Vol.09 No.03(2017), Article ID:74879,20 pages

Barriers and Promoting Strategies to Sexual Health Assessment for Patients with Coronary Artery Diseases in Nursing Practice: A Literature Review

Izzeddin A. Abu Bdair1*, Rose E. ConsTantino2

1School of Nursing, The University of Jordan, Amman, Jordan

2School of Nursing, University of Pittsburgh, Pittsburgh, Pennsylvania, USA

Copyright © 2017 by authors and Scientific Research Publishing Inc.

This work is licensed under the Creative Commons Attribution International License (CC BY 4.0).

Received: January 12, 2017; Accepted: March 21, 2017; Published: March 24, 2017


Background: Sexual health is an important and integral part of human health. Patients often voice their concerns regarding their sexual health after experiencing coronary artery diseases. Nurses face many barriers to conduct sexual health assessment. Although many sexual health instructions have been developed, nurses still pay little attention to sexual health assessment. Purpose: The purpose of this literature review was to identify the barriers and strategies that promoted sexual health assessment in clinical nursing practice. Design: A comprehensive search of the recent literature related to barriers and promoting strategies to sexual health assessment was undertaken. Methods: A review of literature published over the last 10 years on a wide variety of recent studies in nursing and related discipline in the field of sexual health was performed. Findings: Most studies indicated that sexual health was poorly addressed in clinical settings. Barriers to addressing sexual health are multifactorial; we classified them into four categories: patients related barriers, nurses related barriers, organizational related barriers and value related barriers. Many strategies to enhance sexual health assessment and counseling in clinical setting are summarized. Conclusion: Overall, it is evident that nurses encounter many barriers to sexual health assessment. Therefore, investigating these barriers and developing appropriate interventions are recommended.


Sexual Health, Barriers, Nurses, Jordan, Coronary Artery Diseases

1. Introduction

Sexual health is a major health need and concern for patients recovering from major diseases and disorders. Sexuality is a central component of all human functions that need to be fulfilled. The World Health Organization defined sexual health as “a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity” [1] . Sexual activity is defined as “any mutually voluntary activity with another adult person that involves sexual contact, whether or not intercourse or orgasm occurs” [2] . Sexual activities include various behaviors for example kissing, hugging, touching, stimulating and intercourse [3] . Sexual dysfunction is a broad term that reflects any problem which interferes with persons’ sexual desire [4] . Sexual dysfunction includes erectile dysfunction, loss of sexual desire, orgasmic difficulties, lack of interest in sex, and feeling afraid by patients or by the partner in having sex [5] .

Heart diseases are still the number one cause of death in United States and developed world [6] . Annually about 750,000 Americans have a heart attack [7] . In Jordan, heart diseases account for more than 35% of the deaths among Jordanian population [8] .

The CADs and Sexual Health

The experience of living with CADs is associated with a variety of consequences that influence patients’ sexual health [9] . Patients with CADs complain of different sexual health problems including decrease of sexual activities, interest in sex and level of sexual satisfaction [10] , physical discomfort during sexual activities [11] , and alterations in both frequency and quality of sexual activity [12] .

There are many factors that affect sexual health of patients with CADs. Miner and Kim reported that aging, being a male, and having chronic diseases create a negative effect on sexual health [13] . Other factors include comorbidities [14] and associated symptoms such as anxiety and fatigue [15] . The new role of partners in taking care of their spouse instead of engaging in sexual activities also affects patients’ sexual health [16] . Jaarsma and colleagues reported that patients’ activity intolerance, physiological and psychological changes due to health condition, treating medications and recreational habits influence patients’ sexual health [15] .

The prevalence of sexual problems is high among patients with CADs. The rates of sexual health problems vary based on a variety of related factors such as patient’s age, severity of disease and co-morbidities that range between 20% [17] and 70% [18] . About half (46%) of 382 patients with CADs in six rehabilitation centers reported sexual problems [19] . In one study conducted in Jordan (N = 124), about three quarters of patients with heart diseases reported that their sexual health is being altered [20] .

The purpose of this literature review was to identify the barriers and strategies that promote sexual health assessment in clinical nursing practice. In Jordan, there is little research done in the field of sexual health in nursing. The findings may help direct further research and lead to practical interventions for nursing practice. At the heart of this review, the research question is: what are the barriers and prompting strategies to sexual health assessment in clinical nursing practice?

2. Methods

A thorough and exhaustive review of related literature was conducted to analyze and synthesize the literature about barriers and promoting strategies to sexual health assessment in nursing clinical practice. The literature search was conducted by the first author through searches of the following electronic databases: PubMed, Medline, science direct, EBSCO, Google Scholar and CINALH. The search stra- tegy used different key words including sexual health, nurse’s knowledge, barriers, CADs and sexual counseling on a wide range of quantitative and qualitative studies about sexual health assessment in clinical practice. Reference lists of reviewed studies were retrieved to identify additional and relevant studies that were not found through any other search methodologies in electronic databases.

The inclusion criteria were published studies in English language, relevance to the study aims, published within the last 10 years. The exclusion criteria were studies that were not relevant to the study purposes, non-nursing studies, and studies published in languages other than English or before more than 10 years. All obtained articles were filtrated to remove irrelevant and duplicated articles. The process of the articles extraction was selective; the studies that examined barriers or promoting interventions to sexual health assessment in nursing were selected from different cultural backgrounds. The final included studies in the study sample were 19.

3. Background

3.1. Patients’ Needs for Sexual Health Assessment

According to the American Heart Association, fulfilling sexual activity is an important aspect of the quality of life [21] . Patients with CADs are eager to return to their routine after discharge. However, resuming sexual activities is viewed as a challenging activity by patients and their partners [22] . Miner and Kim found that men and their partners have a great concern when they can resume sexual activity safely after CADs [13] . For example, patients may need to know how their sexual health is being affected by the illness, by medications and associated side effects, when can they resume their sexual activities, what are the warning signs reportable to the physician, what sex enhancing medications can they use and what preparations are available to aid in resuming sexual activities. Byrne and colleagues reported that about half of 382 cardiac patients preferred the opportunity of addressing their sexual health concerns by health care providers [19] . Assessment of sexual matters with patients with acute MI is an important factor to prevent loss of sexual activity [23] . Lack of sexual education for patients with MI was a leading cause of absence or less frequent sexual activity in both male and female patients [23] [24] . Therefore, providing patients with sexual health information aids in improving patients’ sexual interest and satisfaction through decreasing patients’ and partner level of anxiety and fear from engaging in sexual activities and improve patients’ sexual life [22] . Providing sexual health instructions for patients with CADs is an essential nursing task [25] . Despite supporting evidence and increased attention to sexual health assessment over the years, it is still a challenge for many nurses to address sexual health in practice [13] .

3.2. Sexual Health Assessment in Clinical Practice

Sexual health assessment in clinical practice is viewed as a private matter between partners by nurses and rarely discussed [26] . For example, in the United States, Lindau et al reported that only one-third of women and half of men with MI were educated about sexual health during their hospitalization [23] . In a pheno- menological study, Andersson and colleagues [12] concluded that majority of young adults with MI mentioned that health care providers did not provide them with information about sexual health. Similar results were found by Ozdemir and Akdemir that none of 108 nurses in cardiac units provided sexual education to patients with CADs after recovery [27] . However, sexual health assessment is important to help patients resume their sexual life [28] .

There is an increasing interest in providing holistic care that includes sexual health assessment [29] . Amongst other healthcare professionals, nurses can play a significant role in conducting sexual health assessment [30] . Nurses have good relationships with patients due to their daily contact with patients that facilitate assessment of sexual health [31] . Moreover, nurses documented that sexual health assessment for patients is a part of their professional role [32] . Nurses have shown little competence in sexual health assessment and therefore requires more practice by nurse clinicians [33] . In short, patients’ sexual health assessment is a nursing task but nurses still hesitate to conduct sexual health assessment in clinical practice [4] .

4. Results

Results were summarized from our review of to nursing, specifically and health re- lated disciplines literature, generally regarding barriers that prevent nurses from conducting sexual health assessment. Barriers and strategies to integrate sexual health assessment in clinical practice are summarized in Table 1.

4.1. Barriers for Assessment of Sexual Health

Sexual health following CADs has gained a great attention in nursing research. Despite increase attention, sexual health assessment still is challenging for the vast majority of nurses. There are several authors that studied barriers to sexual health assessment in nursing practice in different cultural background [34] . For purposes of this paper, authors classified barriers based on previous research work and reviewing the literature into four main categories: nurses-related barriers, patients-related barriers, organizational related barriers and values-related barriers. Barriers to sexual health assessment is viewed differently by different cultures, authors studied barriers taking cultural backgrounds in consideration. This classification organizes and integrates all possible barriers in a comprehensive and clear way that might help nurse clinicians, educators, administrators and re-

Table 1. Barriers and promoting activities for sexual health assessment in clinical practice.

searchers where to focus to find the most appropriate interventions to facilitate sexual health assessment.

4.2. Nurses-Related Barriers

In order to find out the main barriers that constrain nurses from addressing patients’ sexual health in clinical practice, Ho and Fernández found that lack of education, embarrassment, cultural restrictions, lack of experience and religious prohibitions are the main barriers [47] . Saunamäki and Engström reported that some nurses thought that sexual health assessment is a taboo subject and therefore it should not be discussed and it is not within their job description and it is someone else’s responsibility [30] . Doherty et al. mentioned lack of proper training on how to discuss sexual health issues as a barrier [34] .

Other barriers include insufficient nurses’ knowledge and viewing sexual health as a private matter between adult partners that should not be discussed by nurses [27] , lack of time to prepare and feeling uncomfortable to provide patients with sexual education [24] . Some nurses view assessment of patients’ sexual health as at low priority [33] or make them upset, embarrassed or anxious [24] . Byrne and colleagues found that lack of enough time due to workload, feeling that patients are not ready to receive sexual information and lack of education and training are important barriers that nurses may encounter [48] .

Magnan and Reynolds [45] investigated the main barriers for sexual health assessment in five fields of specialization (N = 302) and found that nurses perceived that sexual health is not a part of their patient care have coalesced with their lack of comfort, confidence and time to discuss patient sexual health needs. Huang et al. found that nurses are uncomfortable when addressing patients’ sexual health matters [42] . Doherty et al. outlined a list of barriers including patients’ lack of readiness, knowledge deficit and lack of training programs for nurses [34] . Saunamäki, Andersson and Engström found that Sweden nurses are knowledgeable in sexual health field, feel comfortable and responsible and show readiness to do sexual health assessment, but the vast majority of them did not address patients’ sexual health as they feel unconfident and did not specify a time to do so [36] .

Finally, nurses’ beliefs and attitudes toward sexual health may prevent them from assessing patients’ sexual health. Most of nurses who never assess patients’ sexual health have a negative attitude toward sexual health discussion [48] . The main responses that affect health care providers’ attitudes are difficulties in answering to patients’ sexual problems, concerns, and questions and lack of confidence, skills and training [49] . Some nurses have personal beliefs and values that assessment of sexual issues is not ethical [50] . Therefore, understanding nurses’ attitudes towards addressing patients’ sexual health is an important consideration by encouraging nurses to attend to patients’ sexual concerns within the routine nursing care.

4.3. Patient-Related Barriers

Additional barriers were found that were not related to the competency of health care providers. Patient related factors can also impede the addressing of sexual health needs. Many patients reported their interest to discuss sexual concerns with health care providers, but they did not do so because they are embarrassed [51] , or believe that they just have experienced a diminishing sexuality due to nor- mal ageing process [52] . Sometimes, nurses may be reluctant to start sexual assess- ment and teaching because they fear that discussion of sexual related issues can annoy the patient [51] or fear from any unexpected response from patients [53] . Buttaro et al reported that pateints’ age, culture, sexual orientation, comorbidity diseases, and limited time are main barriers to sexual health assessment [54] .

4.4. Organizational-Related Barriers

Some barriers are related to the academic and health care institutions. Doherty and colleges stated that cardiac nurses ignore sexual health assessment because health institutions lack guidelines regarding sexual assessment and management, specialized referral clinics and nurses do not have enough confidence, knowledge and training [34] . Hoekstra et al. [5] reported that lack of health policies about addressing sexual health was the main barrier. Furthermore, Quinn and colleagues found that healthcare organization view sexual health assessment is not a priority [33] . In China, nurses reported that nurses’ shortage and lack of resources are significant barriers to address patients’ sexual health [55] . Furthermore, lack of support from the institutions [56] , lack of privacy [57] , work overload and a sense that addressing sexual health is non-nursing job [29] are cited as organizational barriers.

Academic nursing curricula in Jordan often ignore discussing of sexual health issues for nursing students. Despite that, several studies reported that addressing sexual health issues during undergraduate education is vital to increase nurses’ knowledge [33] [58] .

4.5. Values-Related Barriers

Finally, culture, society, and religion are external barriers that are related to values of persons or community preventing assessment of sexual health with patients during their hospitalization. Many cultures including Arab Islamic culture considering sexual related topics are sensitive. Goossens et al examined the impact of culture in five Europe countries and found that nurses’ beliefs and attitudes about sexual health are influenced by both culture and country [30] . In some cultures, there is a common belief that sexual health is not a matter for older adults or those who with chronic conditions [59] . Turkish nursing students’ did not offer sexual health assessment and education to patients due to effects of cultural and religious beliefs [60] . In the Turkish culture, open communications about sexual matters between different sexes is prohibited, then preventing nurses from sexual health assessment [61] .

Societal restrictions can interfere with providing sexual health care [29] . Purabuli, Azizzade and Alizadeh found that most nurses in Iran (96%) highlight the necessity for nurse educators to be same sex as the patient [40] . Social interpretation of sexual issues is another barrier, for example, sex means pleasure and enjoyment and it is not logical to address it during illness. Based on this interpretation, Chinese nurses pay more attention to physical health condition rather than sexual concerns [55] .

In summary, to gain more depth insight, all possible barriers to sexual health assessment in nursing practice based on reviewed studies are outlined below in Table 2.

4.6. Promoting Strategies for Sexual Health Assessment in Nursing Practice

As sexual health-related needs are sensitive issues and often challenging task for nurses. Special considerations are required to help nurses conducting patients’ sexual health assessment in clinical practice. In attempts to overcome barriers, we suggest a multidisplinary team to develop standardized guidelines to sexual health assessment. Strategies to facilitate sexual health assessment are outlined below.

First: Integrate sexual health assessment topics in nursing curriculum during undergraduate studies. Jaarsma et al. found that nurses have knowledge deficit

Table 2. Barriers to sexual health assessment in clinical nursing practice.

*Means that barrier is related to two or more categories.

and lack of confidence to talk about sexual matters [24] . Well-prepared nurses in term of knowledge and skills make them more confident in providing sexual health assessment and information.

Second: Conduct training sessions and workshops on sexual health assessment for nurses in clinical setting (sexual health competency). Training programs about sexual health improve nurses’ comfort and attitude toward bringing sexual health assessment into practice [35] [36] . Clinical training workshops with simulation role-play case scenarios by nurse specialist in sexuality matters is highly recommended to help nurses addressing patients’ sexual health [24] .

Third: Teach effective communication skills to nurses and build rapport and therapeutic relationship between nurse and patients to make nurses more able to translate their acquired sexual knowledge into practice [55] . The close relationship between nurses and patients gives both a great chance to discuss sexual con- cerns [62] . Nurses could use their art to address patients’ sexual health in a way that fit with patients’ values, beliefs, culture and religion. As many cultures view sexual matters as secret and private, nurses need to take cultural perceptions in the process of sexual health assessment [37] . To achieve a successful addressing of sensitive information, Waltz, Strickland and Lenz recommended ensuring privacy and confidentiality of patients’ responses; seeking only relevant data starting from less to more sensitive and allowing more time for participants to express their needs [63] .

Fourth: Use written educational material such as brochures and leaflets that are developed by experts about sexual health. These materials play an important role in improving patients’ knowledge and encourage patients to express their sexual health concerns [19] .

Fifth: Select appropriate time is an important factor for effective assessment and teaching of patients’ sexual health. For example, nurses viewed that time is not suitable for discussing sexual concerns as patients are ill and they may have anxiety and fear due to their conditions [59] . As existence of third party is a barrier, before or after visiting hours is more appropriate for both nurse and patient to address sexual health needs. Discharge period is a suitable time where patients become stable and ready for assessment and to receive information. Three quarters of nurses recommended that the best time to assess patients’ sexual health is during their follow-up visits or during medications review [5] .

Sixth: Create, adopt and implement sexual health policies and procedures for sexual health assessment in clinical settings to facilitate nurses’ roles in conducting this important nursing task [34] . For example, integrating sexual assessment as a part to the nurses’ charts enable nurses to address the sexual health during history taking and discharge planing. Annon developed the PLISSIT model as a tool to facilitate the assessment and treatment of sexual related problems. PLISSIT letters are abbreviations for sequent interventions where P means Permission; LI means Limited Information; SS mean Specific Suggestions and IT means Intensive Therapy [64] . The PLISSIT model is a framework that helps nurses to conduct sexual health assessment [42] .

Seventh: Invite partners during sexual health assessment and counseling. Partners may complain of distress and anxiety that may affect patient’s sexual health [65] . Partners play significant roles in patient support and facilitating successful resuming of sexual activities.

Eighth: Break down external barriers, Media can play a vital role in discussing the sexual health and related concerns publicly. Nurses can present a television shows about sexual health and instructions for patients and their partners.

Ninth: Nurses need to understand patients and partners’ sexual health experiences and needs for sexual health information, nurses’ knowledge, attitudes, beliefs, barriers and best teaching methods. Conducting more research in sexual health nursing field is recommended to improve sexual health assessment [44] .

Tenth: Create an appropriate work environment through establishing specialized rooms in health institutions to help both nurses and patients to address sexual health related issues in a more comfortable manner [37] .

5. Discussion

To our knowledge, this is the first nursing review of literature to explore the all-possible barriers and promoting strategies from different cultures on sexual health assessment in clinical nursing practice. It is well documented that CADs have a negative impact on sexual health, both physically and psychologically [43] [66] . Therefore, patients actually need assessment and guidance regarding their sexual concerns after recovery. Several authors reported adequately that assessment of sexual matters is an important factor to prevent loss of sexual activity [23] . Providing patients with sexual health information shows a significant improvement in patients’ sexual interest and satisfaction through decreasing patients’ and partner level of anxiety and fear from engaging in sexual activities and improve patients’ sexual life [22] . It is clear enough that sexual health assessment is an important nursing task [25] .

Based on WHO definition of sexual health, we recognized that sexual health is interrelated with other health domains and therefore nurses need to recognize the importance of addressing sexual health as a part of routine nursing care. However, the findings of reviewed studies indicated that sexual health assessment is often neglected in clinical practice. For example, according to Jaarsma and colleagues; results showed that only 10% of nurses address patients’ sexual health concerns [24] . In Jordan, the same percentage of patients with heart diseases did receive sexual health related assessment and instructions [20] .

Studies have shown that there are multifactorial barriers that prevent nurses from conducting patients’ sexual health assessment during their hospitalizations stay or during follow up visits. These barriers are categorized as patient related barriers, nurses related barriers, organizational related barriers and value related barriers.

First category of barriers are related to nurses, actually nurses may ignore patients sexual health assessment because they do not have an adequate knowledge, training, time, facilities, confidence and comfort. For example, studies have shown that nurses are not prepared to handle patients’ sexual health [34] . In particular, nurses’ attitude and beliefs might influence their behaviors to conduct sexual health assessment. Some nurses consider sex is a taboo subject and it is not their responsibility [30] . A thorough understanding of nurse related barriers including their attitudes and beliefs can provide essential information to establish appropriate interventions that improve sexual health care. Nurses’ age, experience, adequate knowledge and training are factors that contribute to confident and com- fort in their ability to address patients’ sexual health [36] and as a result, they are more able to make a time to address the patients’ sexual health [59] . Based on these results, it seems clearly that providing nurses with sexual education and training is beneficial to overcome barriers to sexual health assessment.

The second category of barriers is relevant to patients. Patients may feel embarrassed, not interested in discussion of their sexual concerns, and may have an offend responses against initiations of their sexual health assessment. Therefore, explaining patients’ needs and concerns to find practical and appropriate strategies to handle their sexual health is an essential in their recovery. Patients with CADs reported the importance of addressing sexual health and showed interest in receiving sexual health instructions [52] [67] . As patients are not ready to receive sexual health information during their illness, Purabuli et al recommended providing sexual health assessment at the time of discharge [40] . In addition, fo- llowing appropriate procedures that are culturally sensitive may encourage patients to vent their needs for sexual health information.

The third category that prevents nurses to consider patients’ sexual health assessment is related to health care organizations. For example, work environment also has barriers to sexual health assessment including lack of time, heavy workload, unavailability of educational materials, and lack of sexual health assessment section in nursing health assessment sheet, privacy issues such as no specialized rooms and the existence of third party with patients during their hospital stay. Academic and clinical health institutions need to prepare and support nurses to initiate assessment of sexual health by providing them with required knowledge and practical training, develop and adopt sexual health protocols, establish policies that consider sexual assessment within patients’ plan of care and providing comfort and private rooms. Despite the importance of adopting evidence guidelines and recommendation about sexual health in clinical setting, Hoekstra and colleagues [5] found that policies regarding discussing patients’ sexual health are still lacking. In summary, health institution plays a role in creating a comfortable work environment for nurses to assess patient’s sexual needs [68] .

The last category of barriers is surrounding external factors such as value related barriers that make both patients and nurses hesitated to initiate sexual health assessment. Certain cultures such as Scandinavian consider talking about sexual matters is liberating; for example, Swedish critical care nurse do not view culture as a barrier to provide sexual health assessment [43] . In opposite, many eastern cultures including Arabic culture has more restrictions over sexual matters. Due to the complexity and sensitivity of the topic, nurses have to consider cultural and social perspectives of patients during sexual health assessment. Nurses are a part of the culture where they live; both nurses and patients may feel uncomfortable to talk about sexual issues in the hospital environment.

While nurses avoidance of sexual health assessment in nursing settings were mentioned clearly in the previous studies, it is obvious that there is a need for more studies that examine the actual barriers and to search for practical interventions that encourage nurses to address patients’ sexual health routinely. This study might help nurse administrators, educators, and policy makers to gain more in depth understanding of barriers and promoting interventions toward sexual health assessment that ultimately could improve patients’ sexual health and quality of nursing care. Furthermore, this study may bring attention and awareness that encourage nurses to include assessment of sexual health as a part of patient holistic care. On other hand, this study might contribute to the body of knowledge; support studies related to sexual health in nursing and other health professions and open the door to further interventional studies.

Limitations: Few studies used qualitative approach, which limits the understanding of phenomenology of sexual health assessment and the real barriers. Most studies are descriptive.

Implications and Recommendations: An action plan to overcome barriers is required from all parties. Overall, the findings illustrate a range of strategies that are important regarding improvement of patients’ sexual health assessment, for example, improving nurses’ proficiency in sexual health assessment, developing appropriate and culturally acceptable teaching methods, adopting and implementing scientific guidelines, and integrating the sexual assessment section to nursing papers. Nursing administrators have a pivotal role in creating a good environment for assessing patients’ sexual health. Lange and Levine have been recommended to establish cardiac rehabilitation program for sexual health assessment and counseling [69] . Nurse researchers are in a key position to investigate patients and nurses points of view regarding sexual health assessment in term of knowledge, needs, attitudes, beliefs, and barriers by conducting more qualitative studies to gain better understanding. Then, appropriate ways of sexual health assessment can be developed and implemented. Providing sexual health assessment helps to improve patients’ quality of life and nurses’ quality of care. This study may corporate advancement of nursing knowledge and help nurses to conduct sexual health assessment routinely.

6. Conclusions

This review examined the current state of knowledge regarding barriers and promoting strategies to sexual health assessment in clinical nursing practice.

Results of this review revealed that sexual health was seldom examined and assessed in nursing profession domains of practice, research and education and nurses did not pay enough attention to patient’s sexual health. We concluded that it was important to provide sexual health assessment in clinical practice as a part of holistic nursing care. However, to improve sexual health assessment, nurses and researchers need to investigate the real barriers and design appropriate interventions to increase nurses and patients awareness towards sexual health. Sexual health assessment needs to be standardized in most of health care institutions [70] .

Several studies have shown that there is an urgent need for nurses to be well- educated and skillful in addressing patients’ sexual issues following CADs [43] . As nurses are in direct contact with patients, nurses have a key role to assess and provide patients with CADs with appropriate instructions [41] . In summary, providing patients with sexual health information is an essential aspect of patient discharge plan [46] .

Cite this paper

Bdair, I.A.A. and ConsTantino, R.E. (2017) Barriers and Pro- moting Strategies to Sexual Health Assessment for Patients with Coronary Artery Di- seases in Nursing Practice: A Literature Re- view. Health, 9, 473-492.


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