Volume 2 Issue 1, April 2016, pp. 9-18

Introduction: The Survey on Transition to Civilian Life (STCL) was created to measure the adjustment outcomes of recently released Canadian Armed Forces (CAF) members. The survey was administered to a sample of CAF regular force members released from 1998 to 2007. The aim of the current study was to examine resources that promote the successful adjustment to civilian life. Specifically, the goal was to conduct a secondary analysis of the STCL that examined the roles of mastery and social environment (that is, community belonging and satisfaction with support) in the transition to civilian life, as well as how these variables correlate with health and life stress. Methods: The sample data were used to conduct Kendall's tau correlations. Prevalence estimates, 95 per cent confidence intervals, and ordinal logistic regressions were conducted using weighted data that accounted for the complex survey design to ensure findings were representative of the sampled veteran population. Results: Ordinal logistic regression results revealed that mastery, satisfaction with types of social support (friends and family), and a sense of community belonging acted as potential protective factors that were associated with easier adjustment to civilian life for Veterans with physical health conditions, mental health conditions, and higher levels of life stress. The first model showed that the odds of an easier adjustment were lower for those who were more stressed (adjusted odds ratio [AOR]=0.13), self-reported a physical health condition (AOR=0.53), and self-reported a mental health condition (AOR=0.23). The second model revealed that the odds of an easier adjustment were lower for those Veterans dissatisfied with their family relationships (AOR=0.42) and their relationships with friends (AOR=0.47) and those with a very weak sense of community belonging (AOR=0.39), and they were higher among those with high levels of mastery (AOR=3.93). Discussion: The results of this study point to the importance of personal characteristics and aspects of the social environment in the adjustment to civilian life among military veterans. As well, ensuring a successful adjustment to civilian life may lead to better outcomes, such as enhanced mastery, following transition.

Introduction : Le sondage sur la transition à la vie civile était une enquête visant à mesurer les résultats de l'adaptation des ex-membres des Forces armées canadiennes (FAC) après leur transition à la vie civile. Le sondage visait les ex-membres de la force régulière qui ont été libéré(e)s entre 1998 et 2007. Le but de l'étude en cours est d'examiner les ressources qui encouragent une adaptation facile à la vie civile. Méthodologie : Spécifiquement, le but était de mener une analyse secondaire du sondage en examinant les rôles de la maîtrise de la situation et de l'environnement social (par exemple, l'appartenance dans la communauté ou le niveau de satisfaction avec le support reçu) durant la transition à la vie civile, ainsi que comment ces variables correspondent à la santé et au stress. Les résultats de la régression logistique ordinale ont révélé que la maîtrise de la situation, la satisfaction relative au type de support reçu (familiale, ami(e), etc.) et l'appartenance à la communauté agissaient tous comme des aides protecteurs associés au niveau d'ajustement à la vie civile pour les vétéran(e)s avec des problèmes de santé physique, mentale ou ayant des taux de stress plus élevés. Résultats : Le premier modèle a démontré que les vétéran(e)s avec plus de stress (le rapport des cotes ajusté [AOR]=0.13), ceux ou celles qui ont signalé une condition de santé physique (AOR=0.53) et ceux ou celles qui ont signalé une condition de santé mentale (AOR=0.23) avaient de moins bonnes chances d'adaptation. Le deuxième modèle a démontré que les vétéran(e)s qui n'étaient pas satisfait(e)s avec leurs relations familiale (AOR=0.42), et leurs relations d'amitié (AOR=0.47), ainsi que ceux ou celles démontrant un plus faible sens d'appartenance à la communauté (AOR=0.39) avaient de moins bonnes chance d'adaptation tandis que ceux et celles qui démontraient une bonne maîtrise de la situation avaient de meilleures chances d'adaptation (AOR=3.93). Conclusion : Donc, cette étude suggère des ressources qui pourraient avoir le potentiel d'aider la transition à la vie civile.

Due to limited research, there is no consistently used definition of a successful transition from military to civilian life.1 Transition to civilian life can be a difficult adjustment for some individuals, particularly those experiencing psychological or physical health issues.2 Veterans have unique experiences (for example, the level of combat they have been exposed to),3 which can affect successful adjustment to civilian life. In addition to individual military experiences, research has revealed that there are many other factors that can affect the successful adjustment to civilian life, including health status (that is, psychological and physical), demographic differences, financial status (for example, post release income), and education (for example, skills that are transferable to the civilian work force).4 Accordingly, it is imperative that resources be identified to help ease the transition to civilian life.

Transition experiences are complex, and ensuring a successful transition requires a multidisciplinary approach to address potential risk and protective factors.5 That is, there is a need for health care providers and other agencies to collaborate to help ease transition experiences. For example, not only should Veterans have access to resources that help them find civilian employment (for example, an employment agency), but measures should also be in place to ensure that the employment is a good match for their personal well-being (for example, a health-care provider who works with the employment agency).

Recently, research using population-based samples has begun to examine the transition experiences of Canadian Armed Forces (CAF) Veterans.6,7 To assist in this examination, the Survey on Transition to Civilian Life (STCL) was developed to measure the health, disability, and determinants of the health of former Regular Force members who were released recently from the CAF.1,4 Although most adjust well to civilian life, it was found that 25 per cent of CAF Veterans experience a difficult adjustment.5 It is important to measure and understand how one adjusts to certain life events to accurately provide or enhance the resources needed to help ease that adjustment. Such resources can exist at various levels, including individual characteristics, support from friends and family, and community support. In particular, both mastery and social support have been shown to have protective effects during stressful events.8 Donaldson and colleagues found that in the civilian workforce, better psychological and physical health and a higher level of mastery accounted for a better adjustment to retirement for men and women.9 Furthermore, a sense of community belonging has also been identified as an important factor for well-being.10 From the perspective of interventions and programs to help individuals cope with stressors, individual-level variables and support networks are particularly important. As such, the present study sought to examine the individual and social factors associated with a potentially stressful event, namely the adjustment to civilian life after leaving military service among CAF Veterans.

Mastery

An individual resource that has been frequently studied, in relation to its protective benefits, is mastery. Mastery is defined as an individual's perceived control over important life events.11 This sense of control equips individuals with skills, such as problem solving, that help them navigate through adverse events. As a result, the level of mastery (that is, control) that individuals exhibit during difficult times can inadvertently impact their psychological and physical health.12 A sense of control can increase with an individuals' level of education, income, employment, occupational status, and job autonomy,13 and it can decrease with stressful events (for example, being laid off).8 Since the transition from military to civilian life is challenging for some,2 individual resources, such as a sense of control, may help Veterans to navigate through this potentially stressful time.

The level of mastery or control has been shown to ease adjustment in several areas. In the civilian workforce, mastery has been shown to ease the retirement process, beyond the effects of health and other individual factors.9 As well, studies have shown that a higher perceived mastery has been related to better health, including fewer symptoms of depression, less frequent episodes of depression, and lower psychological distress.14,15 The skills related to mastery, thus, have the potential to ease adjustment during transitional life events as well as to act as a protective factor for health-related issues.

Research has suggested that mastery can change over time with age, and different factors affect this change. Schieman has found that the sense of control or mastery decreases with age, with older individuals reporting a lower sense of mastery. In addition, Schieman has proposed that education plays a moderating role in the sense of mastery as people age, such that higher education buffers against age-related declines in a sense of control.16 Lachman and Weaver have found that as individuals age there is an increase in the sense of control over work, finances, and marriage and a decrease in control over relationships with children and sex life.15 Thus, the sense of mastery can change with age depending on one's specific life experiences, and different types of control can be more prominent at different stages throughout the course of life. Overall, mastery has been shown to be a strong predictor of adjustment in several different situations, and poor mastery has been identified as a potential risk factor for the difficult adjustment to civilian life for CAF personnel.5

Social environment

The social environment includes elements such as social support and community belonging. Social support can include family and peer support.17 Social support has been shown to have protective effects on mental health issues, such as post-traumatic stress disorder (PTSD) and depression.18 Lower levels of social support in Veterans have been associated with an increased likelihood of the diagnosis of disorders, such as anxiety, addiction, and depression,2 while higher levels of social support have been associated with fewer symptoms of mental health issues such as PTSD.19 Within the military population, social support has been considered a resiliency factor in post-war PTSD.20 Thus, social support may play a protective role among those suffering from mental health issues as well as among those going through significant life events, such as a transition. In addition to mental health, social support may also help with sources of potential stress such as the transition to civilian life.

In addition to social support, community belonging is a strong correlate of health and well-being. Community belonging is associated with self-perceived health, beyond the effects of other factors such as socio-economic status and chronic disease,8 and is related to being older, having a higher income, and living in a rural area.8 Social participation in one's community has been shown to be an important resource among older Canadians in the general population.21 A sense of belonging may be particularly important in the Veteran population, as they have left the social network of the military behind. It is particularly important in light of recent research that has demonstrated that Veterans have a lower sense of community belonging compared to the general Canadian population.4

The rationale for the current study was to examine the role that mastery and the social environment (that is, satisfaction with support and community belonging) play in the adjustment to civilian life among CAF Veterans. The research question of interest was: How does mastery and the social environment relate to other important concepts such as physical and mental health conditions, life stress, and adjustment to civilian life?

Respondents and procedure

The STCL was administered as a telephone survey to a sample of CAF Regular Force Veterans (from the total CAF Veteran population of 32,015) who transitioned to civilian life between January 1, 1998 and December 31, 2007.4 A total of 3,354 Veterans responded to the survey (71.0% response rate), and the final sample included 3,154 Veterans who consented to share their data (94.0%). Participants were asked at the end of the survey whether they would share their data with Veterans Affairs Canada and the Department of National Defence. Those who consented to share their data were included in the final sample. The majority of participants were between the ages of 45 and 49 years (23.9%) and 50 and 54 years (15.1%) (Table 1). The current study involved a secondary analysis using the final STCL sample of 3,154 Veterans. The questionnaire was based mainly on the content of the Canadian Community Health Survey completed by Statistics Canada in 2008 and was administered in February–March 2010 by Statistics Canada, using a computer-assisted telephone interviewing system.1

Table

Table 1. Description of study Veterans

Table 1. Description of study Veterans

Prevalence
Indicator Category % 95% CI
Age 20–4 4.5 3.6–5.6
25–9 11.3 9.9–12.8
30–4 9.5 8.3–10.9
35–9 8.9 7.7–10.2
40–4 9.9 8.9–11.0
45–9 23.7 22.3–25.4
50–4 15.1 13.9–16.4
55–9 9.1 8.1–10.2
60–4 7.1 6.2–8.1
65–9 0.8 0.6–1.2
Gender Male 88.9 86.8–89.4
Female 11.1 10.7–13.2
Life stress Not at all stressful 12.3 11.0–13.6
Not very stressful 24.5 22.8–26.3
A bit stressful 42.0 40.1–44.0
Quite a bit stressful 17.9 16.5–19.4
Extremely stressful 3.3 2.8–4.0
Physical health conditions (PHC) No 17.9 16.3–19.6
Yes 82.2 80.5–83.7
Number of PHCs 0 17.6 16.3–19.6
1 19.3 17.3–21.0
2 22.0 20.4–23.6
3 20.6 19.1–202.1
4 11.9 10.8–13.0
5 6.1 5.4–6.9
6 1.8 1.4–2.2
7 0.5 0.4–0.8
8 0.1 0.02–0.2
Mental health conditions No 76.3 74.8–77.7
Yes 23.7 22.3–25.2
Mastery Low mastery 2.0 1.6–2.5
High mastery 30.9 29.1–32.8
Satisfaction with family members Satisfied 87.8 86.6–88.9
Neither satisfied nor dissatisfied 6.3 5.4–7.3
Dissatisfied 5.9 5.2–6.7
Satisfaction with friends Satisfied 89.1 99.0–90.2
Neither satisfied nor dissatisfied 5.5 4.7–6.4
Dissatisfied 5.4 4.7–6.2
Sense of community belonging Very strong 9.9 8.8–11.2
Somewhat strong 49.0 47.0–51.0
Somewhat weak 28.5 26.8–30.3
Very weak 12.6 11.4 –13.9
Adjustment to civilian life Difficult adjustment 25.3 23.8–26.9
Neither difficult nor easy adjustment 12.7 11.6–14.2
Easy adjustment 61.8 60.0–63.6

Measures

The current study focused on a subset of STCL measures including life stress, health, mastery, social environmental factors, and the adjustment to civilian life. Table 1 presents the percentages and confidence intervals (CI) for these variables as well as demographic variables.

Life stress

Life stress was measured by one item in the STCL that asked participants: “Thinking about the amount of stress in your life, would you say most days are … ?” The item was rated on a five-point scale, which included “not at all stressful,” “not very stressful,” “a bit stressful,” “quite a bit stressful,” and “extremely stressful.”

Physical and mental health conditions

Participants were asked a series of questions regarding physical health conditions (PHC), which were grouped as musculoskeletal, cardiovascular, respiratory, gastrointestinal, hearing problems, obesity, diabetes, cancer, and chronic pain (or discomfort), and mental health conditions (MHC), such as mood disorder, anxiety disorder, depression, and PTSD. The current study aggregated any PHCs (yes/no), any MHCs (yes/no), and the total number of PHCs (0–8).

Mastery

Mastery was measured by seven items in the STCL,11 using a scale with satisfactory consistency (Chronbach's alpha=0.78).22 Some of the items included: “You have little control over the things that happen to you”; “There is really no way you can solve some of the problems you have”; and “There is little you can do to change many of the important things in your life.” Each item had a five-point scale ranging from “strongly agree” to “strongly disagree,” which was transformed to a 0–4 scale, in which positive items were reverse scored and all seven items were summed to obtain a score that ranged from 0 to 28. Higher scores indicated a higher level of control. Responses were categorized according to a low, medium, and high mastery. A participant scoring seven or lower was considered to have low mastery, while an individual who scored 23 or greater was considered to have high mastery.22 These categories have been used before in previous CAF research as a simple way of presenting data on mastery.22 The categories were used to describe frequencies and for the ordinal logistic regression.

Social environment

Satisfaction with relationships was assessed using two items: “How satisfied are you with your relationships with other family members?” and “How satisfied are you with your relationships with friends?” The items were rated on a five-point scale ranging from “very satisfied” to “very dissatisfied,” which was collapsed into a three-point scale for the purpose of this study, ranging from “satisfied” to “dissatisfied.”

A sense of community belonging was assessed using a single item: “How would you describe your sense of belonging to your local community?” and it was rated on a four-point scale ranging from “very weak” to “very strong.”

Adjustment to civilian life

Adjustment to civilian life measured how well Veterans felt they had adapted to civilian life after transitioning from the military. Adjustment to civilian life was measured using a single item based on the study set up by Spiegel and Shultz: “In general, how has the adjustment to civilian life been since you were released from the Canadian Forces?”23 Items were rated on a five-point scale from “very difficult” to “very easy,”4 which were collapsed down to a three-point scale for the current study (“difficult adjustment,” “neither difficult nor easy adjustment,” and “easy adjustment”).

Analyses

The sample data were used to conduct Kendall's tau correlations. Prevalence estimates, 95 per cent CIs, and ordinal logistic regression were conducted using weighted data that accounted for the complex survey design to ensure findings were representative of the sampled Veteran population.4 Using Stata, version 13.1, the ordinal logistic regressions were conducted using the gologit2 function.24 The dependent variable was adjustment to civilian life, and the models were adjusted for all of the independent variables at once. Parallel odds ratios were tested, as both models had double comparisons (odds of difficult adjustment compared to neither or easy adjustment and odds of difficult or neither adjustment compared to easy adjustment; with alpha autofit=0.01). The regression plan included age and sex variables, but since they were not significant in the first model, they were not included in the second model for parsimony.

Descriptive statistics

The descriptive statistics for all of the study variables are presented in Table 1. The majority of Veterans were male (88.1%), 89.1 per cent were satisfied with their relationships with friends, 87.8 per cent were satisfied with their relationships with family, and 82.2 per cent of Veterans had one or more PHCs. More than half were found to have an easy adjustment to civilian life (61.8%). Some Veterans found most days were a bit stressful (42.0%); 30.9 per cent had high mastery; and 29.0 per cent felt a somewhat strong sense of community belonging.

Correlations

Kendall Tau's correlations among the variables contained in the model are presented in Table 2. With higher levels of adjustment to civilian life (that is, easier adjustment), Veterans reported lower levels of life stress (−0.287, p<0.01), higher levels of mastery (0.213, p<0.01), greater satisfaction with support (0.325, p<0.01), lower PHCs (−0.165, p<0.01), and higher community belonging (0.245, p<0.01). All correlations were lower than 0.56; therefore, they did not violate the assumption of multi-collinearity, which is required for the ordinal logistic regression.

Table

Table 2. Kendall Tau's correlations among variables

Table 2. Kendall Tau's correlations among variables

Gen LS PHC MHC MAS SwF SwFr CB ADJ
Gen 1
LS .059** 1
PHC −.009 .094** 1
MHC .082** .288** .196** 1
MAS −.031** −.208** −.111** −.234** 1
SwF .007 .231** .052** .305** −.169** 1
SwFr −.014* .245** .102** .336** −.189** .505** 1
CB −.016** −.204** −.076** −.201** .152** −.218** −.284** 1
ADJ −.044** −.287** −.165** −.385** .213** −.288** −.303** .245** 1

**Significant at the 0.01 level (2-tailed).

*Significant at the 0.05 level (2-tailed).

Gender (Gen); life stress (LS); physical health conditions (PHC); mental health conditions (MHC); mastery (MAS); satisfaction with family members (SwF); satisfaction with friends (SwFr); community belonging (CB); and adjustment to civilian life (ADJ).

Note: Although many of the correlations were significant they may not all be meaningful given the large sample size.

Ordinal logistic regression

Two ordinal logistic regression analyses were conducted: (1) health-related variables, including sex, and (2) mastery and social support variables. For both models, adjustment to civilian life was the dependent variable. The goal of the first model (Table 3) was to examine the observed differences between the adjustment to civilian life and health-related variables (that is, PHC, MHC, and life stress). The first model shows that the odds of an easier adjustment were lower for those who were more stressed (adjusted odds ratio [AOR]=0.13), self-reported a PHC (AOR=0.53), and self-reported a MHC (AOR=0.23). Age and sex were not significant.

Table

Table 3. Models 1 and 2: adjusted odds of adjustment to civilian life

Table 3. Models 1 and 2: adjusted odds of adjustment to civilian life

Model 1
Model 2
Variables Categories Adjusted
odds ratio
95% CI Adjusted
odds ratio
95% CI
Life stress Not at all stressful Reference Reference
Not very stressful 0.87 0.60–1.26 0.89 0.61–1.32
A bit stressful 0.38*** 0.27–0.53 0.44*** 0.31–0.63
Quite a bit stressful 0.26*** 0.18–0.37 0.39*** 0.26–0.57
Extremely stressful 0.13*** 0.08–0.23 0.29*** 0.16–0.50
Physical health
conditions
No Reference Reference
Yes 0.53*** 0.40–0.70 0.58*** 0.44–0.77
Mental health
conditions
No Reference Reference
Yes 0.23*** 0.19–0.27 0.32*** 0.27–0.40
Mastery Low Reference
Average 2.60* 1.08–6.28
High 3.93** 1.60–9.68
Satisfaction with
family members
Satisfied Reference
Neither satisfied nor dissatisfied 0.59** 0.42–0.82
Dissatisfied 0.42*** 0.29–0.61
Satisfaction with
friends
Satisfied Reference
Neither satisfied nor dissatisfied 0.65* 0.45–0.94
Dissatisfied 0.47*** 0.31–0.71
Sense of community
belonging
Very strong Reference
Somewhat strong 1.12 0.80–1.57
Somewhat weak 0.81 0.57–1.16
Very weak 0.39*** 0.26–0.59

*p<0.05, **p<0.01, ***p<0.001, age and sex not significant.

Note: Adjusted odds of an easy or neutral adjustment to civilian life compared to a difficult adjustment and adjusted odds of an easy adjustment to civilian life compared to a difficult or neutral adjustment.

The goal of the second model (Table 3) was to examine the addition of mastery, social support, and community belonging to the model. This model shows that once these three variables were inputted into the model, the odds ratios of life stress and self-reported PHC and MHC increased closer to one, indicating a potential protective effect of adding these variables to the model. The odds of an easier adjustment were lower for those Veterans dissatisfied with their family relationships (AOR=0.42) and their relationships with friends (AOR=0.47) and those with a very weak sense of community belonging (AOR=0.39), it was higher among those with high levels of mastery (AOR=3.93). For both models, age and sex were not significant.

This study found that high levels of mastery, social support, and community belonging were associated with better self-reported health, lower levels of stress, and an easier adjustment to civilian life. The significant association of mastery and social support with the adjustment to civilian life remained after controlling for health conditions and stress. These findings are in line with those of previous studies, which have indicated the importance of psychosocial resources, such as mastery, social support, and community belonging in protecting against the adverse effects of stress.8 The findings suggest the importance of psychosocial resources in the Veteran population.

Mastery may be an important resource in transition, as it has been shown to help ease adjustment in several different areas.7,25 Mastery has been found to buffer the impact of stressors on health,26 indicating that it may be involved in the resilience process. Results from the current study confirm that individuals with a lower sense of mastery reported a more difficult adjustment to civilian life. These results indicate that mastery skills should be taught and nurtured throughout the CAF career to ease transition.

There has been limited research on training programs to enhance mastery as a personal resource. The enhancement of mastery is an important component of training programs and workshops to facilitate employment and reduce depressive symptoms among the unemployed.27 As well, changes in variables that are conceptually similar to mastery have been found following training. For example, hardiness, which is a construct conceptually similar to mastery in that both involve positive expectancy and a sense of personal responsibility toward the future,28 has been found to increase following a hardiness training program.29 Conceivably, building resilience by enhancing beliefs about the ability to influence positive outcomes can have a positive impact on the adjustment experiences of CAF Veterans.

Elements of the social environment (for example, social support and community belonging) are important resiliency factors for Veterans transitioning from military to civilian life. Higher levels of social support have been associated with fewer symptoms of depression, anxiety, and PTSD.2,20 Results from the current study reveal that satisfaction with support (that is, friends and family) and a higher sense of community belonging are associated with an easier adjustment to civilian life. Individuals who reported lower satisfaction with support also reported a more difficult adjustment to civilian life. This indicates the value of having programs and services during transition that assist members in maintaining or developing social support networks.

There were several limitations in the current study. One of the main limitations was that the study was based on cross-sectional data. Therefore, it was not possible to determine whether self-reported health issues and life stress resulted from difficult transition experiences or whether such issues led to a difficult adjustment. Similarly, it is not clear whether psychosocial resources assist with the adjustment to civilian life or whether successful transition leads to increased feelings of mastery and support. Although the adjustment to civilian life was found to be associated with individual and social resources in this cross-sectional study, only longitudinal research will be able to examine the causal relationships among the variables.

Factors in addition to those studied can affect the transition to civilian life (for example, military culture and financial status). In future research, a variety of factors should be examined, and some of the constructs could be further expanded upon to adequately assess the experiences of Veterans. The single item on adjustment to civilian life may have been interpreted in different ways by different participants, such that some only considered the period immediately following the transition to civilian life, while others may have considered themselves continuing to adjust to civilian life several years later. However, for this analysis, the timeframe for the survey following release was fairly short (an average of seven years), and prior research has demonstrated no association between the years since release and the adjustment to civilian life.5 As well, the measure of life stress is an overall measure that does not allow for an examination of the relative impact of various sources of daily stress, and the social support measure used assesses one's satisfaction with social support rather than the number of available sources of support or the differentiation of support from various sources.

Additional limitations include the use of self-reporting data and the examination of only former Regular Force members over a 10-year period of release. There are limitations associated with self-reporting data, including potential issues with the recall of events that occurred in the past. Particularly for those who were released from the CAF in the earlier years of the study cohort, recalling the ease or difficulty of adjustment to civilian life when it occurred many years before the survey may be problematic. In addition, the trajectory of outcomes over longer periods, therefore, could not be examined. In addition, only Regular Force Veterans were included in this study, although reservists may face unique issues with their transition experiences because of their dual civilian and military lives.

The results of this study point to the importance of personal characteristics and aspects of the social environment in the adjustment to civilian life among military Veterans. The results of this study are in line with past research, which has suggested the importance of psychosocial variables such as mastery and social support for individual well-being. To the extent that such resources are predictive of later outcomes, these intra- and interpersonal characteristics could be enhanced and developed throughout the military career to ease later adjustment. As well, ensuring a successful adjustment to civilian life may lead to better outcomes, such as enhanced mastery, following transition.

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None declared.

Krystal K. Hachey, Kerry Sudom, Jill Sweet, Mary Beth MacLean, and Linda VanTil conceived and designed the study. Krystal K. Hachey, Kerry Sudom, Jill Sweet, Mary Beth MacLean, and Linda VanTil acquired and interpreted data. Krystal K. Hachey, Kerry Sudom, Jill Sweet, Mary Beth MacLean, and Linda VanTil drafted and revised the content. All authors approved the final version accepted for publication. J. Sweet was responsible for data analysis.

N/A

Informed consent was obtained from the participants.

N/A

N/A

None declared.

This article has been peer reviewed.