New Approaches to HIV Prevention in African HIV Serodiscordant Couples

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ISBN 13 :
Total Pages : 118 pages
Book Rating : 4.:/5 (89 download)

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Book Synopsis New Approaches to HIV Prevention in African HIV Serodiscordant Couples by : Kathryn G. Curran

Download or read book New Approaches to HIV Prevention in African HIV Serodiscordant Couples written by Kathryn G. Curran and published by . This book was released on 2013 with total page 118 pages. Available in PDF, EPUB and Kindle. Book excerpt: This dissertation informs the future implementation of HIV prevention for HIV serodiscordant couples in Africa. The research objectives include: 1) reviewing effective HIV prevention interventions, 2) evaluating the use of daily short message service (SMS, i.e. text message) surveys to measure sex and pre-exposure prophylaxis (PrEP) adherence, and 3) examining the acceptability of initiation of antiretroviral therapy (ART) at higher CD4 counts, a powerful HIV prevention tool. After the necessary first step of HIV testing and counseling, HIV serodiscordant couples may be offered appropriate HIV prevention interventions, including condoms, male circumcision, treatment of sexually transmitted infections, and two recent biomedical strategies: initiation of ART by the HIV-infected partner and PrEP by the HIV-uninfected partner. Importantly, the widespread implementation and effectiveness of HIV prevention interventions requires understanding and encouraging behaviors for acceptance, adherence, and correct use. We conducted a prospective study of HIV-related behaviors and qualitative research to answer key implementation questions regarding the feasibility of PrEP and acceptability of early ART among HIV serodiscordant couples. Within a clinical trial of PrEP, we evaluated the use of daily SMS surveys to examine patterns in sexual behavior and PrEP use. Daily SMS data collection was acceptable, obtained high response rates, and provided an assessment of temporal patterns of HIV risk behaviors and PrEP use over a 60-day period. Participants were more likely to adhere to daily PrEP doses when they were sexually-active, PrEP use was not associated with unprotected sex, and anticipating sex was difficult. In addition, HIV risk behaviors were reported on more days through daily SMS surveys compared to monthly interviewer-administered questionnaires, highlighting the potential of SMS to collect more accurate self-reported data. SMS may offer a new method for measuring and promoting behaviors related to HIV risk and adherence as well as enhancing communication between patients and providers. Qualitative research with HIV serodiscordant couples familiar with HIV prevention methodologies highlighted common perceived advantages and concerns related to early initiation of ART, and an important conceptualization of ART as the "final stage" before dying. This negative meaning of ART initiation poses a challenge to acceptance of early ART and indicates that new messages regarding ART initiation are needed. These new messages should emphasize the benefits of HIV prevention and maintaining good health; acknowledge concerns such as side effects and life-long adherence; and ultimately, portray a positive image of individuals on ART. Social and behavioral factors, in particular sustained adherence as well as individual and community acceptance, will be fundamental to successful implementation of early ART and PrEP and should remain a focus of HIV prevention and treatment

Cross-Cultural Perspectives on Couples with Mixed HIV Status: Beyond Positive/Negative

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Author :
Publisher : Springer
ISBN 13 : 3319427253
Total Pages : 285 pages
Book Rating : 4.3/5 (194 download)

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Book Synopsis Cross-Cultural Perspectives on Couples with Mixed HIV Status: Beyond Positive/Negative by : Asha Persson

Download or read book Cross-Cultural Perspectives on Couples with Mixed HIV Status: Beyond Positive/Negative written by Asha Persson and published by Springer. This book was released on 2016-10-24 with total page 285 pages. Available in PDF, EPUB and Kindle. Book excerpt: This edited volume presents a detailed portrait of couples living with mixed HIV status, where one partner is HIV-positive and the other negative. Readers will come to understand the various and complex ways in which these mixed-status, or serodiscordant couples build a life together within the shadow of HIV-related stigma. Spanning the globe, coverage explores serodiscordance as a negotiated practice and process, inseparable from the social context in which it is situated. The book shows how couples draw on diverse and sometimes contradictory cultural discourses of medicine, romance, and “normality” to make sense of and manage their mixed HIV status and any perceived risks, not uncommonly in ways that depart from prevailing HIV prevention messages. Throughout, compelling personal stories accompany the empirical research, sharing the firsthand experiences of men and women in serodiscordant relationships. Bringing together research from diverse disciplines and geographical regions, this book contributes important insights for future HIV health promotion as well as offers new knowledge to scholarship on the cultural intersections of illness and intimacy. It will appeal to a broad audience working across the fields of HIV, health, gender, sexuality, development, and human rights.

Preventing and Mitigating AIDS in Sub-Saharan Africa

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Publisher : National Academies
ISBN 13 :
Total Pages : 36 pages
Book Rating : 4.1/5 (375 download)

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Book Synopsis Preventing and Mitigating AIDS in Sub-Saharan Africa by : National Research Council (U.S.). Panel on Data and Research Priorities for Arresting AIDS in Sub-Saharan Africa

Download or read book Preventing and Mitigating AIDS in Sub-Saharan Africa written by National Research Council (U.S.). Panel on Data and Research Priorities for Arresting AIDS in Sub-Saharan Africa and published by National Academies. This book was released on 1996-01-01 with total page 36 pages. Available in PDF, EPUB and Kindle. Book excerpt: The AIDS epidemic in Sub-Saharan Africa continues to affect all facets of life throughout the subcontinent. Deaths related to AIDS have driven down the life expectancy rate of residents in Zambia, Kenya, and Uganda with far-reaching implications. This book details the current state of the AIDS epidemic in Africa and what is known about the behaviors that contribute to the transmission of the HIV infection. It lays out what research is needed and what is necessary to design more effective prevention programs.

Guidelines for the Psychosocially Assisted Pharmacological Treatment of Opioid Dependence

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Publisher : World Health Organization
ISBN 13 : 9241547545
Total Pages : 133 pages
Book Rating : 4.2/5 (415 download)

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Book Synopsis Guidelines for the Psychosocially Assisted Pharmacological Treatment of Opioid Dependence by : World Health Organization. Department of Mental Health and Substance Abuse

Download or read book Guidelines for the Psychosocially Assisted Pharmacological Treatment of Opioid Dependence written by World Health Organization. Department of Mental Health and Substance Abuse and published by World Health Organization. This book was released on 2009 with total page 133 pages. Available in PDF, EPUB and Kindle. Book excerpt: "These guidelines were produced by the World Health Organization (WHO), Department of Mental Health and Substance Abuse, in collaboration with the United Nations Office on Drugs and Crime (UNODC) a Guidelines Development Group of technical experts, and in consultation with the International Narcotics Control Board (INCB) secretariat and other WHO departments. WHO also wishes to acknowledge the financial contribution of UNODC and the Joint United Nations Programme on HIV/AIDS (UNAIDS) to this project. " - p. iv

Guidance on Couples HIV Testing and Counselling Including Antiretroviral Therapy for Treatment and Prevention in Serodiscordant Couples

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Publisher :
ISBN 13 : 9789241501972
Total Pages : 66 pages
Book Rating : 4.5/5 (19 download)

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Book Synopsis Guidance on Couples HIV Testing and Counselling Including Antiretroviral Therapy for Treatment and Prevention in Serodiscordant Couples by : World Health Organization

Download or read book Guidance on Couples HIV Testing and Counselling Including Antiretroviral Therapy for Treatment and Prevention in Serodiscordant Couples written by World Health Organization and published by . This book was released on 2012 with total page 66 pages. Available in PDF, EPUB and Kindle. Book excerpt: "New WHO guidelines recommend offering HIV testing and counselling to couples, wherever HIV testing and counselling is available, including in antenatal clinics. For couples where only one partner is HIV positive, the guidelines recommend offering antiretroviral therapy to the HIV positive partner, regardless of his/her own immune status (CD4 count), to reduce the likelihood of HIV transmission to the HIV negative partner. Today, only 40% of people with HIV globally know their HIV status. Up to 50% of HIV-positive people in on-going relationships have HIV-negative partners (i.e. they are in serodiscordant relationships). Of those HIV-positive individuals who know their status, many have not disclosed their HIV status to their partners, nor do they know their partners' HIV status. Consequently, a significant number of new infections occur within serodiscordant couples. CHTC offers couples the opportunity to test, receive their results and mutually disclose their status in an environment where support is provided by a counsellor/health worker. A range of prevention, treatment and support options can then be discussed and decided upon together, depending on the status of each partner. Recent evidence confirms the benefit of early ART for people with a CD4 count above 350 cells/μL in preventing transmission to HIV-negative partners. In order to benefit from such opportunities, couples should be supported to test together and disclose their status to each other and access prevention, care and treatment services."--Publisher description.

Disease Control Priorities, Third Edition (Volume 6)

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Publisher : World Bank Publications
ISBN 13 : 1464805253
Total Pages : 1027 pages
Book Rating : 4.4/5 (648 download)

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Book Synopsis Disease Control Priorities, Third Edition (Volume 6) by : King K. Holmes

Download or read book Disease Control Priorities, Third Edition (Volume 6) written by King K. Holmes and published by World Bank Publications. This book was released on 2017-11-06 with total page 1027 pages. Available in PDF, EPUB and Kindle. Book excerpt: Infectious diseases are the leading cause of death globally, particularly among children and young adults. The spread of new pathogens and the threat of antimicrobial resistance pose particular challenges in combating these diseases. Major Infectious Diseases identifies feasible, cost-effective packages of interventions and strategies across delivery platforms to prevent and treat HIV/AIDS, other sexually transmitted infections, tuberculosis, malaria, adult febrile illness, viral hepatitis, and neglected tropical diseases. The volume emphasizes the need to effectively address emerging antimicrobial resistance, strengthen health systems, and increase access to care. The attainable goals are to reduce incidence, develop innovative approaches, and optimize existing tools in resource-constrained settings.

Antiretroviral Treatment as Prevention in African HIV-1 Serodiscordant Couples

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Publisher :
ISBN 13 :
Total Pages : 78 pages
Book Rating : 4.:/5 (957 download)

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Book Synopsis Antiretroviral Treatment as Prevention in African HIV-1 Serodiscordant Couples by : Andrew Mujugira

Download or read book Antiretroviral Treatment as Prevention in African HIV-1 Serodiscordant Couples written by Andrew Mujugira and published by . This book was released on 2016 with total page 78 pages. Available in PDF, EPUB and Kindle. Book excerpt: The studies described in this dissertation examine the relationship between use of antiretroviral therapy (ART) and biologic and behavioral factors related to HIV-1 transmission risk in stable heterosexual HIV-1 serodiscordant African couples. ART is recommended for all HIV-1 infected persons, regardless of CD4 count, to reduce HIV-1 related morbidity, mortality and risk of transmission to uninfected partners. ART is a cornerstone of combination HIV-1 prevention, and optimizing use of ART, both for treatment and prevention, is an urgent public health priority. The complementary prospective studies presented in this dissertation were secondary analyses of data from the Partners PrEP Study, a randomized clinical trial of daily oral pre-exposure prophylaxis (PrEP) to decrease HIV-1 acquisition among HIV-1 uninfected members of serodiscordant couples in Kenya and Uganda. This work includes prospective studies of: 1) correlates of failure to achieve plasma viral suppression and virologic rebound after initial suppression, 2) frequency, magnitude and correlates of seminal HIV-1 RNA shedding in men initiating ART, 3) residual HIV-1 transmission risk during the first 6 months of ART, and 4) sexual risk behavior before and after ART. Younger age was associated with delayed ART initiation, failure to achieve viral suppression, and increased risk of virologic rebound after initial suppression. Seminal HIV-1 RNA shedding was infrequent and present at low levels in HIV-1 infected African men with suppressed blood HIV-1 RNA. There were no HIV-1 transmission events on suppressive ART. We observed residual HIV-1 transmission risk during the first 6-months of ART, prior to complete viral suppression in blood and genital secretions. Importantly, substantial risk compensation did not occur following ART initiation among HIV-1 infected persons with known uninfected partners. Results from this dissertation contribute further evidence of the effectiveness of ART for HIV-1 prevention, and provide reassurance that HIV-1 transmission risk declines after starting ART. As treatment guidelines evolve from wait-and-treat to test-and-treat, scaling up access to HIV-1 testing, improving linkage and retention in care, and achieving high ART coverage and complete viral suppression at individual and population levels are essential to achieving zero new HIV-1 infections and zero AIDS-related deaths.

Advances in HIV and AIDS Control

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Publisher : BoD – Books on Demand
ISBN 13 : 1789846021
Total Pages : 260 pages
Book Rating : 4.7/5 (898 download)

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Book Synopsis Advances in HIV and AIDS Control by : Samuel Ikwaras Okware

Download or read book Advances in HIV and AIDS Control written by Samuel Ikwaras Okware and published by BoD – Books on Demand. This book was released on 2018-12-12 with total page 260 pages. Available in PDF, EPUB and Kindle. Book excerpt: The HIV epidemic has had a significant and profound impact on the world and health resources. Considerable progress has been made in understanding the risks and drivers of the epidemic. Antiretroviral drugs have relieved human suffering and prolonged life. However, access to quality management needs to scale up and be made universal. This book discusses critical issues related to the treatment of HIV infection and related co-infections and challenges in adherence and discordancy. New vaccine approaches discussed may provide the ultimate solution for eradication. Sharing knowledge from various experts in medical and basic sciences improves the quality of care for this persistent global threat. This book discusses emerging advances in HIV-AIDS management to support strategies for control and elimination.

Couples of Mixed HIV Status

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Publisher : Routledge
ISBN 13 : 1136406794
Total Pages : 182 pages
Book Rating : 4.1/5 (364 download)

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Book Synopsis Couples of Mixed HIV Status by : R Dennis Shelby

Download or read book Couples of Mixed HIV Status written by R Dennis Shelby and published by Routledge. This book was released on 2012-12-06 with total page 182 pages. Available in PDF, EPUB and Kindle. Book excerpt: Examine the unique emotional challenges and issues that face couples of mixed HIV status today! Previous books on this subject—mostly written in the days when HIV/AIDS was considered a fatal rather than a chronic disease—focused on end-of-life issues. However, Couples of Mixed HIV Status: Clinical Issues and Interventions addresses the unique emotional challenges facing today’s couples of mixed HIV status and provides a conceptual framework for assessment and intervention. The book offers examples of how to apply emotionally focused couple therapy to help them work through issues including disclosure, the fear of HIV transmission, shifts in emotional intimacy, family planning, betrayal, mistrust, and uncertainty. This unique work, its knowledge base, and the interventions you'll find inside, are applicable to any practitioner who provides couple and family therapy—as well as any practitioner who counsels around issues of chronic illness. Couples of Mixed HIV Status provides therapists with a range of theoretical approaches to help mixed HIV status couples deal with their issues and concerns. It includes applications of couple therapy approaches that have proved to be particularly effective as well as case studies that demonstrate how different relationship variables may affect therapy. The book presents the findings of a research study involving 44 mixed HIV status couples in the Northeast and is generously illustrated with tables that make complex research results easy to access and understand. Topics covered in Couples of Mixed HIV Status include: various approaches to couples therapy the historical context of HIV/AIDS HIV transmission family planning and HIV/AIDS emotionally focused couple therapy disclosure issues attachment theory and much more! Couples of Mixed HIV Status: Clinical Issues and Interventions is a valuable resource for therapists and other mental health counselors working with today’s couples of mixed HIV status as well as for students of counseling and health related services. Readers who may be in a mixed HIV status relationship or those who are friends and family members of couples living with HIV will also find this book helpful.

Risk Perception Among HIV Serodiscordant Couples in East Africa Taking Oral PrEP for HIV Prevention

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Publisher :
ISBN 13 :
Total Pages : 34 pages
Book Rating : 4.:/5 (935 download)

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Book Synopsis Risk Perception Among HIV Serodiscordant Couples in East Africa Taking Oral PrEP for HIV Prevention by : Jennifer J. Carroll

Download or read book Risk Perception Among HIV Serodiscordant Couples in East Africa Taking Oral PrEP for HIV Prevention written by Jennifer J. Carroll and published by . This book was released on 2015 with total page 34 pages. Available in PDF, EPUB and Kindle. Book excerpt: Levels of adherence varied across trials for pre-exposure prophylaxis (PrEP) for HIV prevention. One hypothesis for this inconsistency is that low perceived risk of HIV infection drove low adherence in trials where PrEP produced no reduction in risk. Using a mixed methods approach, we explored the level of perceived risk of incident HIV infection in the Partners PrEP Study, in which adherence was generally high. The Partners PrEP Study followed 4747 serodiscordant couples in Kenya and Uganda. A brief cross-sectional survey assessed perceived risk of HIV via questionnaire at 12 months after enrollment. Logistic regression was used to analyze the relationship between perceived risk and demographic variables, sexual behavior, and other objective measures of risk. 3226 couples from the Partners PrEP Study were included in this analysis. Perceived risk was low across the entire study cohort, with only 15.4% of participants reporting high or moderate perceived risk. Participants objectively assessed to be at higher risk for HIV were more likely to report high perceived risk (OR=1.60, 95%CI: 1.30-1.95, p

Antiretroviral Therapy Initiation for Treatment and Prevention in East Africa

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Publisher :
ISBN 13 :
Total Pages : 28 pages
Book Rating : 4.:/5 (88 download)

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Book Synopsis Antiretroviral Therapy Initiation for Treatment and Prevention in East Africa by : Andrew Mujugira

Download or read book Antiretroviral Therapy Initiation for Treatment and Prevention in East Africa written by Andrew Mujugira and published by . This book was released on 2013 with total page 28 pages. Available in PDF, EPUB and Kindle. Book excerpt: In serodiscordant couples, provision of antiretroviral therapy (ART) to the HIV-infected partner significantly decreases risk of sexual HIV transmission of HIV. The World Health Organization has recently issued guidelines recommending ART initiation, regardless of CD4 count, for HIV-infected members of serodiscordant couples to prevent HIV transmission to the uninfected partner. We conducted a prospective cohort study among 1998 HIV-infected individuals with known HIV-uninfected partners who were enrolled in the Partners PrEP Study, an HIV prevention clinical trial in Kenya and Uganda. The primary objective was to assess ART initiation in those who became ART-eligible during study follow-up. The cumulative probabilities of initiating ART at 6, 12, and 24 months after referral were 60.8%, 78.8% and 91.5%, respectively. Approximately 40% of HIV-infected partners had not initiated ART six months after initial referrals. Higher CD4 (p0.001), asymptomatic HIV disease (p=0.04), and alcohol use (p=0.001) were significant predictors of ART initiation. To evaluate whether HIV-infected persons would be interested in earlier ART (CD4 350 cells/ [mu] L) for HIV prevention, as recommended by the WHO, we conducted a cross-sectional study among an additional 571 East African HIV-infected individuals in serodiscordant partnerships. The objective of the study was to determine whether fertility intentions were correlated with a greater likelihood to initiate early ART for prevention. We found that HIV-infected partners with fertility intentions were nearly twice as likely to express interest in early ART for HIV prevention (adjusted odds ratio [AHR] 1.83, p=0.02) than those without fertility intentions. Younger age (p

Understanding and Optimising HIV Prevention and Related Outcomes Among Serodiscordant Couples in Africa

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Publisher :
ISBN 13 :
Total Pages : pages
Book Rating : 4.:/5 (16 download)

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Book Synopsis Understanding and Optimising HIV Prevention and Related Outcomes Among Serodiscordant Couples in Africa by : Britta Jewell

Download or read book Understanding and Optimising HIV Prevention and Related Outcomes Among Serodiscordant Couples in Africa written by Britta Jewell and published by . This book was released on 2015 with total page pages. Available in PDF, EPUB and Kindle. Book excerpt:

AIDS, Behavior, and Culture

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Publisher : Routledge
ISBN 13 : 1315435152
Total Pages : 289 pages
Book Rating : 4.3/5 (154 download)

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Book Synopsis AIDS, Behavior, and Culture by : Edward C Green

Download or read book AIDS, Behavior, and Culture written by Edward C Green and published by Routledge. This book was released on 2016-06-16 with total page 289 pages. Available in PDF, EPUB and Kindle. Book excerpt: AIDS, Behavior, and Culture presents a bold challenge to the prevailing wisdom of “the global AIDS industry” and offers an alternative framework for understanding what works in HIV prevention. Arguing for a behavior-based approach, Green and Ruark make the case that the most effective programs are those that encourage fundamental behavioral changes such as abstinence, delay of sex, faithfulness, and cessation of injection drug use. Successful programs are locally based, low cost, low tech, innovative, and built on existing cultural structures. In contrast, they argue that anthropologists and public health practitioners focus on counseling, testing, condoms, and treatment, and impose their Western values, culture, and political ideologies in an attempt to “liberate” non-Western people from sexual repression and homophobia. This provocative book is essential reading for anyone working in HIV/AIDS prevention, and a stimulating introduction to the key controversies and approaches in global health and medical anthropology for students and general readers.

New Approaches to HIV Prevention

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Publisher :
ISBN 13 :
Total Pages : 34 pages
Book Rating : 4.:/5 (557 download)

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Book Synopsis New Approaches to HIV Prevention by : Global HIV Prevention Working Group

Download or read book New Approaches to HIV Prevention written by Global HIV Prevention Working Group and published by . This book was released on 2006 with total page 34 pages. Available in PDF, EPUB and Kindle. Book excerpt:

Couple-Centred Testing and Counselling for HIV Serodiscordant Heterosexual Couples in Sub-Saharan Africa

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Publisher :
ISBN 13 :
Total Pages : pages
Book Rating : 4.:/5 (129 download)

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Book Synopsis Couple-Centred Testing and Counselling for HIV Serodiscordant Heterosexual Couples in Sub-Saharan Africa by : Annabel Desgrees du Lou

Download or read book Couple-Centred Testing and Counselling for HIV Serodiscordant Heterosexual Couples in Sub-Saharan Africa written by Annabel Desgrees du Lou and published by . This book was released on 2009 with total page pages. Available in PDF, EPUB and Kindle. Book excerpt: In Africa, a large proportion of HIV infections occur within stable relationships, either because of prior infection of one of the partners or because of infidelity. In five African countries at least two-thirds of couples with at least one HIV-positive partner were HIV serodiscordant; in half of them, the woman was the HIV-positive partner. Hence, there is an urgent need to define strategies to prevent HIV transmission within couple relationships. HIV counselling and testing have largely been organised on an individual and sex-specific basis, for pregnant women in programmes for prevention of mother-to-child transmission of HIV and in STI consultations and recently male circumcision for men. A couple-centred approach to HIV counselling and testing would facilitate communication about HIV status and adoption of preventive behaviours within couples. This paper reviews what is known about HIV serodiscordance in heterosexual couples in sub-Saharan Africa and what has been published about couple-centred initiatives for HIV counselling and testing since the early 1990s. Despite positive outcomes, couple-oriented programmes have not been implemented on a large scale. In order to stimulate and strengthen HIV prevention efforts, increased attention is required to promote prevention and testing and counselling for couples in stable relationships.

A Holistic Approach to HIV and AIDS in Africa

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Publisher :
ISBN 13 :
Total Pages : 172 pages
Book Rating : 4.F/5 ( download)

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Book Synopsis A Holistic Approach to HIV and AIDS in Africa by : Marco Moerschbacher

Download or read book A Holistic Approach to HIV and AIDS in Africa written by Marco Moerschbacher and published by . This book was released on 2008 with total page 172 pages. Available in PDF, EPUB and Kindle. Book excerpt: During the 15th Plenary Assembly that took place in Uganda in June 2005, Bishops of the Association of Member Episcopal Conferences in Eastern Africa (AMECEA) came out with a common framework of responding to the challenges of HIV/AIDS in the region. The call was to increase efforts of fighting the pandemic by using the values found in the Gospel and in the Church's social teachings.

HIV Treatment and Prevention in KwaZulu-Natal, South Africa: Individual, Couple, and Household Effects of Antiretroviral Therapy

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Publisher :
ISBN 13 :
Total Pages : pages
Book Rating : 4.:/5 (951 download)

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Book Synopsis HIV Treatment and Prevention in KwaZulu-Natal, South Africa: Individual, Couple, and Household Effects of Antiretroviral Therapy by : Catherine E. Oldenburg

Download or read book HIV Treatment and Prevention in KwaZulu-Natal, South Africa: Individual, Couple, and Household Effects of Antiretroviral Therapy written by Catherine E. Oldenburg and published by . This book was released on 2016 with total page pages. Available in PDF, EPUB and Kindle. Book excerpt: Using the Africa Centre for Population Health's demographic and HIV surveillance program, a population-based open cohort that has been conducting annual surveillance since 2000, this dissertation evaluates the effectiveness of ART in a real-world setting at multiple levels, including for individuals, within couples, and in households. First, this dissertation analyzes the effect of ART uptake in serodiscordant couples in the risk of HIV acquisition by the uninfected partner. Second, the effectiveness of immediate eligibility for ART on household-level HIV acquisition is assessed. Finally, the effect of immediate ART eligibility and uptake on survival in HIV-infected individuals is examined using two causal modeling approaches.