Body mass index
a 0.09 (1.11) 70.49–0.68 0.74
Blood pressure_systolic a 72.87 (7.62) 76.94–1.19 0.152
Blood pressure_diastolic a 70.87 (6.25) 74.20–2.45 0.584
Hematological measures Fasting blood glucose
a 70.74 (0.42) 70.30–0.15 0.489 Total cholesterol
a 70.26 (0.41) 70.48 to 0.03 0.025 C-Reactive protein
a 70.07 (0.83) 70.52–0.37 0.730 Cortisol
a 0.500 (27.69) 714.26–15.26 0.943
a Negative mean difference implies favorable change.
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subscale (Lovibond & Lovibond, 1995) and the CES-D (Radloff, 1977) were below ‘‘clinical’’ levels.
Because of the different measures used, our results are not directly comparable with other resilience training studies. There is however, conceptual similarity between our improvements on measures of valued living, autonomy, and self acceptance, and the higher levels of life purpose, locus of control, and self esteem reported by Waite and Richardson (2004). Consistent with Steensma et al., (2006) our study demonstrated improvements in depression, although as previously stated, this had only borderline significance.
Unlike other studies (Steensma et al., 2006; Waite & Richardson, 2004), we did not find significant improvements on measures of interpersonal relations. We used the MOS Social Support Survey (Sherbourne & Stewart, 1991), which assesses the frequency of the availability of sources of support (e.g. someone whose advice you really want, someone to show you love and affection), which may not have been sufficiently sensitive to change. Resilience was conceptualized as a primarily intra- personal construct to be developed by participants, while this measure assesses supportive behaviours provided by inter-personal networks, which was not under the direct influence of program participants. Other studies used measures that assessed seeking social support as a coping strategy (Steensma et al., 2006) and the frequency of specified interpersonal experiences (Waite & Richardson, 2004).
Consistent with the findings of Bradshaw et al., (2007), we did not find significant changes in the physical or haematological measures, or in self-reported physical activity. A lack of significant change in the hematological measures may be because these were largely within the accepted healthy ranges at baseline. We did however, have a small but significant change in total cholesterol. No significant changes in physical activity may have been because of high baseline levels; the median of 205 min/week is higher than the 5 6 30 min/week of moderate activity or 3 6 20 min/week of vigorous activity specified in national recommendations (Haskell et al., 2007). It should be noted however, that physical activity was conceptualized as only one aspect of resilience, and already active participants could still benefit from other program modules. Furthermore, participants may have qualitatively changed their experience of physical activity participation in response to the other program modules, such as doing physical activity with mindfulness. This could have had a synergistic effect on other outcome measures, such as for example positive emotions.
Limitations
As this study was a small-scale feasibility study, and not a controlled trial, we are unable to make conclusions about the efficacy of the program. There were however, significant pre–post improvements in specific indicators of well being and psychosocial functioning. Without a follow-up assessment, we are unable to comment on the sustainability of these improvements. As the construct of resilience is such that it implies a protective effect against future adversity, the longevity of any improvements will be important to assess in future research. The short implementa- tion period may have been insufficient to see changes in the physiological measures such as BMI. The study relied heavily on self-report data, which are vulnerable to social desirability bias and measurement error. However, we used questionnaires that have previously been demonstrated to have acceptable levels of sensitivity to change and reliability, and complemented the physical activity questionnaire data
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with objective step count (pedometer) data. As the study sample was recruited from staff at a university in a capital city, and included a majority of women and people with a university education, further work is needed to examine the acceptability and effectiveness of the program with a more heterogenous sample.
Conclusions
These results suggest that it is feasible to implement the READY program as a group training program in a worksite setting to promote psychosocial functioning and well- being. Participant feedback indicated that no major changes were required to the session duration, session frequency or program materials, but that a longer implementation period and more time for review activities could be considered. Sessions could also be restructured to allow for more small group work, and more review of previous sessions and homework activities. An alternative measure of social support, that focuses on the behaviours of the respondent (e.g. seeking support) rather than others (e.g. support provision) may be more useful. Future work will examine the efficacy of the program in a controlled trial, the sustainability of any improvements, and the mechanisms of change. This will facilitate our conceptual understanding of resilience, and our practical understanding of how to positively influence it.
Acknowledgements
Nicola Burton is a Heart Foundation Research Fellow (PH 08B 3904), and is also supported by a (Australian) National Health and Medical Research Council Capacity Building Grant (ID 252977) and Program Grant (ID 310200). This study was funded by a Program Grant from the (Australian) National Health and Medical Research Council (ID 301200). The authors thank the participants for their ongoing enthusiasm and support for the program, and Sarah Walters for research support.
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