1 SYMPTOMS OF DEPENDENCE AMONG SELF - IDENTIFIED ADULT RECREATIONAL ILLICIT DRUG USERS: A SUB-ANALYSIS OF THE DRUGNET SURVEY A graduate thesis by Shakti.

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SYMPTOMS OF DEPENDENCE AMONG SELF -SYMPTOMS OF DEPENDENCE AMONG SELF -IDENTIFIED ADULT RECREATIONAL ILLICIT DRUG IDENTIFIED ADULT RECREATIONAL ILLICIT DRUG

USERS:USERS:A SUB-ANALYSIS OF THE DRUGNET SURVEYA SUB-ANALYSIS OF THE DRUGNET SURVEY

A graduate thesis by Shakti Nagarajan, (MPH)

Thesis CommitteeThomas Nicholson, PhD,

David Duncan, DrPH, John B. White, PhD,

Lisa L. Lindley, DrPH, Fred Stickle, PhD.

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INTRODUCTIONINTRODUCTION

The use and sale of illicit drugs in America The use and sale of illicit drugs in America continues unabated despite decades of continues unabated despite decades of the “War on Drugs” and the “ Zero the “War on Drugs” and the “ Zero Tolerance” drug policy.Tolerance” drug policy.

The 2002 National Household Survey on The 2002 National Household Survey on Drug Use and Health (NHSDUH) findings Drug Use and Health (NHSDUH) findings suggest that there has only been a suggest that there has only been a marginal decline in overall drug use.marginal decline in overall drug use.

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NEGATIVE OUTCOMES OF THE DRUG WAR:NEGATIVE OUTCOMES OF THE DRUG WAR:

• Black market for illicit drugs.Black market for illicit drugs.• Largest prison system in the world.Largest prison system in the world.• Lots of money spent on law-enforcement Lots of money spent on law-enforcement

programs, and media campaigns.programs, and media campaigns.• Artificial dichotomy of “good” and “bad” Artificial dichotomy of “good” and “bad”

drugs-- alcohol and tobacco effects are drugs-- alcohol and tobacco effects are undermined.undermined.

• Rise in HIV/hepatitis C.Rise in HIV/hepatitis C.• Distorted public opinion about “illegal drugs” Distorted public opinion about “illegal drugs”

and users.and users.Net result : Millions of Americans break federal Net result : Millions of Americans break federal

laws to use drugs in secrecy.laws to use drugs in secrecy.

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PUBLIC HEALTH APPROACHPUBLIC HEALTH APPROACH

Aim : Harm reduction and to raise the Aim : Harm reduction and to raise the standard of health of illicit drug usersstandard of health of illicit drug users

Conventional methods of studying this “Conventional methods of studying this “hidden populationhidden population” - Medical records, ” - Medical records, surveys.surveys.

DRUGNET survey - An DRUGNET survey - An onlineonline, cross-, cross-sectional, sectional, surveysurvey of of nonabusive, recreational adult drug unonabusive, recreational adult drug userssers. .

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PURPOSE OF CURRENT STUDYPURPOSE OF CURRENT STUDY

It is imperative to study attributes of drug It is imperative to study attributes of drug use at the problematic end of consumption use at the problematic end of consumption spectrum i.e. Dependence and Abusespectrum i.e. Dependence and Abuse

Was conducted to explore the possibility Was conducted to explore the possibility drug dependence symptoms in a self-drug dependence symptoms in a self-identified population of non-abusersidentified population of non-abusers

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NEED FOR THE STUDYNEED FOR THE STUDY

Studies of recreational or occasional non-Studies of recreational or occasional non-dependent drug users are raredependent drug users are rare

Study required to address the health needs of the Study required to address the health needs of the hidden population of healthy American, hidden population of healthy American, recreational drug usersrecreational drug users

Results will provide insights and information Results will provide insights and information about their drug use behaviors that can possibly about their drug use behaviors that can possibly have a profound impact on conventional drug have a profound impact on conventional drug theoriestheories

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RESEARCH QUESTIONSRESEARCH QUESTIONS

1.Are there any symptoms of drug 1.Are there any symptoms of drug dependence or abuse, in a self-identified dependence or abuse, in a self-identified population of non-abusers?population of non-abusers?

2.If yes, how frequent are they? 2.If yes, how frequent are they?

3.Is there any pattern to them?3.Is there any pattern to them?

DELIMITATIONSDELIMITATIONS U.S. citizens, aged 18 years and olderU.S. citizens, aged 18 years and older took the survey on the Internettook the survey on the Internet between December 1997 and June 1998between December 1997 and June 1998

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LIMITATIONSLIMITATIONS ANDAND ASSUMPTIONSASSUMPTIONS

LIMITATIONSLIMITATIONSSelf-selected subjects - Non-random samplingSelf-selected subjects - Non-random samplingSelf-reported behaviors. Validity of responses Self-reported behaviors. Validity of responses

cannot be verified.cannot be verified.

ASSUMPTIONS ASSUMPTIONS Individuals answered the questionnaire Individuals answered the questionnaire

openly and honestly and to the best of their openly and honestly and to the best of their ability.ability.

Individuals were able to understand directions Individuals were able to understand directions for taking the survey.for taking the survey.

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REVIEW OF LITERATUREREVIEW OF LITERATURE

Nicholson (1992) - objection to use of phrases Nicholson (1992) - objection to use of phrases such as "drugs of abuse," and "war on drugs" such as "drugs of abuse," and "war on drugs" because they shape conceptual thinking and because they shape conceptual thinking and attitudes.attitudes.

Jonas (1994) - no scientific (toxicological, Jonas (1994) - no scientific (toxicological, pharmacological, epidemiological or medical) pharmacological, epidemiological or medical) basis whatsoever in segregating the legal basis whatsoever in segregating the legal drugs from the illicit drugs.drugs from the illicit drugs.

Important to clarify nomenclature: use, Important to clarify nomenclature: use, abuse, and dependence.abuse, and dependence.

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LITERATURE REVIEW LITERATURE REVIEW contd.contd.

World health organization (WHO) definition of dependence: World health organization (WHO) definition of dependence:

““it is a state of psychic or physical dependence, or both, on a drug, it is a state of psychic or physical dependence, or both, on a drug, arising in a person following administration of that drug on a periodic or arising in a person following administration of that drug on a periodic or continuous basis. The characteristics of such a state will vary with the continuous basis. The characteristics of such a state will vary with the agent involved, and these characteristics must always be made clear by agent involved, and these characteristics must always be made clear by designating the particular type of drug dependence in each specific case; designating the particular type of drug dependence in each specific case; For example, drug dependence of morphine type, of barbiturate type, of For example, drug dependence of morphine type, of barbiturate type, of amphetamine type, etc”. (WHO, 1965).amphetamine type, etc”. (WHO, 1965).

To make the term "drug dependence" more precise - a To make the term "drug dependence" more precise - a cluster/collection of events that occurred in relation to the cluster/collection of events that occurred in relation to the dependence pattern in a drug user and called it the “drug dependence pattern in a drug user and called it the “drug dependence syndrome”. (WHO 1981)dependence syndrome”. (WHO 1981)

Dependence concept defined in DSM III, DSM III-R, and Dependence concept defined in DSM III, DSM III-R, and DSM IVDSM IV

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Past Year Any Illicit Drug or Alcohol Substance Past Year Any Illicit Drug or Alcohol Substance Dependence or Abuse among Persons Aged 12 or Older: Dependence or Abuse among Persons Aged 12 or Older:

20022002

Note. From “Substance Dependence, Abuse, and Treatment,” by Substance Abuse Note. From “Substance Dependence, Abuse, and Treatment,” by Substance Abuse and Mental Health Services Administration (SAMHSA), 2003, Results from the and Mental Health Services Administration (SAMHSA), 2003, Results from the 2002 National Household Survey on Drug Use and Health (NHSDUH), Chapter 8.2002 National Household Survey on Drug Use and Health (NHSDUH), Chapter 8.

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METHODSMETHODS

Purpose - to explore the presence of drug Purpose - to explore the presence of drug dependence symptoms in a non-random dependence symptoms in a non-random sample of recreational drug users from the sample of recreational drug users from the DRUGNET study. If such symptoms are DRUGNET study. If such symptoms are present, the study will examine their present, the study will examine their frequency, and patternsfrequency, and patterns

Results compared to National Household Results compared to National Household Survey on Drug Use and Health (2002) and Survey on Drug Use and Health (2002) and the Epidemiologic Catchment Area study the Epidemiologic Catchment Area study (1980-1985)(1980-1985)

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RESEARCH QUESTIONSRESEARCH QUESTIONS

Are there any symptoms of drug dependence?Are there any symptoms of drug dependence? If yes, how frequent are they?If yes, how frequent are they? Is there any pattern to them?Is there any pattern to them?

Population - Non-clinical, adult recreational Population - Non-clinical, adult recreational drug users having access to the Internet.drug users having access to the Internet.

Sample Selection - American citizens aged Sample Selection - American citizens aged 18 years and older, who completed the 18 years and older, who completed the DRUGNET survey on the Internet between DRUGNET survey on the Internet between December, 1997 through June, 1998. December, 1997 through June, 1998.

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PROCEDURESPROCEDURES

Sub analysis of the DRUGNET Sub analysis of the DRUGNET survey. survey.

Respondents were solicited via Respondents were solicited via mailing lists mailing lists

Anonymizer link was provided, Anonymizer link was provided, informed consent taken informed consent taken

Respondents were allowed to choose Respondents were allowed to choose between ranges of coded responses.between ranges of coded responses.

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DESIGN - CROSS-SECTIONAL STUDYDESIGN - CROSS-SECTIONAL STUDY

Sub-analysis of previously collected Sub-analysis of previously collected DRUGNET survey data (March, 1997 - June, DRUGNET survey data (March, 1997 - June, 1998). 1998).

Questions pertaining to drug dependence Questions pertaining to drug dependence based on the DSM-III-R drug dependence based on the DSM-III-R drug dependence criteria were formulated and incorporated criteria were formulated and incorporated into the survey in December 1997. into the survey in December 1997.

541 respondents 541 respondents

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INSTRUMENTATIONINSTRUMENTATION

Four major subdivisions :Four major subdivisions :              Demography and lifestyle indices Demography and lifestyle indices               Experiences with drugsExperiences with drugs                Past legal history and attitudes regarding drug use Past legal history and attitudes regarding drug use

And,And,            The general well –being schedule (GWBS)The general well –being schedule (GWBS)

Focus of this study - items 26 through 33 (based on Focus of this study - items 26 through 33 (based on DSM III-R), - demographics subdivision.DSM III-R), - demographics subdivision.

A subject who responded positively to three or more A subject who responded positively to three or more of the drug dependence questions would qualify of the drug dependence questions would qualify as a potential “drug-dependent individual.”as a potential “drug-dependent individual.”

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DATA ANALYSISDATA ANALYSIS

Input Variables:Input Variables:1)1) Problems in life from drug useProblems in life from drug use2)2) Using drugs dangerouslyUsing drugs dangerously3)3) Problems with legal systemProblems with legal system4)4) Argument with family and friends about use Argument with family and friends about use

of drugsof drugs5)5) Withdrawal symptoms Withdrawal symptoms 6)6) Problems stopping useProblems stopping use7)7) Obtaining drugs consumes a lot of timeObtaining drugs consumes a lot of time8)8) Been in treatment for dependenceBeen in treatment for dependence

Coding of responses:Coding of responses:Responses coded as follows:Responses coded as follows:

Yes - 1Yes - 1 No – 0No – 0

Data analyzed using SPSS.Data analyzed using SPSS.

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DATA ANALYSIS DATA ANALYSIS contd.contd.

• First two research questions –First two research questions –Answered by examining responses of items 26-33Answered by examining responses of items 26-33Utilizes the Frequencies subprogram of SPSS. Utilizes the Frequencies subprogram of SPSS. Reported using regular frequency and cumulative Reported using regular frequency and cumulative

frequency tables.frequency tables.

• Third research question – Third research question – Utilizes the Principal Components Analysis (PCA) Utilizes the Principal Components Analysis (PCA) subprogram of SPSS.subprogram of SPSS.

Initial tests of assumptions Initial tests of assumptions Kaier-Meyer-Okin Measures of Sampling Adequacy Kaier-Meyer-Okin Measures of Sampling Adequacy Bartlett ‘s Test of SphericityBartlett ‘s Test of Sphericity

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PCA PCA

• is a statistical technique that can be applied to a is a statistical technique that can be applied to a single set of variables to discover “which single set of variables to discover “which variables in the set form coherent subsets that variables in the set form coherent subsets that are relatively independent of each other” are relatively independent of each other” (Tabachnik and Fidell, 1989).(Tabachnik and Fidell, 1989).

• summarizes patterns of correlation among summarizes patterns of correlation among observed variables and reduce it to a small observed variables and reduce it to a small number of components to provide an operational number of components to provide an operational definition (in terms of Eigen values) of underlying definition (in terms of Eigen values) of underlying processes and test theories that will explain the processes and test theories that will explain the underlying processes.underlying processes.

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Scree plots will be graphed to determine the Scree plots will be graphed to determine the

components that will account for meaningful components that will account for meaningful amounts of shared variance in the sample.amounts of shared variance in the sample.

Further analysis of patterns will be done using Further analysis of patterns will be done using Rotated Component Matrix technique to redefine Rotated Component Matrix technique to redefine factors of importance by enhancing the variance factors of importance by enhancing the variance produced by the weighted factors.produced by the weighted factors.

The results will then be interpreted and discussed The results will then be interpreted and discussed accordingly.accordingly.

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RESULTS -RESULTS - SUMMARYSUMMARY

Sample Selection - 541 United States Sample Selection - 541 United States citizens, aged 18 years or older who citizens, aged 18 years or older who responded to the DRUGNET survey, responded to the DRUGNET survey, between December 1997 and June between December 1997 and June 1998. 1998.

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Demographics of Study Sample:Demographics of Study Sample:

• 88.9% - White 88.9% - White • Average age 31.8 yrs.Average age 31.8 yrs.• Men outnumbered women 3:1.Men outnumbered women 3:1.• Ninety-four percent employed.Ninety-four percent employed.• Approximately one-third of the subjects were married, Approximately one-third of the subjects were married,

and 43.9% had never been married.and 43.9% had never been married.• More than 9 out of 10 individuals were happy with their More than 9 out of 10 individuals were happy with their

marital status.marital status.• The majority of the survey participants had a college The majority of the survey participants had a college

education and one-fourths of them were currently education and one-fourths of them were currently attending college.attending college.

• Average GPA 3.4 Average GPA 3.4 • Median income of $50,000 - $69,999Median income of $50,000 - $69,999

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LIFESTYLELIFESTYLE ANDAND BEHAVIORALBEHAVIORAL INDICESINDICES

• 88.6% of the survey respondents did not attend religious 88.6% of the survey respondents did not attend religious services regularly.services regularly.

• Almost half of the subjects reported strong feelings of Almost half of the subjects reported strong feelings of spirituality. spirituality.

• 39.6% respondents reported that they participated in 39.6% respondents reported that they participated in community activities.community activities.

• 72.8%, (n = 394) voted regularly in the general elections.72.8%, (n = 394) voted regularly in the general elections.• More than 9 out of 10 respondents felt that they were in good More than 9 out of 10 respondents felt that they were in good

health. health. • 97.2% engaged in non-drug related recreation. 97.2% engaged in non-drug related recreation. • One-third had regular parental childcare responsibilities, One-third had regular parental childcare responsibilities, • 4 out of 10 individuals reported that their children knew about 4 out of 10 individuals reported that their children knew about

their use of illicit drugs.their use of illicit drugs.

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Frequency of Drug Dependence SymptomsFrequency of Drug Dependence Symptoms

Drug Dependence Symptom

Yes NoMissing Data

n % n % n

Problems in life from use of illicit drugs158 29.2 383 70.

8--

Using illicit drugs under dangerous circumstances

358 66.7 179 33.3

4

Problems with legal system due to use of illicit drugs

101 18.8 437 81.2

3

Argument with family and friends over use of illicit drugs

168 31.3 369 68.7

4

Withdrawal symptoms on stopping the use of an illicit drug

78 14.5 459 85.5

4

Problems stopping use of illicit drugs67 12.5 471 87.

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Procuring and using illicit drug takes a lot of time in the life of the respondent

36 6.7 499 93.3

6

Has ever been in treatment for drug abuse or dependence

30 5.6 507 94.4

4

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Total Problem Score (showing reported number of drug dependent Total Problem Score (showing reported number of drug dependent

symptoms).symptoms).

Number of drug dependent symptoms

Frequency Valid % Cumulative Percent

None 119 22 22

One 168 31 53

Two 106 19.6 72.6

Three 66 12.2 84.8

Four 42 7.8 92.6

Five 22 4.1 96.7

Six 11 2 98.7

Seven 5 0.9 99.6

Eight 2 0.4 100

Total 541 100  

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Using the frequency of these Using the frequency of these symptoms, it was ascertained symptoms, it was ascertained that 27.4% (n = 148) of the that 27.4% (n = 148) of the respondents (i.e. roughly every respondents (i.e. roughly every one in four respondents) were one in four respondents) were potentially “drug dependent” potentially “drug dependent” individuals.individuals.

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The following criterion tests were applied:The following criterion tests were applied:(a)(a)  The Kaiser-Meyer-Olkin Measure of The Kaiser-Meyer-Olkin Measure of

Sampling Adequacy – Our study sample Sampling Adequacy – Our study sample achieved a value of 0.763achieved a value of 0.763

(b)(b)  Bartlett’s Test of Sphericity – An Bartlett’s Test of Sphericity – An approximate Chi-Square value of 454.525 approximate Chi-Square value of 454.525 with a 28 degree of freedom, and a with a 28 degree of freedom, and a significance value of 0.000 was achievedsignificance value of 0.000 was achieved

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Total Variance Explained in Principal Component Total Variance Explained in Principal Component

AnalysisAnalysis

  Initial Eigenvalues Rotation Sums of Squared Loadings

Component Total % of Variance

Cumulative %

Total % of Variance

Cumulative %

1 2.422 30.275 30.275 1.951 24.391 24.391

2 1.039 12.983 43.258 1.509 18.867 43.258

3 0.97 12.128 55.387  

4 0.89 11.128 66.515

5 0.824 10.302 76.817

6 0.689 8.607 85.425

7 0.61 7.626 93.051

8 0.556 6.949 100

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SCREE PLOTSCREE PLOT

First two components were extracted.First two components were extracted.  

0

0.5

1

1.5

2

2.5

3

1 2 3 4 5 6 7 8

Component Number

Eig

enva

lue

Eigenvalue

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Rotated Component MatrixRotated Component Matrix11 for Principal Component Analysis for Principal Component Analysis

Input Variables 1 2

Problems in life from use of illicit drugs 0.491 0.509

Using illicit drugs under dangerous circumstances 0.3 0.254

Problems with legal system due to use of illicit drugs -0.039 0.841

Argument with family and friends over use of illicit drugs 0.544 0.134

Withdrawal symptoms on stopping the use of an illicit drug 0.731 0.047

Problems stopping use of illicit drugs 0.732 0.115

Procuring and using illicit drug takes a lot of time in the life of the respondent

0.464 0.092

Has ever been in treatment for drug abuse or dependence 0.193 0.661

1Rotation Method: Varimax with Kaiser Normalization

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NET RESULTNET RESULT The first two components account for approximately 43% of The first two components account for approximately 43% of

the total variance.the total variance. The Varimax rotation helped ascertain that physical The Varimax rotation helped ascertain that physical

symptoms of drug dependence like withdrawal illness, and symptoms of drug dependence like withdrawal illness, and difficulty stopping use loaded high on the first component, difficulty stopping use loaded high on the first component, while problems with the legal system and having been in while problems with the legal system and having been in treatment loaded high on the second component.treatment loaded high on the second component.

This meant that the first component comprised of a pattern This meant that the first component comprised of a pattern of individuals suffering from physical symptoms of of individuals suffering from physical symptoms of withdrawal illness. These individuals constitute a potential withdrawal illness. These individuals constitute a potential target population for treatment and rehabilitation target population for treatment and rehabilitation interventions. On the other hand, the second component interventions. On the other hand, the second component reflects a pattern of individuals who have had legal reflects a pattern of individuals who have had legal problems due to the use of illicit drugs and have received problems due to the use of illicit drugs and have received

treatment although they report less physical symptoms.treatment although they report less physical symptoms.

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COMPARISON OF RESULTS WITH THE ECA AND THE COMPARISON OF RESULTS WITH THE ECA AND THE

NHSDUH 2002 FINDINGSNHSDUH 2002 FINDINGS

A direct comparison of the results of the A direct comparison of the results of the DRUGNET survey to the results of the ECA or DRUGNET survey to the results of the ECA or NHSDUS cannot be done because the samples NHSDUS cannot be done because the samples surveyed are different. surveyed are different.

The ECA found that in the total sampled The ECA found that in the total sampled population of 3,925 individuals, 6.2% had a population of 3,925 individuals, 6.2% had a history of abuse/dependence syndrome (Anthony history of abuse/dependence syndrome (Anthony & Helzer, 1991).& Helzer, 1991).

According to the NHSDUH, among those who had According to the NHSDUH, among those who had ever used illicit drugs, 4.3% were classified as ever used illicit drugs, 4.3% were classified as being substance dependent in the past year.being substance dependent in the past year.

Our study ascertained that 27.4% (n = 148) of Our study ascertained that 27.4% (n = 148) of the respondents (i.e. roughly every one in four the respondents (i.e. roughly every one in four respondents) were potentially “drug dependent” respondents) were potentially “drug dependent” individuals.individuals.

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DISCUSSIONDISCUSSION

Study provided an adequate demographic and Study provided an adequate demographic and

behavioral profile of the survey participants.behavioral profile of the survey participants.

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DISCUSSIONDISCUSSION Do 1 in 4 respondents really suffer from drug Do 1 in 4 respondents really suffer from drug

dependence? Further clinical evaluation would dependence? Further clinical evaluation would give the right picture.give the right picture.

Our survey had close-ended questions – hence Our survey had close-ended questions – hence no qualitative assessment of responses. no qualitative assessment of responses. Instrument bias possible.Instrument bias possible.

Lack of a specific time frame for the persistence Lack of a specific time frame for the persistence of drug dependence symptoms in the survey of drug dependence symptoms in the survey instrument. Study projects lifetime prevalence of instrument. Study projects lifetime prevalence of drug dependence in the sample. drug dependence in the sample.

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IMPLICATION OF VARIMAX ROTATION OF PCA IMPLICATION OF VARIMAX ROTATION OF PCA RESULTSRESULTS

Encounters with law enforcement were driving Encounters with law enforcement were driving treatment among the study sample.treatment among the study sample.

This also indicates that scarce treatment This also indicates that scarce treatment resources are being wasted on the wrong resources are being wasted on the wrong subset of the populationsubset of the population

Alternatively, non-abusive drug users may not Alternatively, non-abusive drug users may not need treatment for dependence but may be need treatment for dependence but may be engaging in risky behaviors that can be engaging in risky behaviors that can be addressed through harm reduction addressed through harm reduction interventions. interventions.

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THE RESULTSTHE RESULTS

Validates the existence of a hidden population of Validates the existence of a hidden population of recreational drug users. recreational drug users.

Demonstrates value of an on-line computer based tool in Demonstrates value of an on-line computer based tool in accessing such populations. accessing such populations.

Provided a broad profile of recreational drug users. Provided a broad profile of recreational drug users. Validates the arguments put forth by opponents of the Validates the arguments put forth by opponents of the

“drug war.” “drug war.” That is, although prevention of drug dependence is a much That is, although prevention of drug dependence is a much

talked about issue in this country, it is still the legal system talked about issue in this country, it is still the legal system that drives the clinical system to implement treatment and that drives the clinical system to implement treatment and rehabilitative measures on those individuals that it feels rehabilitative measures on those individuals that it feels right for such measures. The majority of individuals who right for such measures. The majority of individuals who actually report symptoms of dependence have been left to actually report symptoms of dependence have been left to fend for themselves. fend for themselves.

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RECOMMENDATIONSRECOMMENDATIONS Drug policy makers need to consider the Drug policy makers need to consider the

ramifications of studies like the DRUGNET survey ramifications of studies like the DRUGNET survey and other such community studies that differ and other such community studies that differ from conventional concepts. from conventional concepts.

More tolerant and more practical drug policy.More tolerant and more practical drug policy. Further research that explores patterns of drug Further research that explores patterns of drug

dependence in non-biased, non-clinical dependence in non-biased, non-clinical populations should be encouraged populations should be encouraged

Essay questions should be used in the Essay questions should be used in the questionnaire format of studies like DRUGNET, questionnaire format of studies like DRUGNET, this will allow for qualitative research.this will allow for qualitative research.

Studies like the DRUGNET survey need to be put Studies like the DRUGNET survey need to be put back on line to access populations with sensitive back on line to access populations with sensitive issues.issues.

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For copies of survey instrument, references and For copies of survey instrument, references and resources used in this study address all resources used in this study address all correspondence to correspondence to [email protected]@yahoo.com

or or [email protected]@wku.edu..

Thank youThank you