MobileMen and mHealth

MobileMen and mHealth

Ms. Amanda Brice, Klein Buendel Project Coordinator, is the lead author on a research paper published in the journal mHealth. The paper reports on the development of MobileMen, a mobile app to promote physical activity in African American men.

African American men experience higher rates of chronic diseases including diabetes, cardiovascular disease, and obesity compared to other race and gender groups. This population also has high levels of inactivity, one of the major risk facts for chronic disease. Due to the promise shown by mobile apps in providing tailored and easily accessible health interventions, the authors set out to design an app to help African American men initiate and maintain their physical activity.

The research team conducted focus groups with 24 African American men to gain insight on the features and design aspects to include in the app prototype. They then used an iterative design process to conduct multiple rounds of beta and usability testing to create a prototype that was easy to use, visually pleasing, and culturally tailored. A satisfaction and helpfulness questionnaire and the System Usability Scale (SUS) were used as quantitative measures in addition to qualitative data provided by participants. Tasks were given to participants to test for ability to navigate and use the app features.

The average satisfaction and helpfulness ratings from participants were 3.9/5 and 3.7/5 for beta testing and 4.3/5 and 4.1/5 for usability testing, which met the pre-determined criteria of ≥3.5. Only one of the satisfaction questions, which was about cultural tailoring for African American men, was below the pre-determined criteria (2.7). By round two of usability testing, most tasks were able to be completed by all participants, and the mean SUS score was 90.36 out of 100 which exceeded a priori feasibility criterion of a mean rating of 68.0. The feedback on the finalized features was positive, and participants expressed that they would use the app if it were on the market.

Based on both the qualitative and quantitative data obtained from multiple iterative design rounds, the MobileMen app was easy to use and contained culturally tailored features. It was well received by the target population and deemed ready to be tested on a larger scale for effectiveness. Full descriptions of the methods, analyses, and findings can be found in the mHealth paper.

This research is funded by an STTR Fast Track grant to Klein Buendel from the National Institute on Minority Health and Health Disparities (MD014947). The Principal Investigator is Dr. Robert Newton from the Pennington Biomedical Research Center. Authors on this paper include Amanda Brice, Steve Fullmer, Charles Barger, Joel Serbinski, Michael Gallik, Dr. David Buller, and Dr. Kayla Nuss from Klein Buendel; Phillip Nauta, and Dr. Robert Newton from the Pennington Biomedical Research Center; Dr. April Stull from Baylor University; Dr. Damon Swift from the University of Virginia; and Dr. Derek Griffith from the University of Pennsylvania. The MobileMen app was designed and programmed by the Klein Buendel Creative Team.

No Weigh!

No Weigh!

Klein Buendel Scientist, Dr. Kayla Nuss, has launched a new research project, funded by the National Institute of Diabetes, Digestive and Kidney Diseases. It will test a novel approach to physical activity promotion. The proposed intervention, NoWeigh!, is a mobile app based on a framework called body neutrality. Body neutrality emphasizes gratitude for the body’s function, a neutral attitude about the body’s appearance, and engagement in movement that is enjoyable, rather than weight loss.

Obesity rates are on the rise in the United States. Weight loss has been the primary recommendation for managing comorbidities with obesity, such as elevated blood lipids and glucose, despite ample evidence that weight loss attempts generally lead to weight regain and weight cycling, which are associated with negative mental health outcomes like anxiety and depression. Experts have called for non-weight loss obesity management, by emphasizing health behaviors such as physical activity. An effective method to deliver physical activity interventions is via mobile apps, of which women are the most frequent users. However, most physical activity apps emphasize weight loss.

The goal of the new Phase I SBIR project is to demonstrate the technical merit and feasibility of developing a smartphone mobile app (NoWeigh!) to support physical activity engagement using the tenants of body neutrality and Self-Determination Theory as frameworks. Mobile health (mHealth) approaches using smartphones offer several advantages for dissemination and implementation of health interventions including that they are portable, typically “on,” readily available, affordable, and offer advanced functionality. In addition, ownership of smartphones among adults is high, enabling potentially vast reach and apps have been shown to improve uptake of, and adherence to, healthy lifestyle strategies.

Project Specific Aims

Aim 1: Perform iterative focus groups in adult women (aged ≥18 years) from diverse backgrounds to collect potential-user information to identify barriers, needs and preferences for a body-neutrality physical activity app design.

Aim 2: Design the conceptual model and develop planned components of the NoWeigh! app which will include storyboards and clickable wireframes.

Aim 3: Conduct beta and usability testing on the clickable wireframes prototype of the NoWeigh! app to show feasibility, acceptability and potential for engagement, and finalize the app design.

Successful completion of Phase I SBIR research will provide evidence to support a larger Phase II project to program and test the full-scale NoWeigh! app in a randomized comparative effectiveness trial. The goal is to produce a commercially ready mobile app for physical activity promotion that does not center on weight loss, a cost-effective lifestyle intervention for decreasing disease risk and reducing healthcare costs. This mHealth approach is an ideal medium for physical activity promotion because the reach, portability, and advanced functionality of mHealth devices allows for effective use by a broad range of adult women.

This grant was awarded to Klein Buendel by the National Institute of Diabetes, Digestive and Kidney Diseases (DK142209; Dr. Kayla Nuss, Principal Investigator). Dr. Nuss’ research collaborator on this project is Anne Poirier. She is the owner of a body neutrality coaching company and the author of the book, The Body Joyful, a guide to a life based on self-care and compassion. The NoWeigh! app will be designed and programmed by the Creative Team at Klein Buendel.

Analysis of Municipal Shade Policies

Analysis of Municipal Shade Policies

Shade is an essential environmental feature to prevent heat illnesses and skin cancer. A research team led by Klein Buendel has published a description of municipal shade policies in Frontiers in Public Health. Written policies related to shade from municipalities in four southwest and four northeast U.S. states were collected and analyzed.

Municipal codes, planning documents, and manuals/guidelines from 48 municipalities in eight U.S. states were coded for content related to shade by research assistants. A standardized protocol was used to assign numeric codes to each document to assess type of document, type of shade, location, resource allocation, accountability, and design standards. Results were summarized using descriptive statistics.

Three-quarters of municipalities (75.0%) had a policy document that addressed shade, including municipal codes (54.2%), planning documents (29.2%), and manuals/guidelines (12.5%). Protecting from heat (31.3%) was mentioned in policies more than protecting from ultraviolet radiation (8.3%), as was natural shade (56.3%) rather than constructed shade (25.0%). Policies prescribed several design standards, most frequently shade material, proportion of area covered, and attractiveness. Half (50.0%) of municipalities mentioned accountability for shade in the policy, but only a third (35.4%) addressed resource allocation. Regional differences were seen in policy document type, shade type, locations, design standards, and resource allocation.

Many municipalities had policies that mentioned shade, but only a minority of policies indicated that the purpose of the policy was protection from heat or ultraviolet radiation. In northeast municipalities, which can have local home rule traditions, policies on shade appeared almost entirely in municipal codes. Southwest municipalities often included policies in planning documents that may have less legal force than municipal codes.

This research was funded by Klein Buendel and a grant from the National Cancer Institute to the Rutgers Cancer Institute at Rutgers University (CA072720; Dr. Steven Libutti, Principal Investigator). Authors include Phoebe Grutter from Science Park High School, Dr. Margaret Morrissey-Basler from Providence College, Dr. Ian Buller from DLH, Dr. Carolyn Heckman from Rutgers University, and Alishia Kinsey, Taylor Sullivan, and Dr. David Buller from Klein Buendel.

In Memoriam: Dr. Erwin Bettinghaus 1930-2025

In Memoriam: Dr. Erwin Bettinghaus 1930-2025

Erwin (Erv) P. Bettinghaus, PhD, Senior Scientist at Klein Buendel, died peacefully on July 7, 2025. Prior to joining Klein Buendel in 2005, Erv was a Senior Scientist at the Cooper Institute, Denver and AMC Cancer Research Center and Dean and Professor in the College of Communication Arts and Sciences at Michigan State University. It was as Dean that Mary Buller, President and Dr. David Buller, Senior Scientist and Director of Research at Klein Buendel first worked with Erv. In 1997, Erv was instrumental in hiring them at AMC Cancer Research Center and its affiliate, Partners for Health Systems.

Erv was an early champion of health communication research and devoted many years to creating effective methods of communicating with Americans about lifestyle changes that would improve their health and prevent disease. He was appointed by President Ronald Reagan to the National Cancer Advisory Board of the National Cancer Institute. He was a member of the research team for the ground-breaking Community Intervention Trial for Smoking Cessation (COMMIT) supported by the National Cancer Institute. After his retirement from Michigan State University, Erv joined AMC Cancer Research Center and initiated its program in health communication research. It was in this chapter of his life that Erv brought together many of the individuals who would create and nurture Klein Buendel. 

Over 20 years at Klein Buendel, Erv had many colleagues and friends and served in important roles at Klein Buendel, including as a Senior Scientist and member of its Board of Directors. He participated on numerous health communication studies as Principal Investigator and Co-Investigator with collaborators both inside and outside Klein Buendel. Most of all, Erv was a mentor to many of us at Klein Buendel, offering timely advice and relentless encouragement for our endeavors.

Klein Buendel’s management and staff feel privileged to have worked with Erv. We celebrate his professional life and friendship. He will be greatly missed.

Visit the Neptune Society for obituary, memorial, and condolence information.

MobileMen Project Protocol

MobileMen Project Protocol

African American men are at higher risk for serious health conditions such as cardiovascular disease, diabetes, and stroke compared to non-Hispanic White men. Physical activity is a modifiable health behavior that has been shown to decrease chronic disease risk. Still, engagement in physical activity is alarmingly low in African American men. While interventions to improve physical activity engagement are effective in several populations, very few have been tailored to the unique needs of African American men. Even fewer have leveraged mobile health apps, despite African American men’s interest in and willingness to use such technologies for health improvement.

Now a multi-disciplinary research team from Klein Buendel, Pennington Biomedical Research Center, and three universities is conducting a comparative effectiveness trial that aims to evaluate MobileMen, a physical activity promotion app tailored to the needs and preferences of African American men. The team has published the plans and methods for the trial in JMIR Research Protocols.

The trial compares the MobileMen app to a commercially available physical activity promotion app with similar features but without culturally tailored components. Specifically, the study is recruiting a sample of 100 “low active” (less than 7500 steps per day) African American men aged 30 years or older from Baton Rouge, Louisiana and its surrounding communities. All participants are given a Fitbit Charge 6 wearable activity tracker to assess daily physical and steps. Participants are randomly assigned to either the MobileMen intervention app or a comparator app. The intervention period is six months, during which participants will interact with their assigned mobile app.

MobileMen includes features such as digital badges earned for physical activity, tangible prizes like exercise equipment, challenges among participants, goal setting, nutrition, physical activity, and behavior change educational information in text, audio, and video formats.

Participants complete assessments at baseline and at six months after random assignment. Assessments include objective measurements of daily steps and minutes of moderate to vigorous physical activity, quality of life, dietary measures, self-efficacy for fruit and vegetable consumption and physical activity, and autonomous motivation for physical activity. Detailed descriptions of measures and methods can be found in the JMIR Research Protocols paper.

Mobile apps are a widely accessible means to disseminate culturally tailored physical activity promotion interventions to various populations, including African American men. MobileMen has the potential to impact physical engagement in African American men, to help improve the overall health and chronic disease risk in this underrepresented population.

This research is funded by an STTR Fast Track grant to Klein Buendel from the National Institute on Minority Health and Health Disparities (MD014947). The Principal Investigator is Dr. Robert Newton from the Pennington Biomedical Research Center. Authors on this paper include Callie Hebert, Phillip Nauta, and Dr. Robert Newton from the Pennington Biomedical Research Center; Dr. April Stull from Baylor University; Dr. Damon Swift from the University of Virginia; Dr. Derek Griffith from the University of Pennsylvania; and Dr. Kayla Nuss, Amanda Brice, and Dr. David Buller from Klein Buendel. The MobileMen app was programmed by the Klein Buendel Creative Team.

Proximity of Alcohol Establishments and Sales of Cannabis to Intoxicated Customers

Proximity of Alcohol Establishments and Sales of Cannabis to Intoxicated Customers

A multi-disciplinary research team led by Klein Buendel presented data from an active polysubstance (alcohol and cannabis) project at the 48th Annual Research Society on Alcohol Scientific Meeting on June 21-25, 2025 in New Orleans, Louisiana.

Dr. David Buller presenting poster

State laws prohibiting sales of alcohol to apparently intoxicated customers are intended to prevent morbidity/mortality from impaired driving, impulsive behaviors, injuries, and violence. A few states (including Oregon) have similar prohibitions for recreational cannabis sales. Compliance with state prohibitions against sales to intoxicated customers by co-located alcohol and cannabis sales establishments was examined in two metropolitan areas in Oregon.

In 2024, actors trained to feign alcohol intoxication visited state-licensed recreational cannabis stores in four counties containing Portland and Salem metropolitan areas and attempted to purchase a low-cost cannabis product while displaying alcohol intoxication. These same actors assessed sales of alcohol products at licensed on-site and off-site alcohol premises located near cannabis stores, using the pseudo-patron protocol. Concordance in refusals (1=both establishments refused vs. 0=else) and concordance in sales (1=both sold vs. 0=else) and point-to-point distances (in kilometers) between alcohol premises and each cannabis store were calculated.

Pseudo-patron teams consisting of a buyer feigning intoxication and an observer assessed 173 cannabis stores and 39 alcohol premises, resulting in 6,747 pairs of establishments. Logistic regression revealed that concordance in refusals (regulatory compliance) was higher in pairs of establishments that were located closer together rather than farther apart. Concordance in sales (regulatory non-compliance) was higher in pairs of establishments that were farther apart rather than closer together, even when examining pairs within the same city and county.

Neighborhood influences on alcohol and cannabis use may arise from the consistency of responsible sales behavior of co-located retailers. When both alcohol and cannabis establishments fail to refuse sales to intoxicated customers, use of alcohol and cannabis and accompanying harms may increase, especially from co-use which can result in high impairment. Community norms associated with, for example, social class or presence of children or regulators’ enforcement efforts may determine similarity in compliance. Responsible vendor training requirements or additional enforcement efforts might reduce co-location effects (neighborhood differences). The small number of alcohol premises and single state somewhat limited the study.

This research is supported by a grant from the National Institute on Alcohol Abuse and Alcoholism (AA031591; Dr. W. Gill Woodall and Dr. David Buller, Multiple Principal Investigators). Additional collaborating authors include Dr. Robert Saltz from the Pacific Institute for Research and Evaluation; Dr. James Fell from the National Opinion Research Center; Dr. Ian Buller from DLH Corporation, Inc.; Dr. Gary Cutter from the University of Alabama; and Ms. Lila Martinez, Mr. Noah Chirico, and Ms. Amanda Brice from Klein Buendel.

Collaborator Spotlight: Dr. Christopher Houck

Collaborator Spotlight: Dr. Christopher Houck

Christopher Houck, Ph.D., collaborates with Klein Buendel investigators and its Creative Team on multiple behavioral research projects. His research interests focus on affect management for early adolescents and the development and evaluation of risk prevention interventions for at-risk early adolescents. He conducts research on factors related to adolescent risk behaviors, especially sexual behaviors and dating violence risk, and the role of emotion regulation in health behavior interventions.  

Dr. Houck is a Professor of Psychiatry and Human Behavior and a Professor of Pediatrics at Brown University. He is the Director of the Clinical Child Psychology Specialty Program for postdoctoral training in the Brown Clinical Psychology Training Consortium’s Postdoctoral Fellowship Training Program. He also works as a staff psychologist in the Department of Child and Adolescent Psychiatry at Rhode Island Hospital. It is in this capacity at Rhode Island Hospital that Dr. Houck is currently leading two research projects in conjunction with Klein Buendel that are funded by the National Institutes of Health:  

An Interactive Education Program to Reduce High Risk Behavior in Adolescents (HD110333) 

Klein Buendel Investigator, Ms. Julia Berteletti, is collaborating with Dr. Houck to develop and evaluate the impact of an emotion regulation program for adolescents. iTRAC is a web-based program for “Talking about Risk and Adolescent Choices” to prevent risky sexual behavior and negative sexual health outcomes through emotion regulation strategies. 

Emotion Regulation Intervention to Prevent Substance Use Among Youth in the Child Welfare System (DA059785) 

Klein Buendel Investigators, Ms. Julia Berteletti and Dr. W. Gill Woodall, are collaborating with Dr. Houck and Dr. Stephanie Parade from Brown University on this 5-year project to integrate substance use content with iTRAC emotion regulation material to reduce substance use among child welfare involved youth. The web-based intervention is being developed and evaluated in partnership with the Rhode Island Department of Children, Youth, and Families. 

Dr. Houck earned his B.A. degree from the University of Michigan in 1996. He completed his Ph.D. in Clinical and Health Psychology from the University of Florida in 2002. He completed his internship at the Children’s Hospital of Orange County in Orange, California and a postdoctoral fellowship at Brown University. 

Immersive STAC Luminary Presentation

Immersive STAC Luminary Presentation

Dr. Aida Midgett, BSU Principal Investigator

The imaginative illustrations and digital production work of the Klein Buendel Creative Team were featured in a life-size immersive luminary display in the Keith and Catherine Stein Luminary at Boise State University in April.

The STAC intervention, developed by Dr. Aida Midgett from Boise State University, was the subject matter on full display. STAC provides middle school students who witness bullying with strategies to act as “defenders” to help reduce both active bullying and the negative associated outcomes for both targets and bystanders. The content is delivered in person or via web-based lessons and activities which includes avatar-based scenarios, practices, and quizzes.

STAC Bullying Bystander Strategies

(1) “Stealing the Show” – using humor or distraction to interrupt a bullying situation and remove the attention away from the target;

(2) “Turning it Over” – identifying a trusted adult at school, reporting, and asking for help during a bullying incident;

(3) “Accompanying Others” – befriending and/or providing support to a peer who was a target of bullying; and

(4) “Coaching Compassion” – gently confronting the perpetrator and increasing empathy for the target.

The research to design and evaluate the interactive web-based version of STAC is funded by an STTR Phase II grant to Klein Buendel from the National Institute on Minority Health and Health Disparities at the National Institutes of Health (MD014943; Dr. Aida Midgett, Principal Investigator, Boise State University). Co-investigators include Dr. Diana Doumas from Boise State University and Mary Buller from Klein Buendel. The web-based STAC modules were designed and programmed by Klein Buendel’s Creative Team: Steve Fullmer, Creative Director; Peter Fu, Illustrator and Developer; Charlie Barger, Developer; and Brandon Herbeck, Project Coordinator.

The Stein Luminary is an all-digital museum space at Boise State University that produces a variety of immersive, interactive, and sensory experiences. Touch-activated screens and immersive projection deliver cutting-edge visual content for the Boise State University community. According to their website, “The Stein Luminary invites the Boise State community to explore creative arts, cultural sites, and scientific phenomena from around the globe. We foster interdisciplinary collaboration and research-based innovation by featuring exhibitions, performances, and installations of emerging media. Our participatory content generates vital and meaningful conversations about arts, humanities, technology, and science.”

As illustrated in the luminary, the STAC program has been implemented in middle schools across the United States and multiple other countries worldwide.

Cost Analysis of an Occupational Sun Safety Intervention

Cost Analysis of an Occupational Sun Safety Intervention

Klein Buendel investigators and their collaborators have e-published the results of the cost analysis of distributing the Go Sun Smart at Work program via two different methods in the Journal of Occupational and Environmental Medicine (JOEM).

This randomized trial compared two methods (digital and in-person) for scaling up an evidence-based occupational sun protection program nationwide. The program was designed to help workplaces implement skin cancer prevention policy and training for employees who work outdoors. One hundred thirty-eight (138) regional districts in 21 state Departments of Transportation throughout the United States were randomized to receive the Go Sun Smart at Work program via in-person or digital scalability methods in 2019-2022. Results of the effectiveness of the trial were published in JOEM in January 2025.

For the economic analysis reported in this companion publication, the cost of delivering the Go Sun Smart at Work program was obtained from project accounting records and manager reports. The study followed the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) reporting guideline for economic evaluation (1). The primary outcome of the economic analysis was an incremental cost-effectiveness ratio (ICER) from the perspective of the disseminating organization, although induced costs to the employer were also recorded and reported. The ICER numerator is the incremental difference between digital and in-person strategies in average program cost (C) per regional district. The denominator is the incremental difference between digital and in-person strategies in the mean number of implemented workplace sun protection actions (per regional district) (E [for effect]):

                                    ICER = (Cdigital – Cin-person) / (Edigital – Ein-person)

Program delivery costs were estimated to be $15,658 for the digital strategy and $74,275 for the in-person strategy. Across all districts, the ICER was $3,305, representing average cost savings from a sun safety action not implemented under the digital strategy but implemented under the in-person strategy. In summary, the digital scalability strategy was cost-effective relative to an in-person strategy, generating substantial cost savings and offsetting a lower mean number of implemented program actions. Full descriptions of the research methods, results, and limitations are included in the JOEM publication.

The research was supported by a Cancer Moonshot Initiative grant from the National Cancer Institute (CA210259; Dr. David Buller, Principal Investigator). Co-authors include Dr. Richard Meenan from Kaiser Permanente Center for Health Research; Dr. Gary Cutter from the University of Alabama in Birmingham; Dr. Kimberly Henry from Colorado State University; Dr. Sherry Pagoto from the University of Connecticut; and Mary Buller, Julia Berteletti, Irene Adjei, and Noah Chirico from Klein Buendel. The authors thank the American Association of State Highway and Transportation Officials (AASHTO) and the senior managers of the participating state Departments of Transportation for supporting this research project.

References

  1. Husereau D, Drummond M, Augustovski F, et al. Consolidated health economic evaluation reporting standards 2022 (CHEERS 2022) statement: updated reporting guidance for health economic evaluations. Value Health. 202;25:3-9.

KB Research Presented at SBM – Part 2

KB Research Presented at SBM – Part 2

Ms. Amanda Brice from Klein Buendel presented a Live Research Spotlight at the 46th Annual Sessions and Meeting of the Society of Behavioral Medicine in San Francisco, California, March 26-29, 2025.

*Klein Buendel authors are bolded.

Ms. Amanda Brice

Research Spotlight

Title: Rural Emerging Adults’ Physical Activity Motivation, Intentions, Planning, and Engagement Patterns: A Cross-Sectional Analysis

Presenter: Amanda Brice

Authors:  Kayla Nuss, Julia Berteletti, Amanda Brice, Alishia Kinsey, Noah Chirico, and Sierra Held

Emerging adulthood, the period between 18 and 26 years old, is critical for the development of long-term health behaviors, like physical activity engagement. Only 25% of emerging adults meet the recommended 150 minutes per week of moderate to vigorous physical activity (MVPA). In rural communities, where residents have less access to behavioral health resources, healthcare, and community services, fewer than 20% of adults meet physical activity recommendations, but data on rural emerging adults is limited. Further, data are lacking in this population on potent drivers of physical activity, such as motivation, intention, and planning. Therefore, the purpose of this study is to describe physical activity engagement, motivation, intention, and planning in a sample of emerging adults from the rural western United States.

Participants were recruited via a nationwide survey panel. Inclusion criteria were: 18 to 26 years old, able to read and understand English, and live in a rural country as defined by the Rural Urban Commuting Area Codes 4-9 in one of the Western states of Colorado, Utah, New Mexico, or Arizona. We assessed physical activity with the Global Physical Activity Questionnaire (GPAQ), Self-Determination Theory motivation with the Behavioral Regulations in Exercise Questionnaire v.3 (BREQ-3), intention and planning with the Behavioral Intentions Scale, and collected demographic variables.

Means, standard deviations, and percentages were calculated for descriptive and outcome variables. Participants reported minutes of MVPA accumulated through work and recreation, and we calculated total MVPA minutes. Using the Shapiro-Wilk test for normality, we found neither total nor recreational weekly minutes of MVPA were normally distributed. The non-normality was due to a high number of participants reporting zero MVPA minutes. We created binary variables of “Meets Recommendations” (≥ 150 minutes of MVPA per week) vs. “Does Not Meet Recommendations” (≤ 149 minutes of MVPA per week) for both total and recreational MVPA.

The sample included 141 respondents: 115 (81.56%) female and 25 (17.73%) male, aged 22.00±2.63 years. Seventy-five (53.19%) met MVPA recommendations when work was included whereas without, only 32 (22.70%) met recommendations. Participants reported low levels of amotivation, external, introjected, identified, and integrated regulation, and intrinsic motivation. They also reported low levels of intention and planning for physical activity.

More emerging adults met MVPA recommendations when minutes accumulated at work were included. Rural emerging adults have low quality of motivation and low intention and planning for physical activity. Researchers should investigate barriers to physical activity participation in this group as they have high instances of health disparities and low access to health resources.

This research was sponsored by Klein Buendel and led by Dr. Kayla Nuss.