young adults with type 1 diabetes transitioning living in Philadelphia, PA transitioning from pediatric care to adult health care providers.

Order Description

This assignment is a continuation from the last three assignments that is attached assignment 1,2 & 3 to the description so you will have a better understanding of assignment #4( that I need the paper written on). My population is young adult with type 1 diabetes living in Philadelphia county Pennsylvania and my main focus is on the young adults with type 1 diabetes transitioning from pediatric care to adult healthcare providers(the goals is have transitional care programs that make it easily for young adult with type 1 diabetes transition easily to have better glycemic control and have overall good management of their diabetes). You need to read the three attached paper to have a better understanding of my population and once you read it you will see the three health metrics I choice(concerning the health metrics I choice my teacher gave me these comments for improvement that you need to follow: ?while hba1c is a good clinical measure – need to find another valid and reliable peer reviewed published metric to be used here. you can keep hba1c as a recommended clinical step or a screening measure?.)

Here is a description of the assignment 4:

Assignment 4: Developing a Population Health Plan (15 pages; also attach assignment 1, 2, and 3 in an appendix)
This paper integrates the findings from the previous 3 papers into 1) A description of a population specific and problem specific heath plan addressed from a theoretical perspective, 2) An individual and community level assessment of the extent and context of the health problem, and 3) potential individual and community level interventions that can be used to improve the problem within the population, using specific health metrics. This paper is truly integrative. You need to assess the interrelatedness of the three components (theory and population specific problem, individual and community context and outcome assessment) to propose a plan for population specific health care. Incorporate the feedback you have received on the earlier papers to strengthen your overall product.

Assignment #1: Selecting a Population (3 pages)
Identify a population for study (e.g. impoverished children, elders living at home, young adults with Type 1 diabetes, Latino migrant women of child-bearing age) that you will focus on for the four papers. Using one of the conceptual or theoretical models identified in your readings, discuss the health risks for this population and the factors that increase or decrease risk for this population. From these, select a specific health problem (e.g. falls in the elderly living at home, perinatal health problems for Latino migrant women) and discuss how you would identify cases especially at risk.

My population of interest is the young adult with type 1 diabetes (DM1) the reason am interested in this population goes back to my time spent working in ICU. I frequently cared for young adults in the age range 18-30 readmitted with diabetes complication such as diabetic ketoacidosis, hyperglycemic episode and hypoglycemic episode. One of the most challenging, non-modifiable risk factors in this population was their young age; Thorpe, Lewis, and Sterba (2008) described young adulthood as beginning in their late teenage and into the late twenties or early thirties. Most of these young adults were away from parents for the first time during their college, new job or early military experience, and had no one else to fall back on for managing their diabetes regimen (Markowitz & Laffel, 2012). The physical and emotional stress of relocating in a new environment and assuming primary responsibility for their own health is a unique challenge to young adults as they transition to independent adult living.
Additional health risks for this population include immature psychosocial development, which can present with feelings of invincibility and generalized lack of serious approach to self-care (Markowitz & laffel, 2012). Failure to prioritize their health care leads to poorer outcomes in DM1 management in young adult population, as they struggle to not only gain control over their chronic disease, but also struggle with all the other issues of transition to adulthood: self-identity, secure employment, academic performance, intimate relationships, and continuing to meet family obligations.
Young adults need psychological support, as a young adult, I can imagine how hard it is to stop what you doing to monitor your blood sugar levels especially when you are around friends or doing something with peers. They need the emotional support to manage the social stress that comes with the management of the disease. According to Brierley, Eiser, Johnson, &, (2012) multidisciplinary team approach complicated the management of DM1 because of differences in consultation styles causing poor team cohesion and communication. Young adults battling with DM1 will encounter different recommendations for management of the disease with each provider, making it confusing for the patient, who does not yet possess the mature cognitive skills and neurobiological development to utilize critical thinking and make the best decision for him or herself.
One risk factor that every child diagnosed with DM1 will face is the transitioning of care from pediatric to the adult primary care provider. This transition for young adult can be difficult, especially if they do not have adequate psychosocial support from family and loved ones. Young adults may not fit in well with either adult or pediatric care providers, the goal is tailor a transitional care clinic for the young adult population (Lancaster et al., 2010). However, this transitional period is crucial for successful management of DM1; loss of a consistent, trustworthy provider in this stage will have a major effect on the young adult?s total health outcome in the long run.
There are many health factors that can increase or decrease health risk. One health factors that will increase health risk is that many young adults see the complex DM1 treatment regimen as inconvenient to them (Thorpe, Lewis & Sterba, 2008). Another factor that can increase health risk is that young adult sees themselves as invincible that they don?t believe or understand the outcome associate with poor glycemic control over a period of time. Young people do not believe they can end up with hypertension, kidney failure, stroke, loose limbs and other adverse outcomes associated with poor diabetes management. Factors that will decrease health risk are things or behaviors that will improve glycemic control therefore having within normal limits of HgA1C levels.
Having family support can be beneficial as long as the young adult is well prepared for and remains the primary caregiver of their own diabetes regimen themselves. The moral support of family involvement and easy transition to adult provider help decrease health risk. Parents of young adults should resist the temptation to continue managing their child?s DM1, but instead should teach and prepare their young adult child for independent health management and independent adult living.
Emerging adulthood is a period of uncertainty, exploration and inconsistent behavioral patterns that make it particularly hard for young adults to follow treatment regimens (Lancaster et al., 2010). Young adults may not be influenced by the potential long-term issues associated with DM1(Lancaster et al., 2010).
Identifying cases that are high risk for poor glucose control and behavior adherence produce significant physical and psychological complications for individuals with diabetes. Therefore, problems such as blindness, lower limb amputation, renal failure, heart attack and stroke create obvious health issues for the individual, as well as significant financial impact in the healthcare system as whole (Lancaster et al., 2010). Even though it is hard to adhere to glucose control in older adults, research shows that glycemic control is even worse in the young adult population (Lancaster et al., 2010). Young adults away from home to college experience more difficulties following their diabetes regimen. This period in the adult life maybe the first time they have to take charge of managing their diabetes which can be challenging. They can develop psychological issues regarding the management of the disease, and they may lack the motor and cognitive skills (calculating proper doses, performing self-injections). Diabetes management can be overwhelming when dealing with other stressors of being a young adult.
In conclusion, young adulthood is a challenging phase in the human lifespan, and having to manage a complex disease like diabetes can be an additional battle. The goal is to find ways to control diabetes through pharmacological interventions, diet control, a healthy exercise program, and regular fellow ups with physician. Having normal HgA1C levels is the optimum goal for young adults with type 1 diabetes and a smooth transition of care helps most patients achieve this goal. As an advance practice nurse, I my goal is to combat problems with transitional care phase, to help the young adult population have a better transition of care to gaining knowledge and skills for successful manage of their DM1.

Brierley, S., Eiser, C., Johnson, B., Young, V., & Heller, S. (May 01, 2012). Working with young adults with Type 1 diabetes: Views of a multidisciplinary care team and implications for service delivery. Diabetic Medicine, 29, 5, 677-681.

Lancaster, B. M., Pfeffer, B., McElligott, M., Ferguson, A. T., Miller, M., Wallace, D., & Lane, J. T. (January 01, 2010). Assessing treatment barriers in young adults with type 1 diabetes. Diabetes Research and Clinical Practice, 90, 3, 243-9.

Markowitz, J. T., & Laffel, L. M. (January 01, 2012). Transitions in care: support group for young adults with Type 1 diabetes. Diabetic Medicine : a Journal of the British Diabetic Association, 29, 4, 522-5.

Thorpe, C., Lewis, M., & Sterba, K. (January 01, 2008). Reactions to Health-Related Social Control in Young Adults with Type 1 Diabetes. Journal of Behavioral Medicine, 31, 2, 93-103.
Assignment 2: Assessing the Community Context and Significance (5 pages; also attach assignment 1 in an appendix)
Describe a typical community where your population resides (e.g. Latino women of child-bearing age might be found in Wilmington or in Sussex counties). Using
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, the HRSA data warehouse
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or other publically available data bases, describe the general health context in the community (e.g. health care facilities that provide services for your population and their health need), level of population, racial and ethnic make-up?use whatever descriptors that will convey the opportunities and challenges your population might have in accessing population sensitive and problem specific health care in that community. In this paper also describe the specific demographics for the population you have selected (e.g. % people over 65) and the extent to which the specific health problem you have selected exists within that community. Finally describe the extent to which the built environment within the domicile and/or community increases or decreases the risk for the population you have selected.
A population living in a city, state, or region has to have resources available for the specific population. In this paper I will analyze a specific population in a certain location or region in the united states. Young adults with type1 diabetes living in Philadelphia county, Pennsylvania. This paper will give a detailed description of the population in Philadelphia county, discuss the opportunities and challenges of young adults with type 1 diabetes transitioning from pediatric care to adult care providers, and the environmental problems that will enhance or decrease health problems for young adults with type 1 diabetes.
Pennsylvania population as of July 1, 2015 was 12,802,503 and of that 1,567,442 as of July 1, 2015 reside in Philadelphia county (United states Census Bureau, 2015). Whites make up 45.1%, Black or African American alone is 44.0, American Indian and Alaska Native alone, percent is 0.8%, Asian alone is 7.4% (United States Census Bureau, 2015). Native Hawaiian and Other Pacific Islander alone is 0.1% of people living in Philadelphia county (United states Census Bureau, 2015). Other Pacific Islander alone is 14.0% (United states Census Bureau, 2015). White alone, not Hispanic or Latino is 35.4% as of July 1, 2015 (United states Census Bureau, 2015). Many people living in Philadelphia county are living in poverty. The median household income (in 2014 dollars) 2010-2014 was $37,460(United states Census Bureau, 2015). Per capita income in past 12 months (in 2014 dollars), 2010-2014 was $22,542(United states Census Bureau, 2015). The percent of persons in poverty was 25.8% (United states Census Bureau, 2015).
In Philadelphia as a whole African American were the largest racial group in 2015, representing 44 percent of the entire population (United states Census Bureau, 2015). Among ages 20 to 34 the census tracks educational attainment of individuals age 25 and over. Philadelphians ages 25 to 34, the percentage reporting bachelor?s degrees or higher was 37.4 percent in 2012 (up from 30.5 percent in 2006) (Eichel, 2014). As is the case nationally, Philadelphia?s young adults are far more likely to lack health insurance than are members of the city?s other age groups, many of whom get coverage through their places of employment or government programs such as Medicaid and Medicare (Eichel, 2014). According to HRSA, (2010) young adults ages 20-29 in 2010 was 282,327. About 22 percent of Philadelphians ages 18 to 34 had no health insurance in 2012, a rate about twice as high as that for all other city residents (Eichel, 2014). In fact, this age group accounts for nearly half of all uninsured Philadelphians, compared with 19.7 percent of Philadelphians age 35 and over(Eichel,2014).. In Philadelphia individuals without health insurance, under age 65 years, percent 14.4% ( United states Census Bureau, 2015). The total number of primary care providers is 474, and there are only 5 care centers that specialize in Diabetes in the city of brotherly love ( HRSA, 2010). The centers designed for diabetes were Einstein Diabetes, Penn Rodebaugh Diabetes Center, Endocrinology, Diabetes, and Metabolic Diseases at Jefferson, Joslin Diabetes Center, Diabetes Center: Schutta Mark MD.
After careful review of my population, I found a great opportunity for young adults with type one diabetes to transition from pediatric care to adult primary care provider at the children’s hospital of Philadelphia (CHOP). CHOP transition encompasses all facets of adult life, including healthcare, education, employment, socialization and recreation (CHOP, 2016). Their goal for the transition is for adolescents to move toward independence. The transition of care program in CHOP helps young adults transition from pediatric care to adult care. The program provides such support to young adults and their families with services. These services include teaching the young adult and parents that they are legal decision-makers, calling and scheduling most or all their own appointments. Once the young adult has chosen new providers, the pediatric healthcare providers make sure their health care binder is up to date (CHOP, 2016). The new doctors will get a better understanding of the young adult?s condition once they receive one or two pages of medical summary from the pediatric doctors (CHOP,2016).
The Children’s Hospital of Philadelphia runs several programs to support patients who are getting ready to transition to adult health care and adult life, including the program, REACH (Rapport, Empowerment, Advocacy, through Connections and Health). REACH is for young people with chronic conditions and their parents; it?s mission is to prepare youth, ages 14 to 24, with special health care needs, for a successful transition into adulthood by providing peer support, guidance and resources (CHOP, 2016).
The challenges in receiving care for young adult in Philadelphia with type 1 diabetes are many in the Philadelphia county. Philadelphia with a population of 1,567,442 and about 22% being of ages 18-34 years (Eichel, 2014). I found it difficult to believe that it is only one transitional care program for young adults emerging to adult health care facilities. It is also shocking that there is only a total of 5 specialty diabetes care centers in the county of Philadelphia while there are many primary care providers who provide the same or similar services.
Health problems in this population of young adults with type 1 diabetes transitioning of care can be negatively impacted if the transition of care does not happen at all or improperly happens. Transitioning care is not widespread in the united states, and providers must arm themselves with a working knowledge of available outcomes, data, and a solid understanding of the developmental phases and challenges of young adulthood (Garvey & Wolpert, 2011). Research on diabetes control has shown that HbA1c levels are best controlled when follow-up rates with providers are around 75% (Holmes-Walker, Llewellyn, & Farrell, 2007). In young adults who are appropriately supported with adult services, and clinic attendance is maintained, diabetes control was improved and hospital admission rates with DKA are reduced (Holmes-Walker, Llewellyn, & Farrell, 2007). Poor glycemic control, is associated with risk factors for complication such as hypertension, dyslipidemia, and high risk behavior (cigarette smoking and drug/alcohol abuse). Transitioning into adulthood may be accompanied by issues regarding health insurance coverage, or leaving parental home. Those in this transition may be uninsured or underinsured (Peter & Laffel, 2012). Additionally, it is imperative for these young adults to achieve target glycemic control in order to prevent long-term complications and to maximize lifelong functioning (Peter & Laffel, 2012). Pediatric to adult care can be conceptualized as having ?macro-level? and ?micro-level? components (Garvey & Wolpert, 2011). The macro level consists of the actual transfer process by the actual physical movement of patients from pediatric to adult care services (Garvey & Wolpert, 2011). The micro level involves thinking about how diabetes providers understand the challenges facing young adults with diabetes and their approach to education and support during clinical encounters. Providers need to help patients in the transitional period by writing a summary report to new provider to gain knowledge of the individual care needs (Garvey & Wolpert, 2011).
Philadelphia is not helping young adult transitioning to make better health choices because of the economic and social issues. Unites States Census Bureau record show persons in poverty percent is 25.5% in Philadelphia. It is important to know, according to Philadelphia Department of Public Health (2011) diabetes and hypertension disproportionately affect Black Philadelphians compared to White and Hispanic Philadelphians. Rates of chronic disease among Philadelphian adults are increasing. In 2009, Philadelphia had the highest prevalence of hypertension (34.5%) and heart disease (4.5%), the second highest prevalence of diabetes (10.7%) and obesity (29.3%) among counties containing one of the ten largest cities, Philadelphians? consumption of fresh fruits and vegetables is poor with only 10.5% of all adults eating the USDA recommended five daily servings (PDPH, 2011). Agency for Healthcare Research and Quality found that in Pennsylvania, patients admitted to hospital for diabetes with short-term complications per 100,000 population was 73.75% in ages 18 and over, compare to a national average of 71.9 in 2011-2013. If providers do not make it easier for young adult with diabetes to transition, the extent of health related issues in Philadelphia county will increase.
The environment does not make it easy for young adults with type 1 diabetes living in Philadelphia county in transition to adult care providers. For example, the poverty level is high in Philadelphia and Health disparities within the African American population is apparent. According to, (2016) median household income in 2013 for African American was $30,010. This data does not help an individual living with diabetes have better health outcomes to achieve good glycemic control because those in poverty are less likely to focus on their transition of care. The more providers get involved and incorporates good transitional care programs into their practice, the more likely young adults will be able to follow through with their diabetes care.
In all, young adults face many challenging when dealing with the complicities of caring for their diabetes. Philadelphia county providers need to be more aware of transitional care needs during adolescent years. There is a need for improvement with providers in Philadelphia county when caring for young adults with type 1 diabetes. Providers need to incorporate similar programs like, CHOP transitional care program to help young adult population in Philadelphia in treating and preventing diabetic complication in their future.

Children?s Hospital of Philadelphia. (2016). Transitioning to adulthood program. Retrieved from (2016). Philadelphia, Pennsylvania. Retrieved from
Eichel, L. (2014). Millennials in Philadelphia: A promising but fragile boom. The Pew Charitable Trusts. Retrieved from
Garvey, K.C., Laffel, L.M., Telo, G. H., Needleman, J. S., Laffel, L. M., Forbes, P., Finkelstein, J. A. (2016). Health care transition in young adults with type 1 diabetes: Perspectives of adult endocrinologists in the U.S. Diabetes Care, 39, 2, 190-197.
Garvey, K.C., Wolpert, H.A. (2011). Identifying the Unique Needs of Transition Care for Young Adults With Type 1 Diabetes. Diabetes Spectrum, 24, 1, 22-25.
Garvey, K.C., Wolpert, H.A. (2011). Transitions in young adults with type 1 diabetes: a call to action.(Preface). Diabetes Spectrum, 24, 1.)
Holmes-Walker, D.J., Llewellyn, A.C., Farrell, K. (2007). A transition care programme which improves diabetes control and reduces hospital admission rates in young adults with Type 1 diabetes aged 15-25 years. Diabetic Medicine, 24(7) 764-769.
Health Resources & Service Administration data warehouse. (2010). Data portal report. Retrieved from
Peters, A., Laffel, L. (2012). Diabetes care for emerging adults: Recommendations for transition from pediatric to adult diabetes care systems. Diabetes Care, 35, 1.
Philadelphia Department of Public Health. (2011). Overview of chronic disease and healthy eating and active living Indicators for Philadelphia adults and children. Retrieved from
United States Census Bureau. (2015). Philadelphia county. Retrieved from,42
U.S Department of Health & Human Services. (n.d.) Agency for healthcare Research and Quality/Pennslyvania. Retrived from
Assignment 3: Determining Health Outcome Metrics (3 pages; also attach assignment 1 and 2 in an appendix)
Select at least 3 metrics that you would use to assess health outcomes pertaining to your population. At least one of these metrics must address the specific health problem that you have focused on. Describe how you would collect this information, and how often you would measure it. For each outcome indicator determine what change you would expect that would reflect a positive and a negative health change. Discuss how often the heath outcome indicator would need to be monitored to capture positive and negative changes in the indicator. Using the information from the previous two papers, describe potential individual and community level changes could be enacted to improve health in your population and for the specific health problem you are measuring.

Young Adults with Type 1 Diabetes
My population of interest includes young adults with type 1 diabetes. In particular, I will focus on young adults with type 1 diabetes living in Philadelphia County, Pennsylvania. There is a great opportunity for members of my population to transit from pediatric care to adult care. Factors that contribute to effective transitioning include availability of programs that ensure smooth transition from pediatric care to adult care and level of awareness of the importance of ensuring smooth transition. The main objective is to facilitate effective self-management of type 1 diabetes (DM1) among young adults (aged between 18 and 30 years) to prevent the development of secondary health implications such as lower limb amputation. The proposed metrics that will facilitate the achievement of these three objectives include: glycated hemoglobin (HbA1c), Rapid Assessment Protocol for Insulin Access (RAPIA), PROMIS (Patient-Reported Outcomes Measurement Information System), and increase the use of recommended transitional care tools that facilitate easy transition from pediatric to adult care.
The purpose of this paper is to evaluate metrics in the assessment of the health outcomes pertaining to the population of young adults with type 1 diabetes. Monitoring and control are critical elements of the implementation process of any health improvement program. Monitoring and control are aimed at steering the program to ensure that it achieves set objectives (Singh, Gupta & Kant, 2012). Negative deviation from the intended performance serves as an indicator that control measures are required to achieve desired performance. Therefore, performance evaluation is critical to the success of any health improvement program. The paper will describe techniques and processes for the collection of the information, as well as frequency in the assessment of the information. For each outcome indicator, the paper will determine the change to expect in reflecting positive or negative and health change. Additionally, the paper will explore how often the outcome indicator would need monitoring and evaluation for the illustration of the positive and negative changes.
HbA1c is a widely used tool for evaluating the quality of long-term diabetes management and control practices (Kohnert et al., 2015). A high value of HbA1c will suggest that the patient has not been practicing self-management practices, which in turn puts him or her at an elevated risk of developing long-term implications. Blood glucose is usually attached to hemoglobin so that it can be transported to various sites where needed. The resulting compound is known as HbA1c. There is a direct relationship between the amounts of blood sugar that attaches to hemoglobin and glucose in the body (Kohnert et al., 2015). Red blood cells (RBCs) live for about 8-12 weeks (National Health Services [NHS], 2016). Therefore, the HbA1c test will show a patient?s levels of blood glucose over the last eight to twelve weeks. Accordingly, this test shall be done after every three months. Values greater than 7% will indicate that young adults with DM1 are not taking appropriate self-control practices (Daugirdas, 2011). Consequently, this shall imply that there are no effective transition programs that help young adults with DM1 to start taking care of themselves to prevent long-term diabetes implications. This will in turn prompt additional effort to facilitate smooth transition such as providing education to pediatric health care professionals taking care of diabetic teenagers (and young adults). High levels of HbA1c will also prompt educating parents on the importance of providing social support to young adults with type 1 diabetes to facilitate self-care.

Rapid Assessment Protocol for Insulin Access (RAPIA)
In the second instance, the paper will highlight the influence of Beran, Yudkin, & Courten (2005) RAPIA to facilitate effective and efficient assessment of the health systems for the type 1 diabetes among the young adults. Evidently, improvement of the health of the young adults with Type 1 diabetes demands clear and precise analysis of the constraints to the insulin access, as well as diabetes care vital for the population. The tool is critical in the provision of diverse questionnaires and protocol for collecting data. In the course of attaining this information, there is need for the integration of site visits, discussions, and subsequent reviews.
The tool plays a critical role in the assessment or generation of diverse information. In the first instance, the tool will play a critical role in the illustration of information concerning written and enacted diabetes policies, practice for the diabetes management, and availability of the insulin, syringes, and monitoring equipment. The tool also plays a vital role in the illustration of the cost of insulin, syringes, and monitoring equipment, as well as the presence of the distribution networks for insulin (Evert, 2004). The tool will also explore critical issues or problems, which might hamper the access of the proper insulin and care. In the course of enhancing effectiveness and efficiency, there is need to consider executing this assessment twice per year among the young adults with Type 1 diabetes. The approach will enhance quality access to the health population, thus, the platform for the management of their health conditions through improved access and utilization of insulin for Type 1 diabetes (Bryden et al., 2003).
PROMIS Measures
PROMIS (Patient-Reported Outcomes Measurement Information System) comes out as a set of person-centered measures aiming at evaluation and monitoring of the physical, mental, and social health among adults and children. It is possible to integrate such mechanism among the general population, as well as individuals living with chronic conditions. In the tool below, PROMIS metrics will facilitate assessment of the functions, symptoms, behaviors, and feelings for the young adults with Type 1 diabetes. The tool proves to be appropriate or applicable because of its flexibility in applying to the general population, as well as persons with the chronic conditions.
There is need for frequent integration of the tool, maybe after every three months with the intention of improving physical, mental, and social wellbeing of the young adults with Type 1 diabetes. The approach will contribute to the realization of positive health outcomes through transform of the behavior and interactions, as well as physical activities of the patients (O?Connor et al., 2011).
Thirdly, the level of support that young adults with diabetes receive from care providers and parents/guardians. Awareness is the first step towards taking necessary measures (Childs, Cypress & Spollett, 2005). If young adults are aware of self-management practices and their benefits or roles in ensuring effective management of diabetes, they are highly likely to engage in recommended practices and behaviors such as adequate consumption of fruits and vegetables. The awareness is expected to come from effective transitioning from pediatric to adult care as well as support from the transitional care program through the provision of necessary education. However, maintenance of recommended self-management practices will only occur if there is sufficient social support from care givers and parents/guardians. This metric shall measure a crucial input of the study, which is social support.
The tool-kit provides many check list that can help the care team begin a conversation with the patient about what they need to do to successfully managing their diabetes and how to begin the transition process for patients with type 1 diabetes. Elements of social support under interest in this study shall include effective transition from pediatric to adult care, reminders from family, continued education on self-management practices, and necessary training and provider follow up during the transitional phase such as use of relevant tools to monitor blood glucose. If young adults receive adequate support, they are highly likely to adopt self-management practices. Otherwise, they are highly likely to fall back to risky health behaviors due to negative influence received from peers.

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