Peer Reviewed Articles on Health and Fitness Free

• Journal List
• Prev Chronic Dis
• five.15; 2018
• PMC6093269

Prev Chronic Dis. 2018; xv: E101.

Peer Reviewed

Changes in Physical Activeness Later Installation of a Fitness Zone in a Community Park

Mojgan Sami

ⁱDepartment of Population Wellness and Disease Prevention, Plan in Public Health, University of California, Irvine

Megan Smith

ⁱⁱDepartment of Statistics, Academy of California, Irvine

Oladele A. Ogunseitan

¹Department of Population Health and Disease Prevention, Program in Public Health, University of California, Irvine

ⁱⁱⁱSchool of Social Ecology, Academy of California, Irvine

Abstract

Introduction

Increases in physical activity can lead to decreases in the prevalence of chronic diseases. Parks provide an ideal setting for concrete activity. Nosotros investigated the effect of a fitness equipment installation on the intensity of park users' concrete activity at a community park.

Methods

Nosotros used the Organization for Observing Play and Recreation in a Community to tape physical activity in Eastgate Park in Garden Grove, California, in Baronial 2015 (preintervention [northward = ane,650 person-periods]) and in Feb 2016 (postintervention [n = 1,776 person-periods]). Nosotros quantified physical activity in target areas of the park during 15-minute ascertainment periods in ii ways: 1) we categorized each user'south activity level during the menses (sedentary, walking, vigorous), and two) nosotros converted action levels to numeric metabolic equivalent task (MET) scores and calculated the menstruation-average score across users. We used mixed-effects regression models to appraise 1) the proportional odds of higher activity level at postintervention and 2) the association between intervention condition (pre vs post) and mean flow-average MET scores.

Results

In the firsthand zone around the fitness equipment, the odds ratio for a college activity level was 1.58 (95% confidence interval [CI], 1.14–2.eighteen; P = .006) and the hateful period-boilerplate MET score was 0.33 (95% CI, −0.07 to 0.74; P = .11) units college at postintervention. Beyond the park as a whole, the odds ratio for a higher activity level was 1.41 (95% CI, 1.21–1.63; P < .001), and the hateful period-average MET score was 0.34 (95% CI, 0.12–0.56; P = .003) units higher at postintervention.

Decision

Installing fitness zones appears to be an effective intervention for increasing physical activity of park users. Further studies demand to be conducted to understand the sustained impact of fettle zones over time.

Introduction

Physical inactivity contributes to obesity and chronic diseases such as cardiovascular harm and diabetes (1). Even so, less than 5% of American adults run across the national moderate-to-vigorous physical action target of 150 minutes per week (two). Strategies to increment concrete action are a recognized pathway to decreasing the prevalence of preventable chronic diseases (3). Public wellness and urban planning link the built environment to the promotion or deterrence of physical activity (2,4,5). Parks provide an ideal setting for physical activity. Public wellness agencies advocate customs-based environmental interventions, such as those implemented in parks, to improve access to physical action facilities (2,v,6), and health professionals prescribe park visits (7,8). Cities are improving parks, and these improvements can lead to increases in physical activity levels (9,10). In 2016, the city of Garden Grove, California, installed outdoor exercise equipment, or a fitness zone (11), in its Eastgate Park.

Several studies evidence that fitness zones are associated with increases in physical activity (x,12), while other studies evidence no significant correlation (xiii). Our written report investigated the effect of the installation of fitness equipment on physical activity in Eastgate Park. The primary objective of our study was to describe the distribution of park users' observed action levels (sedentary, walking, and vigorous activities) earlier and afterward installation of the fitness equipment and to quantify the association between intervention status (preintervention vs postintervention) and action level. The secondary objective was to investigate the association betwixt the intervention and the period-average metabolic equivalent chore (MET) score, a composite score described elsewhere (14). The menstruum-average MET score represents the average physical activeness intensity during an ascertainment period. Our findings will assistance united states amend understand the effectiveness of fitness zones equally a strategy to increase concrete activity with the goal of reducing the prevalence of preventable chronic diseases.

Methods

Eastgate Park is a 4.5-acre park in a suburban community in northern Orange County and has civilities such equally open green infinite, a children's playground, a community pool, a meeting facility, and a covered picnic area. The fettle zone in Eastgate Park was installed in Dec 2015 in a previously open infinite. The urban center'southward parks and recreation section worked with Greenfields Outdoor Fitness Equipment, Inc (fifteen), an Orangish County–based company, to install eight pieces of equipment: a 2-person lateral pull, a 2-person back and artillery combination resistance, a 2-person vertical arm press, a 2-person chest press, a set of combination bars, a 2-person sit-upwards bench, a parallel dip and stretch machine, and polymetric steps (Figure one).

Fettle zone in Eastgate Park, Garden Grove, 2016. Photography by Mojgan Sami.

This photograph shows 8 pieces of equipment installed in a park: a 2-person lateral pull, a ii-person back and arms combination resistance, a 2-person vertical arm printing, a ii-person chest printing, a set of combination confined, a 2-person sit-upward bench, a parallel dip and stretch machine, and polymetric steps. The background shows that the park is close to the street. Copse, small buildings, and cars are besides shown.

The institutional review lath of the Academy of California, Irvine, deemed that this observational written report in a public park required no review considering it involved no directly interaction with human participants. To assess park users' levels of concrete activity preintervention (before installation of equipment) and postintervention (after installation), we used the Organization of Observing Play and Recreation in Communities (SOPARC), a standardized observation tool (xvi). To quantify physical activeness in the park as a whole, nosotros divided Eastgate Park into 5 target areas (Figure 2). Trained researchers made preintervention observations during iii days in 2015 (August 29, Baronial 31, and September 2) and postintervention observations during three days in 2016 (Feb 1, Feb 3, and February vi). Each target area was monitored by a researcher during four i-hour intervals (seven:00 to 8:00 AM, 12:00 to 1:00 PM, 3:xxx to 4:30 PM, and 6:00 to vii:00 PM) on all 3 report days (Monday, Wednesday, and Saturday). According to SOPARC guidelines, we divided each 60 minutes into 15-minute increments, and nosotros sampled user activity continuously during each increment.

This Google Maps Prototype shows an aerial view of Eastgate Park which is a small park in a suburban neighborhood in Garden Grove, California. The park is divided into five quadrants with a public pool visible in the center, a community center visible towards the right mitt side of the paradigm and a covered picnic area in the left mitt side of the paradigm. There are clusters of trees, a playground and green spaces visible.

One researcher observed each assigned target area for the duration of the one-hr interval, per SOPARC protocol. The researcher recorded the sex, age grouping, and race/ethnicity of each user and categorized each user's activeness level equally sedentary, walking, or vigorous. Researchers coded equipment employ in the fettle zone every bit sedentary when the machines were non used equally intended (eg, used equally seating rather than practise); they coded action as vigorous when each appliance was used as instructed. The smallest unit of measurement of measurement in the SOPARC data is 1 person-period, defined as the contribution to the study of a unmarried park user who occupied a target area for all or office of a 15-minute period. If a park user occupied the target expanse longer than a unmarried 15-minute period, or if a park user left the target area and returned during a later period, researchers created multiple unique person-menses records. We calculated ane,650 person-periods at preintervention and 1,776 person-periods at postintervention.

The action levels for park users were subsequently converted into MET scores. In that location are only 3 possible MET scores: sedentary is equal to 1.five METs, walking is equal to 3.0 METs, and vigorous is equal to six.0 METs (14). We calculated a period-average MET score for each observation flow in a target area by averaging the individual MET scores for all person-periods in the period. The period-average MET scores quantify the overall boilerplate level of user activity in each target area during each ascertainment period.

We used χ² tests to examine the demographic distribution of park users preintervention and postintervention.

Proportional odds mixed-furnishings regression model

We used a proportional odds mixed-effects regression model to estimate the odds ratios for a higher activity level at postintervention than at preintervention. The dependent variable, activity level, is ordered, with vigorous existence the highest level, followed past walking and and then sedentary. The unit of analysis in these models is the person-period. The proportional odds model was adjusted for age group, sexual activity, race/ethnicity group, and day of week (weekday vs weekend day). To account for correlation among observations measured at the same time of day or in the same target area, random intercepts for time and target area were included. The model has the following grade:

50 ^C _ijk = β₀ + β_P X_ijk + β _DD_ijk + β _AA_ijk + β _{Due south}Southward_ijk + β _EE_ijk + a_j + b₁₀₀₀ + ε _ijk

Hither, the index i indicates an individual person-period, j indicates fourth dimension of day, and k indicates target expanse. The log odds of a park user's activity being classified above category C versus into or below C (for category C = walking) or versus into C (for category C = sedentary) is denoted by Fifty^C _ijk . The variable X_ijk is intervention status (post = one, pre = 0), D_ijk indicates day of week, A_ijk is the age group, Southward_ijk is sex, and East_ijk is the race/ethnicity respective to the park user. The overall intercept for the proportional odds model is β₀, and β _P is the coefficient associated with intervention condition. The random intercepts are denoted by a_j (fourth dimension of twenty-four hours) and b_k (target surface area); ε _ijk denotes the random within-person-catamenia error and is assumed to be an independent commonly distributed random variable. Similar proportional odds models stratified past target area were also fit to examine the association between activity level and intervention status (preintervention vs postintervention) in each target area. Some target areas had singled-out congenital environment elements or patterns of usage. The stratified models were designed to determine in which of the v target areas, if any, changes in concrete action postintervention occurred and which areas of the park were the strongest drivers of the estimated changes in activeness for Eastgate Park overall. Nosotros tabulated odds ratios (ORs) and 95% confidence intervals (CIs).

Linear mixed-effects regression model

To assess the association between period-average MET score and park intervention status, we fit a linear mixed-effects regression model with menstruation-boilerplate MET score as the outcome and period as the unit of analysis. The model was adjusted for day of week (weekday vs weekend day). Random intercepts for time of day and target surface area were included to account for correlation amidst measurements taken during the same fourth dimension of day or within the aforementioned target area. The model has the following form:

Y _ijk = β₀ + β_P X_ijk + β _DD_ijk + a_j + b_k + ε _ijk

Here, the index i catalogs individual periods, j indicates time of solar day, and k denotes target area. The outcome Y_ijk is the menstruum-boilerplate MET score, and the variable X_ijk is intervention status (mail service = 1, pre = 0) for the period. The overall intercept for the linear model is β₀, and β _P is the coefficient associated with intervention status. The random intercepts are denoted by a_j (time of day) and b_k (target area). The random within-period error in the flow-average MET score, denoted ε _ijk , is assumed to be an independent normally distributed random variable. We later on conducted a stratified analysis of the association between menstruum-average MET and intervention status within each target area. The resulting regression coefficients for intervention status yielded the estimated differences in mean flow-average MET score (either overall or past target area) comparing postintervention park use with preintervention park utilize.

Results

We establish pregnant differences in the observed demographic distribution of park users earlier and after installation of the fitness zone (Tabular array 1). The proportions of sedentary, walking, and vigorous action levels observed among park users differed from preintervention to postintervention past target expanse and in the park overall (Figure 3). In target area 5, the distribution of activity levels for the person-menses observations at preintervention (47.5% sedentary, 15.3% walking, 37.3% vigorous) was markedly unlike from the distribution of activity levels for person-flow observations at postintervention (18.6% sedentary, 62.1% walking, 19.two% vigorous). Postintervention users in the park overall were estimated to have 41% higher odds of being classified in a more active category than were preintervention users with similar demographic characteristics (OR = 1.41; 95% CI, 1.21–one.63, P < .001) (Table 2). Among the 5 target areas, postintervention users had significantly college odds of being observed at a higher activity level in target area 1 (OR = two.11; 95% CI, 1.51–2.97; P < .001), target expanse 3, the location of the fettle zone (OR = 1.58; 95% CI, ane.14–2.18; P = .006), and target surface area 5 (OR = 1.97; 95% CI, ane.34–two.89; P < .001).

Table 1

Percentage Distribution of Demographic Characteristics Amidst Park Users, Overall and by Target Area^a, Preintervention and Postintervention^b, Eastgate Park, Garden Grove, California, 2015–2016

Characteristic	Target Area 1		Target Area 2		Target Area 3		Target Surface area 4		Target Area 5		Overall
	Pre	Post	Pre	Post	Pre	Post	Pre	Post	Pre	Post	Pre	Mail service
Total no. of person-periodsc	378	347	261	590	294	371	357	151	360	317	i,650	1,776
Sex
% Male	50.0	71.2	57.1	64.ii	51.4	62.iii	48.2	58.ix	41.four	54.nine	49.1	63.1
% Female	50.0	28.8	42.9	35.8	48.six	37.seven	51.viii	41.i	58.half dozen	45.1	l.ix	36.nine
χ2 (P value)d	33.0 (<.001)		3.half-dozen (.06)		seven.5 (.006)		4.v (.03)		11.8 (<.001)		67.3 (<.001)
Age group
% Kid	22.8	12.vii	nineteen.2	17.8	32.0	16.iv	30.viii	7.9	43.3	32.viii	30.one	eighteen.4
% Teen	9.5	22.8	twenty.7	30.two	xix.four	29.9	10.6	11.3	five.6	17.0	12.4	24.seven
% Adult	48.9	45.0	44.viii	44.6	36.4	44.2	45.9	57.0	41.9	44.v	43.9	45.half-dozen
% Senior	18.8	19.6	15.3	7.5	12.2	9.iv	12.6	23.eight	nine.2	v.7	thirteen.vi	11.three
χ2 (P value)d	30.9 (<.001)		17.5 (<.001)		27.eight (<.001)		34.2 (<.001)		28.2 (<.001)		121.nine (<.001)
Race/ethnicity
% White	65.9	61.iv	64.8	52.nine	58.viii	69.5	57.i	74.ii	52.5	59.0	59.6	60.9
% Hispanic	13.viii	32.0	17.2	35.9	twenty.seven	19.vii	5.0	19.9	7.2	23.vii	12.ii	28.2
% Black	1.3	one.7	1.one	two.7	2.0	3.0	three.6	0	2.eight	12.0	2.2	4.0
% Other	nineteen.0	4.9	16.nine	8.5	18.4	7.8	34.two	6.0	37.five	v.4	25.9	half dozen.9
χtwo (P value)d	57.0 (<.001)		38.nine (<.001)		xviii.two (<.001)		67.9 (<.001)		129.5 (<.001)		307.8 (<.001)

Distribution of activity levels in Eastgate Park at preintervention and postintervention, by target area and overall, Garden Grove, California, 2015–2016. Percentages were calculated on the basis of person-periods, defined equally the contribution to the written report of a unmarried park user who occupied a target area for all or part of a 15-minute menses.

Target Area	Intervention Status	Percentage	Activeness Level
1	Pre	38.3	Sedentary
1	Pre	36.1	Walking
1	Pre	25.7	Vigorous
i	Post	10.4	Sedentary
1	Postal service	62.8	Walking
i	Postal service	26.8	Vigorous
2	Pre	17.0	Sedentary
2	Pre	43.2	Walking
2	Pre	39.viii	Vigorous
ii	Mail	19.three	Sedentary
2	Post	48.five	Walking
ii	Post	32.ii	Vigorous
3	Pre	16.3	Sedentary
three	Pre	63.9	Walking
iii	Pre	19.7	Vigorous
3	Post	12.9	Sedentary
3	Post	56.3	Walking
3	Post	30.seven	Vigorous
4	Pre	16.2	Sedentary
4	Pre	41.v	Walking
4	Pre	42.3	Vigorous
4	Mail service	4.0	Sedentary
iv	Mail	85.4	Walking
4	Mail service	10.half dozen	Vigorous
5	Pre	47.5	Sedentary
5	Pre	15.3	Walking
v	Pre	37.3	Vigorous
five	Post	18.6	Sedentary
five	Post	62.one	Walking
five	Postal service	xix.2	Vigorous
Overall	Pre	47.5	Sedentary
Overall	Pre	15.3	Walking
Overall	Pre	37.three	Vigorous
Overall	Post	18.half-dozen	Sedentary
Overall	Post	62.i	Walking
Overall	Mail service	19.2	Vigorous

Table 2

Proportional Odds Mixed-Effects Regression Model: Estimated Odds^a of Having a Higher Activeness Level at Postintervention Than at Preintervention^b, Overall and by Target Area^c, Eastgate Park, Garden Grove, California, 2015–2016

Park Area	Activeness-Level Odds Ratioa (95% Confidence Interval)	P Value
Target area i	2.11 (1.51–ii.97)	<.001
Target area 2	0.91 (0.66–one.26)	.58
Target area 3	1.58 (1.fourteen–2.18)	.006
Target area iv	0.fourscore (0.53–1.22)	.thirty
Target expanse 5	i.97 (1.34–2.89)	<.001
Overall	1.41 (one.21–i.63)	<.001

The hateful menses-average MET score at preintervention was three.twenty (25th percentile, 2.fifty; 50th percentile, 3.32; 75th percentile, 4.00). At postintervention, the mean flow-average MET score was three.52 (25th percentile, 3.00; 50th percentile, 3.16; 75th percentile, 4.00). Decision-making for day of week, the mean catamenia-average MET score at postintervention in the park overall was an estimated 0.34 (95% CI, 0.12–0.56, P < .001) units higher than the mean period-boilerplate MET score at preintervention (Table iii). Among the v target areas, the hateful period-average MET score was significantly higher at postintervention than at preintervention in target area 1 (0.57 units; 95% CI, 0.07–1.07; P = .03) and in target area five (0.69 units; 95% CI, 0.21–1.16; P = .005). In target area three, the location of the fitness zone, the mean period-average MET score at postintervention was 0.33 (95% CI, −0.07 to 0.74; P = .11) units college than at preintervention.

Table 3

Linear Mixed-Effects Regression Model: Estimated Departure in Mean Period-Average MET Scores^a Between Preintervention and Postintervention,^b Controlling for Day of Week (Weekday or Weekend), Overall and past Target Expanse^c, Eastgate Park, Garden Grove, California, 2015–2016

Park Area	Estimated Difference (95% Conviction Interval)	P Value
Target area ane	0.57 (0.07 to 1.07)	.03
Target expanse 2	0.17 (−0.25 to 0.59)	.37
Target area 3	0.33 (−0.07 to 0.74)	.xi
Target area iv	−0.21 (−0.76 to 0.34)	.45
Target area v	0.69 (0.21 to one.16)	.005
Overall	0.34 (0.12 to 0.56)	.003

Discussion

Our findings support the hypothesis that physical activity levels amid Eastgate Park users would be higher after a public health intervention consisting of the installation of fitness equipment, where individuals' physical activity is categorized as sedentary, walking, or vigorous through use of the SOPARC assessment tool. Nosotros establish strong prove of an increment in Eastgate Park as a whole, both when physical activity was measured at the level of the individual park user person-menstruation and when concrete activeness was quantified by using the aggregate mensurate of the period-average MET score.

Furthermore, afterward installation of the fitness zone, nosotros plant significantly higher levels of physical activity in particular target areas of the park. Community park users had higher odds of being observed at a more than intense activeness level at postintervention than at preintervention in target area 1, target area 3 (location of the fitness equipment), and target area v. The increment in moderate and vigorous activity subsequently the installation of the fettle zone was not surprising. The intervention was associated with increased action in target expanse ane and target expanse 5 in terms of catamenia-average MET scores as well.

Target surface area one is an open green space that researchers observed to be used every bit a shortcut through the park. No information were systematically collected to draw park users walking through the park (rather than using the park as a destination). To distinguish between passive and active use of parks, future studies should investigate how the location of a park and its proximity to residential neighborhoods and transit corridors affect park employ. Target area v has a playground and a pool. The pool was closed in February, during postintervention data collection. The seasonally dependent physical activity in target area 5 illustrates one limitation of our report: preintervention and postintervention information collection periods were not matched on weather and temperature. In target area 5, the distribution of activity levels at preintervention was markedly different from the distribution at postintervention. This difference in distribution reflects seasonal differences in park use: stationary sunbathing and agile pool play in August and by and large walking by the closed pool area in Feb. The potential touch on of the fitness zone could be partially obscured in our analysis because of these seasonal differences. When target area 5 was excluded from the overall analysis, the odds ratio for a higher action level in the park overall was i.33 (95% CI, 1.12–1.57, P = .001).

Research supports the connection between park space and walking activities (17). Indeed, we found walking to be the dominant action observed in Eastgate Park at postintervention. Interestingly, walking activities increased in the park later the fitness zone installation, suggesting that park improvements may motivate activity because of their novelty. For example, people may have been walking in Eastgate Park to see the fettle equipment out of marvel. Future studies could investigate the value of periodic changes to a park's congenital environment to continually attract visitors and provide inspiration for exploration and action.

Organized activities and outreach are pivotal to increasing a community's usage of a neighborhood park, and community-based participation can contribute to increased concrete action levels (17,eighteen). Our data show the immediate impact of the fitness zone in Eastgate Park. The fettle zone installation could be associated with even greater increases in physical activity after the community has more than fourth dimension to discover, appoint with, and learn proper usage of the equipment. On the other hand, without continued customs engagement, use of the fitness zone may decrease. Future studies could appraise whether park use and physical activeness in Eastgate Park increment afterwards additional fourth dimension and community appointment.

Our written report has several limitations. Although our findings back up a strong association between pre–post intervention status and observed physical activeness, we cannot draw conclusions on causality without because other potential explanations for the observed associations, such every bit season of year or calendar time, and other unmeasured changes in the Garden Grove community between preintervention and postintervention. Practical considerations related to grant guidelines, customs partnerships, and bookish scheduling required us to comport preintervention and postintervention observations during two unlike seasons; futurity studies would ideally compare preintervention and postintervention physical action in the park nether similar environmental conditions. Comparisons of study data collected during unlike seasons in a temperate climate, such every bit southern California, however, are likely to be less problematic than comparisons of study data nerveless in a location with more farthermost seasonal climate fluctuations. Other limitations include possible misclassification of the concrete activity upshot variables or demographic descriptors and possible (conscious or unconscious) bias among the researchers collecting data, who were aware of the purpose and timing of the intervention and data collection. Although it is important to exist cautious about generalizing this study'south results to other contexts, these findings do back up park infrastructure improvements as a vehicle for wellness-promoting behavior in Eastgate Park.

Finally, although our report provides articulate evidence of increased levels of physical action after the installation of the fitness zone, the SOPARC mensurate does not account for contextual information that may explain this increment. We establish significant differences in the observed demographic makeup of park users earlier after installation of the fitness zone; thus, it is important to control for sexual practice, age grouping, and race/ethnicity in the analysis of park users' physical activity in future studies. We recommend more qualitative and ethnographic studies to explore the increase in physical activeness. Such studies may be of value in understanding the reasons for observed demographic differences in physical action levels later the installation of fitness zones.

To promote concrete activity equally a strategy for preventing chronic diseases, it is beneficial to evaluate park design and sustain customs outreach efforts to promote knowledge of park amenities. Characteristics such as accessibility, safe, quality of amenities, and park maintenance are of import considerations for physical activity interventions. Park programming also attracts park users (xix). The Centers for Illness Command and Prevention-coordinated Partnerships to Improve Community Wellness, which funded the interventions in Eastgate Park, provides an opportunity to generate and amass evidence nationwide nigh interventions that promote physical activity. Although we constitute overall physical activeness to increment in the park after the fettle zone installation, we besides note the need for continued research to understand the contextual factors that may explicate such increases.

Acknowledgments

We thank inquiry administration Dhruvi Chauhan, Rintu Saju, Hannah Salao, Gerardo Magana, and Rossini Batino for their all-encompassing work in field data collection, preliminary analysis, and early on drafts of this article. Nosotros besides thank the Community Action Partnership of Orangish County (CAPOC), Garden Grove Parks and Recreation; John Montanchez, Garden Grove Department of Public Works; and Dr Gaby Abdel-Salam, Harya S. Dillon, Asiya Netakel, Saira Nawaz, and Ashani Johnson-Turbes from ICF International. This research was supported in part by an award from the Centers for Disease Control and Prevention (CDC) (no. U58DP005861). Portions of this projection'southward work involve the Partnerships to Meliorate Customs Health initiative supported by CDC funding. Still, the findings and conclusions in this article are those of the authors and exercise not necessarily represent the official position of CDC. SOPARC is a publicly available observational protocol used by agile-living researchers throughout the globe.

Footnotes

The opinions expressed by authors contributing to this periodical exercise not necessarily reflect the opinions of the U.South. Department of Wellness and Human being Services, the Public Health Service, the Centers for Affliction Command and Prevention, or the authors' affiliated institutions.

Suggested citation for this article: Sami M, Smith M, Ogunseitan OA. Changes in Physical Activity After Installation of a Fitness Zone in a Community Park. Prev Chronic Dis 2018;fifteen:170560. DOI: https://doi.org/10.5888/pcd15.170560.

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Articles from Preventing Chronic Affliction are provided hither courtesy of Centers for Affliction Control and Prevention

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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6093269/

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