Relevancy, Accuracy & SCI Research: A request for Consumer Input in an SCI Related Survey. Presenters: Pei-Shu Ho and Mel Neri. >> LAUREL: Good afternoon. This is Laurel Richards with ILRU in Houston. Thank you for joining us for today's webcast, which is on relevancy, accuracy and spinal cord injury research, a request for consumer input into an SCI related survey. It's a slightly different approach that we're using this week and we have two researchers who have prepared a research instrument, a survey instrument, and by golly, they're asking for feedback from folks in the field. And we're just real, real pleased to be part of this project. This program is a program of the spinal cord injury -- the Research and Training Center on spinal cord injury prevention of secondary conditions with the emphasis on exercise and prevention. And it's funded by the National Institute on Disability and Rehabilitation Research, of course the U.S. Department of Education, and NIDRR has a history of wanting to disseminate research findings to those of us who are not researchers, but who have a high stake in the outcome of the research, and this is -- this is part of that initiative that it funds in that regard. We're part of a Research and Training Center, as I said, on spinal cord injury. The grant is head quartered and operated out of the National Rehab Hospital's Center for Health and Disability Research. And this is the second of four town hall meetings in which we will present a bit about the Research and Training Center and then request feedback from people in the field looking for those who really know what spinal cord injury -- the impact of spinal cord injury on one's health and wellness and well-being and to obtain feedback that way. Before we get into the presentation, just a real quick note, you can see on your screen that there is typing going on. This is our realtime captioner who is first rate, but if I go too fast, I get in trouble. Mel and Pei-Shu, we got to go slowly, and that way we're in good shape, and we'll get an interruption after a bit if we go too fast. But she first rate. So you see that in the large screen, and then down at the bottom it says if you have questions or care to comment, click here. And that will bring up your E-mail server, whether it's outlook or Eudora or whatever it is that you use and it's preaddressed to ILRU. So you just type in your question or comment and let it send it, and it will be retrieved at our office and then posed to our presenters when they ask for it. Laurie Redd will do the question and answers today. She was supposed to host this teleconference, but she's contracted a severe cold and she doesn't want to spread it to all of us. So she's going to restrict her time. Also she's got -- if the coughing starts, I'm happy to do it. I don't have a spinal cord injury myself. We have a number of staff members who do, so the research being done by this center is just meat and potatoes to us. We care severely about the outcomes of the research. And so Mel and Pei-Shu -- Pei-Shu Ho, welcome to today's presentation and we look forward to hearing from you. And I believe Pei-Shu, you're going to take over first. >> PEI-SHU: Yes. >> LAUREL: Please go ahead. >> PEI-SHU: Thank you, Laurel, for your great introduction. First I would like to thank ILRU who is our collaborators for their assistance in posting the information on the web in a very timely and efficient manner. I just want to say thank you. And secondly, I would like to inform the audience that today we will use a different format for our webcast session. As you may see, we have posted the draft survey on the web for your review and comments. And some of you already sent your feedback to us and we want to thank you as well for your input. And we also posted some questions for today's discussion after our presentation. During our webcast session, Mel and I will spend about ten to fifteen minutes to review the research project; and then we will open the floor for questions and comments on the survey questionnaire. And this survey is part of the Rehabilitation Research and Training Center, which we call on RRTC on spinal cord injury, prevention of secondary conditions and exercise. This RRTC is funded by a grant from the National Institute on Disability and Rehabilitation Research, which is part of the U.S. Department of Education, and this Research and Training Center includes five research and four training projects, and Dr. Susanne Groah is the principal investigator and Dr. Thilo Kroll is the coprincipal investigator. Today's presentation focuses on the research project No. 5 that studies the relationship of exercise and physical activity to the onset of secondary conditions using a national survey of individuals with SCI. The purpose of the study is two fold: One is to determine the individual and environmental factors that are associated with participation in physical activity or exercise among people with SCI. Another one is to determine if participation in physical activity or exercise can predict the onset of secondary conditions and social participation. What we meant about secondary condition, we define if the person has developed a health condition as a result of SCI that has required a change in their daily routine or require any medical attention, such as fractures, UTI or pressure sores. And in terms of social participation or social integration, we meant the type of activities that person has engaged in or how the person spends the time of the day. Having said about the purpose of the study, we asked two particular questions that related to our purpose of the project. One is to ask what are the factors associated with participation in physical activity or exercise among people with SCI. The second question we asked does participation in physical activity or exercise predict the onset of secondary conditions and levels of social participation over time? In terms of methods we use in this project, first we use a quantitative methodology. In other words, we will conduct a mail survey with 1,000 adults with SCI nationally, and you probably will ask how can we get a thousand people. And that's a challenging question, and basically we will work with one of our collaborators which is National Spinal Cord Injury Association. They have been very supportive. We will work with them to get a membership and mailing list and we will randomly select 250 people per U.S. census region, and after that we will send a questionnaire to those people we think that would participate and after we receive their survey back with complete answers and input, we will send them the same survey one year after the first survey they have completed. And after saying that, I would like to ask Mel to share with us about how we come up with those questions. >> MEL: Thanks, Pei-Shu. As far as the sources of the survey questions that you will have seen on the draft survey that was posted on ILRU's website, we did reference some of the questions from existing surveys. One of the surveys that we looked at is the NHIS, and that's the national health interview survey, and we looked at the sample adult module. The NHIS was developed by the C. D. C, it's administered every year to adults living in the community, and it asks questions about use of health care services, access to health care services, as well as physical activity. So we did reference some of those questions for our survey. In addition, we looked at the PA D. S, that's the physical activity and disability scale. And that was developed at the University of Illinois at Chicago. So we looked at some of those questions and referenced some of those for our survey. As well as the C. IQ. We also looked at the community integration questionnaire that was developed by a previously RRTC on community integration and TB I. We also are including the CAGE questions -- that's C-A-G-E -- that was developed by Ewing in 1984 and those are four very simple and brief questions that relate to alcohol dependency and abuse. And actually what we did with those questions was we took the same format for the alcohol questions and we also created some of our own regarding smoking. So hopefully we'll be able to look at smoking -- levels of smoking and such. And then we also used some questions from a previous survey that we had done here at the Center for Health and Disability Research, and that was also under the auspices of a previous RRTC on managed healthcare and disability that was also a partnership between us and ILRU. >> LAUREL: Very effective one I might say. >> MEL: I would agree, Laurel. We tend to work together quite well I think. So that was another longitudinal multiyear survey, and that looked at access satisfaction and use of health care services by people with disabilities. So we took some of those questions that we had used before and included them in this survey as well. And then in the addition, we did develop some new questions, Thilo Kroll, the co-PI for this RRTC developed a set of ten questions on self-efficacy. So we're going to go ahead and use those questions in this survey and then validate them and then actually what we'll do is for another of the research projects for this RRTC, once we validate these self-efficacy questions, we'll go ahead and use it in another research project of the RRTC. And what we mean by self-efficacy, briefly, is basically confidence that one's own behavior can lead to change regarding certain things. So I'll get into that more when we talk about the survey content areas here in just a minute or two. So the survey -- those were the sources that we referenced for the survey content areas and then as you can see, when you were looking through the survey, we did break it down into certain content areas based on some of those sources. In order of appearance, I'll just briefly go through what the content areas are in the survey: So first we asked about chronic and secondary conditions. So we're interested in any chronic conditions that individuals may have, preexisting conditions, so to speak, asthma, diabetes, conditions such as those. And then we're also asking about secondary conditions as Pei-Shu had mentioned. So those are conditions we're interested in that occur as a result of the SCI and require a change in daily living. So for that we're looking at fractures, UTI's, pressure sores, et cetera. After that, we're asking about functional conditions of the respondents. So, for example, we're looking at ADL's which are activities of daily living as well as IADL's, which are instrumental activities of daily living. Those are common questions asked in certain surveys and you'll -- you may be familiar with them. They ask such things as how much you might need assistance with shopping, dressing, bathing, eating, doing housework or yardwork around the home and such. After that, we do ask about physical activity, and we ask about levels of physical activity as well as frequency. So we ask, for example, about aerobic activities you might do such as swimming, strength activities that you might also engage in such as weightlifting, and flexibility activities, such as basic stretching. So we ask about those types of activities as well as how often and how intensely you do those. We then also ask about therapy and, again, the type and frequency that you've received -- type of therapy that you've received and how frequent you do it. We ask about physical therapy. We also ask about occupational therapy and recreational therapy. And then we go on in the survey and ask about wheelchair use. We're interested to know if you use a manual wheelchair or a power chair. And based on which type of chair you use, we're also interested in if you push yourself, somebody else pushes you, how often you push yourself, how much of the day you are in your wheelchair and how much time you spend in your wheelchair each day. After that section of the survey, we go on to ask about health risk behaviors, and that's where the questions -- the cage questions I was describing before about alcohol and smoking come into play. And then we go on to ask about community integration, and as Pei-Shu had mentioned, with that we're looking at how you fill your time, your social interactions, what activities you do and who you do them with as well as how frequently you do them. And then there is a section on self-efficacy, and again, that's where we're looking at how confident you are that your own behavior can lead to change. And then we end the survey with the basic demographic questions that I'm sure you're very familiar with. We ask about level of injury, level of education, we ask about date of birth, et cetera. So that's how the survey is ended. But as far as what we're doing now with this, to give you an idea of the time line, after we obtain your feedback today and hear what you have to say about the survey we've created, we're going to go ahead and incorporate as much as we can and make revisions. Then we will pilot test it and we will do that with five inpatients at the National Rehabilitation Hospital who have spinal cord injury. We're also going to ask some of the clinicians, spinal cord injury clinicians for feedback on this survey, and then we will revise again and hopefully we'll have it finalized in the next couple of months here. And then the survey administration will begin this fall. So just to make it clear as well, even though this survey was available for you to see the draft version on line and on the Internet, this is actually a mail administration survey of the so we'll administer it via the mail, via the U.S. postal service. It is a paper or pencil questionnaire or paper and pen questionnaire and it's self-administered. So individuals will fill it out on their own. Of course if there are issues where individuals would like to receive it over E-mail or it's more accessible that way, we'll accommodate that, but for the most part this is going to be mailed out to individuals, community dwelling individuals with spinal cord injury. So we hope to begin with that this fall. And then as Pei-Shu had mentioned, this survey is two years long. So after we receive the first survey, a year after that, we mail out the second survey, but in between that time, we're going to be looking at some of the data we obtain, and we will then talk with 30 more individuals, and we're going to conduct some qualitative in-depth interviews over the telephone with 15 individuals who said in their questionnaire that they exercised, and 15 individuals who reported in their question fair that they did not exercise. And what we'll be doing with them when we talk with them is we're going to try and determine what factors prevented them from exercising or what factors were able to help promote exercise behavior and physical activity. So then of course after that the second questionnaire will go out in the second year. So that's kind of the time line and the framework of this particular project. And again, what we're looking at is the secondary conditions and how exercise and physical activity plays a role in that. So with that overview, we would like some feedback from you. So at this point I'll turn it over to Laurie and see if we have any questions or if we can get some feedback on our survey. >> LAURIE: Okay, thank you, Mel. Yes, we do have a couple of questions. One person E-mailed and suggested that we include a question on how long you've been injured. >> MEL: and that actually will be included in the demographic section, I believe in the end. We ask how old were you when you acquired your SCI and then later on in the demographic section we do ask your date of birth. >> LAURIE: Okay, tricky way. >> MEL: We don't ask it directly. >> LAURIE: Okay, great. Then there was another question about -- on Page 2 of the survey there is a question about drug use. >> MEL: Oh, on Page 3 maybe, the second -- question No. 2? >> LAURIE: Okay. Yes, I'm sorry. Question No. 2 on Page 4 of the survey, and someone E-mailed that we ought to try and tease out what that drug use or drug problem is, if it's perhaps a problem with prescription drugs that are being used improperly or with illegal drugs. >> MEL: Okay, good point. And some of the discussions that have gone on back and forth here as we've been developed this, too, is the issue of when you ask about drug use questions in surveys, often times you get under reporting because people may not be willing to admit to that. So it's definitely something important to know, but it's a matter of also being able to ask it where we can find out that information and also be sensitive to the experiences of the individuals. >> LAUREL: I assume the confidentiality. >> MEL: Right. Right. But that is definitely something that has been talked about that we can revisit again. >> LAUREL: We had noticed on the questions that are a little bit later, with smoking and alcohol, it's so clear right there that other major probably bad habit that would affect one's -- affect one's secondary conditions and the quality of life is the one on drugs. And Laurie, I believe we were -- our colleagues at TIRR did a study of quality of life of folks after spinal cord injury and didn't they find drug abuse kind of a high -- there was a higher incidents than we thought it would be? >> LAURIE: I remember there was. I can't remember the percentage, but I remember it was higher. >> LAUREL: They did have a pretty good response rate on that a I don't know why. Maybe it could be put in terms as optional, but I see what you're saying. So if you ask the question and people under report, it might skew the findings, is that what the concern is? >> PEI-SHU: We play not get enough responses to really look at the association between drug use and drug problem and then the onset of secondary conditions; but we can I think definitely revisit this to list it some -- >> LAUREL: It's a hard one. I can understand -- it's a hard one to ask. Laurie, on that spinal cord injury study, I don't think -- Duff the sense that people were reluctant to is answer that question? >> LAURIE: No. I mean, I didn't have that sense, but I don't know how the study was structured and confidentiality and all. I don't know that. >> MEL: I'm just wondering, too, for the audience if they had any suggestions of how to word that or in a way that they wouldn't feel -- or where they would feel that they could answer honestly. Because that is something we've struggled with and we don't want to word it to assume that they have drug problems or to -- we don't want to say something about -- you're right, illegal drugs because then of course there would be that concern as far as confidentiality, even though we do obtain informed consent and there are all of those federal regulations that of course don't allow us to share that information and we wouldn't, but I could definitely see the concern, but we just -- it's just difficult as far as how to ask it so that they don't feel threatened by the question. >> LAUREL: Delicate. >> LAURIE: Okay, I have a couple more questions that have come in. One person wrote in that this is a two-year study, is that correct? >> MEL: Yes. >> LAURIE: and how many times will they be surveyed? >> MEL: Twice. >> LAURIE: Twice. Okay, and then the question they have is will there be any incentives for people participating in the study? (Laughter) >> PEI-SHU: We will have some very nominal kind of thing, but it's really not monetary incentives, but we probably would think of some creative way to thank them. >> MEL: Right, or if anyone has suggestions has far as low budget. >> LAUREL: We've begun using chocolate. >> MEL: That would work for me. But definitely that is something where we do realize we'd like to, one, thank the people who are filling out the survey and also have something that can motivate them aside from helping us with the research and being able to contribute to that body of knowledge, but we realize that it is asking for a lot as far as time and effort and the fact that it's administered more than once. So even if anyone has any suggestions there, what we commonly do as well with longitudinal multiyear surveys is we will send out progress reports. So we don't leave participants hanging. We've let them know what we found with that information, but that's usually in the future and not an immediate feedback mechanism. >> LAUREL: Of course we might be able to do a little bit faster via a webcast. >> MEL: That's true. I think it's more on our part though it takes us awhile to analyze the data. >> PEI-SHU: We try to be timely. >> MEL: But definitely we are looking into options as far as something we can send out with the survey. >> LAUREL: Great. Laurie, others? >> LAURIE: Yes, a couple more. One person wrote in why is mail the preferred method of distribution? Wouldn't the Internet be a better alternative? It would really have an impact on Questions 18 A and B, which in parentheses, who and how did someone help you with this survey? >> PEI-SHU: The other concern is -- we thought the web would be very timely, too, but the other concern we have, we don't know who filled out the questionnaire. We really want to have people who are individuals with SCI fill out the information for us and then I think that's the primary concern and also the cost that we thought about in the very beginning when we developed this proposal. >> MEL: Well, and also there is the issue of the digital divide, quote-unquote, and we don't necessarily want this survey to only be administered to people who have Internet access because we realize not everyone does of the so on the one hand it might be a more efficient means of administration, but on the other hand, we totally neglect a subset of the population of individuals with spinal cord injury who may not have access to the Internet. So, again, I think we're trying to do it via mail first and then if people do have accessibility issues or if it's easier for them to complete the survey via the Internet or via a downloadable version that we can send to them via E-mail we're more than willing to do that. But one of the things we are doing that is a little different that we didn't mention is that recruitment is going to be done via E-mail. So that's kind of mixing and matching so to speak and we're going to again, like Pei-Shu said, use the NSCIA mailing list and we'll send out recruitment notices and calls for participants via the E-mail to kind of narrow down our population. So in that sense, we're already kind of limiting our survey population to people who do have E-mail, but at the same time, we know that they do have a spinal cord injury since they are on the NSCIA mailing list and oftentimes recruitment being a problem, we realize, too, we're also going to have to send out some mail recruitment postings and use other means to recruit. >> PEI-SHU: and also if the person is not convenient for him or her to fill out the form, we will be flexible if they feel comfortable to have a phone interview, that would be okay, too. >> LAUREL: Good. >> LAURIE: Okay, another question on -- this question 5 under the functional conditions section of the survey, and had to do with bowel program and someone wrote in and thought that it had to do with assistance with bowel program that perhaps you can ask what kind of method was used if you wanted to get more specific about that. >> MEL: I'm guessing they're referencing -- we've got one that says is there any help using the toilet, including getting to the toilet. So what was the suggestion again? >> LAURIE: Some people wouldn't even use the toilet in terms of a bowel program. >> MEL: You're right. So it would be more specific with that, right. So just to even more generally have it say bowel program. >> PEI-SHU: I like that. >> LAUREL: You know in that same area you had asked if there was any question that wasn't quite clear, and this may be regional, but I got confused about shopping for personal items such as toilet items or medicine. Is that like clothes? I mean is that what you mean by personal items like shopping for clothes or shopping for shoes or cosmetics or whatever? >> MEL: Right, any and all of the above. >> LAUREL: Personal stuff as opposed to like cooking stuff? >> MEL: Right. >> PEI-SHU: Shopping actually. >> LAUREL: Well, I sure know shopping. >> LAURIE: and then also getting back to the toilet questions, also it may be perhaps asking one on emptying the bladder if they need assistance with that. >> MEL: So also to separate bowel and bladder programs, than just general toileting. That's good. >> LAUREL: Back on the issue of mail outs versus electronic copies, pardon me, if someone does request an electronic copy, what kind of -- how can they indicate on the silhouette -- you know, I thought those were excellent uses of silhouettes. >> MEL: Demands. >> LAUREL: So you can figure out some method of -- >> MEL: I'm hoping we can. I had gotten feedback from one gentleman last week who had said that it was difficult to mark the answers and obviously how the draft is now it's not set up for it to be completed on the computer. We had intended for people to perhaps print it out and then complete it. So I know there are ways we can obviously make it so they can fill in the boxes so that's something that we would definitely toy with as far as them being able to either check on demand where they feel the pain or draw in where there is the pain -- >> LAUREL: Like what they call those radial buttons? Or I guess you can just say my head, you know, my arm. >> MEL: Right. So that's definitely something that we'll need to revisit as well as far as making it accessible, but we definitely plan on doing that if the need arises. >> LAUREL: And you can never tell. >> MEL: Right. >> LAUREL: Some people may feel strongly about staying as independent as possible and preferring to do it via electronically so they aren't required to ask for assistance, just whatever. >> MEL: I mean, that's something, too, where we needed to do that one section even on the telephone with a person then they could maybe describe it over the phone and then we can color it in for them. We're open. We're flexible. >> LAUREL: Laurie, may I interrupt with a couple of questions on the chronic and secondary conditions. >> LAURIE: Sure. >> LAUREL: One was -- and this was, again, somebody was asking for clarification on this list of things, they didn't see chronic UTI, urinary tract infection, and wasn't sure if it would come under renal kidney -- of course chronic could be, couldn't it, so they didn't know if that was -- that should be included or not or whether or not that should be included. >> MEL: And I'm wondering if they had specified chronic UTI as a result of SCI. >> LAUREL: Ahhh. >> MEL: Therefore becoming a chronic condition. >> LAUREL: That's what I don't know. That may have been. >> MEL: And that's something Suzanne Groah, again, the PI of this RRTC -- she's an M.D. and her expertise is with SCI. As we've developed this survey we'd get feedback from her and she was very helpful on these two sections on the chronic and secondary conditions. So we can go ahead and ask her about that. >> LAUREL: That's great. If a person has one of these conditions, let's say, for instance, diabetes or let's say depression or osteoporosis and is not sure if it's a part from or as a consequence of or just complimentary with, there would be another category of not sure if it's -- I can imagine osteoporosis. >> MEL: We've talked with Suzanne about this and that issue did come up and, sure, a lot of people might not know if they have osteoporosis or not and we had tried a couple of different ways. Maybe we should ask them if they had a bone scan and then it got too complicated, and as you'll see for Question No. 2 for that table, the way that we're kind of getting at that is we're asking about fractures or any broken bones because that's how it will manifest itself as a secondary condition. >> LAUREL: So you smart guys that construct these surveys -- in terms of like depression, if one is -- has clinical depression and has a spinal cord injury and is not sure if the depression is a consequence of the injury, would they mark it -- or you can just take that -- you'll consider whether or not they need to mark it or not mark it. >> MEL: Well, and hopefully, again, the thing with a self-administered survey is it's self-report, too. We do have depression listed both as a chronic condition, hopefully respondents will be able to differentiate as a chronic condition and then as we ask it as far as a secondary condition, we ask again depression as diagnosed by a health care professional and has it developed as a result of your SCI -- >> LAUREL: I can see right now that some of these may need to be underlined or put in all caps apart from and as a result of. >> MEL: Sure. >> LAUREL: People like me who read kind of fast it may be sort of not as carefully as I ought. >> PEI-SHU: And that is a good point. The depression category under question 1, we also emphasize that, apart from your SCI, has your doctor or health care provider ever told you. So hopefully it's diagnosed and then it's clear. >> LAUREL: Good. By the way, you did a real nice job on 3 and 4 about emphasizing the past 12 months. >> MEL: We tried to be consistent with that. >> LAUREL: Laurie, do you have -- >> LAURIE: Yes, one person wrote in about physical activity and the question is on Page 8, and they wanted to know that they do pilates and would that be considered a flexibility exercise or strengthening exercise? >> MEL: Or all of the above. Excellent. Gosh, in that sense, from what I know of pilates, I would suggest that they would almost mark it as both. Again, that's my suggestion and whenever of course we ask for a survey respondents -- we ask them to interpret the questions on their own, but just you throwing the question out there as such from what I know of pilates, I think it would be both. It's based on their interpretation and that's what we tried to do with a little bit of the examples and such to try and help them figure on it ut on their own as far as where it fit on the table. >> LAUREL: In those physical activities, we also had a question related to exercise that wasn't done primarily or the first reason wasn't to increase or maintain fitness, the first reason was some other reason, but as it turns out it served that purpose as well. For instance, taking the dog out and getting exercise of that kind or even gardening in some regards. So it is sort of a wide net. We had an example given to us about a year ago in a webcast that Dot Nary did on a research project that was implementing exercise programs for folks with all kinds of disabilities, and one exercise that came up was a lady who had severe -- I guess it was muscular dystrophy, anyway, had somewhat compromised breathing and her exercise -- and I guess it would come under the flexible one -- was to put a book on her chest and breathing in and out was quite good -- was good for her. Another one was range of motion movement with attendant. So I don't know how -- I guess those would fit under flexible, but would you be open to things like that? >> MEL: Oh, definitely. Definitely. And one of the difficulties, actually, that we've had with this table and the many different iterations that we have created is how to try and be all inclusive, but yet not have it be so unwieldy that we have ten different types of exercise or ten different scenarios. So I guess in those instances like you were saying, the book on the chest -- for them to try and fit it in as best they can into the table and the same with the walking the dog or the gardening, granted like you said, they may not have started out doing that for the purpose of maintaining or increasing their fitness, but if they feel like it has, I would probably say, again, for them to make the best judgment on their own and to interpret the questions and what we're asking on their own, but again, I guess to see kind of like the end result what we're looking at is levels of physical activity and if they're walking their dog, they're being physically active. >> LAUREL: That helps. Thank you. >> PEI-SHU: and I think that's open-ended you know question in terms of type of activities and people can use their interpretation of the definition and put in each category. >> LAUREL: Good. Laurie. >> LAURIE: Another question on -- had to do with wheelchair use and it was a question on 11 A. on Page 11. And they wanted to know if it would be important to you to know what kind of power chair, for instance, that someone uses? Like there are many different kinds of power chairs, the kinds that recline, the kinds that can be raised and lowered. >> LAUREL: Look the scooter, does that count? >> LAURIE: Yeah, a scooter or there are just different kinds of chairs or is a manual chair a folding manual or rigid. >> PEI-SHU: Oh, wow, that's right. >> LAUREL: That makes a difference, Laurie, the rigid? Is that where you have to take off the wheel? I would think that would be exercise in itself. >> MEL: Right. We haven't thought of that. >> PEI-SHU: We'll revisit this. >> MEL: That just might be a good question, you're right, for us to ask as an open-ended question and if they say power or manual, then we can put what type and have them fill it in. >> LAUREL: Sow Laurie is the consideration that in a power chair that will raise up and down or recline, that it might be more useful in terms of doing -- or it's just good to know what kind it is in terms of how it works into -- I'm just trying to figure out with regard to exercise. >> LAURIE: I think -- I don't know. Some people who use manual chairs tend to use them for different reasons because they are more sturdy, and they are more -- I think take more abuse than a power chair. So maybe that's one of the reasons. >> MEL: I'm wondering, too, Laurie, do some manual chairs -- do they take more exertion? Are some like you say easier to use than others? >> LAURIE: No. No. In fact, they may be easier -- >> MEL: Because like Laurel is saying, too, what we're trying to get at here is how much -- I guess physical activity, physical movement it takes for them to get around and to move around and obviously in a manual chair they would be exerting more effort in moving themselves around than they would in a power chair. >> LAURIE: the only thing I would think of in a rigid chair you would have to have a lot more strength to be able to get -- I use a rigid chair and in terms of taking it a part and putting it in my car, it's harder than it was when I used a folding chair. >> MEL: So would it be safe to say then, generally, too, those who use manual chairs, regardless of the type of manual chair they are using, might be -- might have more upper body strength? >> LAURIE: I would think that would be true. >> MEL: Than a power chair. Because again, I think the main thing we're looking at is that difference and knowing that they are in a power chair versus a manual and so, therefore, they might be engaging in more physical activity in a manual chair than in a power chair. So this is something to think about definitely as far as what type of chair they are using and I guess Pei-Shu and I are nodding and making faces at each other. It probably wouldn't hurt to have that information. >> PEI-SHU: Not at all. That's great. >> LAUREL: Laurie, I thought these questions on wheelchair use were kind of interesting. You've used one for -- I don't know -- 14 decades, but it seems like they are right on target with regard to how many years or how many minutes a day. Is that something that you could answer pretty easily? Like 11 D? >> LAURIE: Yes. I know that I could. I don't know -- you know, I couldn't speak for anyone else, but someone did ask -- actually someone here on staff who wanted to know why that question was included in here. So could one of you kind of speak to that, why you wanted to know that. >> MEL: 11 D? >> LAURIE: 11 C. About how many minutes do you spend in a chair, do you push yourself in a chair per day? >> MEL: Right, and with that a couple of things. When we were working on that question, it actually had started out as do you push yourself -- I believe it was for less than an hour or more than an hour, and then we had discussions with Suzanne Groah, again, the M.D, the PI of the RRTC as far as meaningful time frames and we had very long discussions as far as what was meaningful basically and what we're trying to look at with that question, again, is levels of physical activity. Obviously there will be some difference if you're only pushing yourself five minutes a day versus two hours a day. So that's what we were trying to get at and we decided to just leave it open-ended as well so that we could, hopefully, with the answers we get find some sort of meaningful break down. So I hope that that kind of speaks to it a little bit, but we are interested as far as how much activity and physical activity they are engaging in as far as just a means of getting around. So the same as asking me how often do I walk, and I walk to work each day. So I walk an hour each day so that is obviously going to be a little different as far as my levels of physical activity than someone who drives to work. >> LAUREL: Like, for instance, on Question 13 that says during the time you are awake, how much time do you spend in your wheelchair each day and almost and just a few hours. Are you thinking that as you get 1,000 responses to this that you may be able to make some sort of correlation between I spend all my day in a chair and however -- whether or not I have chronic secondary conditions? >> PEI-SHU: Yes, I think that's -- >> LAUREL: Is that right? >> PEI-SHU: In a way, yes. Actually we want to see even one hypothesis to look at that the level of injuries associated with average time spent on exercise or physical activities and also we want to look at -- in terms of the amount of time spent on exercise or physical activity that's associated with accessibility. So that's what we are coming from in asking this question. >> LAUREL: That's a very interesting -- I had never thought of time in a chair versus quality -- quality of health. >> MEL: and secondary conditions. And I think that question will be interesting to look at in terms of pressure sores and to be able to see just if people are spending perhaps more time in their chairs, more prone to pressure sores than those who are moving around a bit more and relieving pressure in certain areas, they'll have less incidents of pressure sores over time over the two years we're asking about. So that could be interesting in terms of that as well. >> LAUREL: There was a question that came up actually among our staff members awhile back whether or not as one ages as you're more prone to pressure sores or if elasticity of use and I don't imagine it would be part of this study, but it was a consideration of whether if one travels a great deal and in one's 20's travels a great deal and does pretty good with regard to how much time, pressure sores, et cetera, and then maybe 30 years later. Can we expect -- people -- there are not that many people with spinal cord injury that are living long enough to do these aged studies. >> MEL: Right. >> LAURIE: Or the relationship between pressure sores or skin breakdowns and exercise. Is exercise, you know, leads to better circulation and prevents pressure sores. >> PEI-SHU: And I think in your statistical analysis we can take into account the number of years the person has been injured. So take into account that and we can tease out some questions we will have. >> MEL: What's interesting, too, on a side note, the previous RRTC, the one that we had collaborated with you with ILRU on on managed health care disability, Thilo and I were doing some analysis on some of that data as well and one of the things we were looking at is the incidents of pressure sores and UTI's over the three years, that was a three year survey, and I believe we were actually looking at men -- no, no, I'm sorry -- we were looking at just spinal cord injury on secondary conditions and what we had found actually from our sample is that those who were younger were more prone to pressure sores and UTI's. So that was really interesting. >> LAUREL: That is interesting. >> MEL: We are writing on paper on that as well and just in the discussion section think of some issues on why that might be, but I think one of the other things that we had found if I recall correctly was also just having had pressure sores before leads to a greater likelihood that you will have them again. >> LAUREL: That's a very interesting finding, and I would have guessed just offhand that you get smarter the longer you have a spinal cord injury and you're better able to take care of yourself. >> MEL: Right. Right. >> LAUREL: I don't know that that's necessarily -- >> MEL: Well that -- and that was another interesting thing that we had looked at because it also showed what we looked at as I said assistance needed with activities of daily living and those who needed more assistance were also more prone to report more secondary conditions and that's one of -- I thought it was a little counter intuitive as well because like you said, as you're aging, you are more aware, you are a little smarter and you know better how to care for yourself, but going in hand with that is you might become a little more dependent. So that might actually lead to increased occurrence. >> LAURIE: Okay, I have one last question here, and a comment. And it has to do with the section on community integration. Let's see, no, I'm sorry, I think it's the demographic. It's the page 18. >> MEL: Okay. >> LAUREL: What question is that, Laurie? >> LAURIE: It's No. 15. How many people do you live with? And they want to know if you should add a question that says what is your relationship to those in the household? >> LAUREL: What do you think? I mean, is that -- you do you think that's telling? >> MEL: I don't know. Because there are questions like how many people do you live with and I'm not sure what they're getting at. (Laurie) (Multiple Speakers). >> MEL: It's funny because this question -- I remember, too, that has a little bit to do with No. 14 because we did ask No. 14 a little differently as well. You know, oftentimes what you might usually see as far as marital status is you'll see married, single, they'll also separate as another response option, widowed, divorced, separated and then break it down by that way, but as we were developing this, one of the conversations that we had had was, well, what are we looking at here? Basically what we're looking at, what we want to know is do you live with someone. And that's why we had grouped married or living with a partner. And that's why in parentheses, after single we put all of the different types of singles that there were, we want to know are you alone or is someone living with you, and I remember discussing that question and someone in our meeting had just said, well, why don't we ask them how many people we live with. We can know their marital status, but let's just also come right out and ask how many people they live with. >> LAURIE: Do you want to know if they're taking care of someone or someone is providing assistance to them? >> LAUREL: or just how many people in the house? >> MEL: I think it's more of -- our reasoning behind this was how many people in the house because, again, how that plays in with as far as community integration and do they have people there that they are living with that they can interact with socially. So -- I mean, it would be interesting to know the relations, but then we also had discussions about what if some people are living in -- temporarily in a nursing home or they are in transition or what have you and how do you count that? Are they living with 50 or 100 people or are they living with just their roommate or are they living alone in a single room or are they living alone? >> LAUREL: Actually, Mel, that came up in a question I was given related to when you ask about living circumstances and community integration and as well as the demographics, does one live in an apartment complex versus a house or a nursing home or other institutional type setting and we know that people live in all three and others, too, but it would have, I would think, impact on one's social integration -- community integration. I don't know if it's greater or less to live in an apartment or a house, but I suspect it makes a difference. So they were wondering if that would be a useful question. And we doe know that quite a few people are living in nursing home type settings and although, you know, thank God we're being more and more successful in helping people transition out who care to transition out, but it would be interesting to know if -- what we believe is true, which is quality of life living in a nursing home is not as wonderful nor -- (Inaudible) I don't want to impose on your study. >> MEL: I think that would be definitely good -- you're right -- information to know as far as the setting that they are living with. I can speak from personal experience living in an apartment than a rural dwelling house and the number of people you run into at the mailbox. >> LAUREL: That's exactly right. >> MEL: That's a really good suggestion. >> LAUREL: And the issues related -- the same is true with urban and rural, but I assume you have to draw the line somewhere. >> MEL: Right. >> LAUREL: Not to say someone is more isolated in a rural setting, because you're not, it's just way different. >> MEL: That had come up as well because then when you look at rural settings and you look at the questions where we ask about do you exercise in a facility and then you get into access issues as well. >> LAUREL: Do you count a barn? Does a barn count? You know, along those same lines, one question I had -- that occurred to me was how one -- I think you had down here about -- in community integration about visiting and doing things outside the house. I wonder if it would be useful to have a question on how you travel if you're outside the house? For instance, the difference of driving or the bus or just as it were on foot or wheeling around. One would think that if you drove you would be more independent and you might tend to get out more than someone who was dependent on public transportation. But anyway, just -- >> MEL: No, good suggestions. >> LAUREL: Laurie, I've got a couple more. Do you mind? >> LAURIE: No. >> LAUREL: Yeah, I think that was -- what I was talking about was primary means of transportation. You know, if it's paratransit or cab or rail -- >> MEL: Right or like you said if it's their own car. >> LAUREL: Or like, Mel, you, like -- >> MEL: Walking to work. That's something we hadn't discussed which would be really helpful information. It's got a lot of implications as far as physical activity and independence and social interactions. >> LAUREL: On community integration, there was a couple of things that were given to me or I was able to get. One was -- they were struck by employment being a minor portion of these questions rather than a major one, and that -- especially like under 17 but also 16 it seems like employment is -- for some people it's a big part of their life and probably it ought to be. So community integration is a major part of that as well. >> MEL: Right. So perhaps even did they say as far as whether they thought there should be a separate section just on employment or more questions or more in depth questions? >> LAUREL: You know, I don't think it went that far. I think they were just observing about community integration how theirs was a great deal of their -- what might be classified as social life is water cooler type and work related. >> PEI-SHU: Or even volunteer work. >> LAUREL: Yes, that was good. Also under like under 17 where you talk about how many times in an average month do you participate in the following? Having people over was suggested as one of the options, not just going to other folks' house, but entertaining oneself, having people come over and entertain. >> MEL: So entertaining in the home. >> LAUREL: Yes, I wouldn't do it, but Laurie -- >> LAURIE: My place is too small to have more than two people over. >> LAUREL: Now, also the question on No. 20, how often do you travel outside the home? The question I received was is that like going somewhere else in town or do you mean like traveling and if whatever the answer is if they thought traveling -- you might consider having travel as a -- >> MEL: As a separate. >> LAUREL: Yeah. >> MEL: Don't mind our pauses, we're just taking notes. >> PEI-SHU: I'm taking notes, too. >> LAUREL: When we collected these questions, we realized that some might not be pertinent to the study that you're conducting. It may be things that stimulated ideas that folks gave us. >> MEL: Sure. >> LAUREL: Gosh I almost forgot the one about working, also then a question was they said it might be useful to know if the person worked in an office setting or if he or she telecommutes. >> MEL: Right. >> LAUREL: and then like I said, they'd like to see more on just traveling. >> MEL: Right. So also it sounds like with that traveling question to be more specific about what we mean about travel. >> LAUREL: Yeah, and would it be worth considering travel like going to different places like vacations and stuff. >> MEL: Like skiing if Vale. >> LAUREL: Although I believe our girl is taking up kayaking next. >> MEL: Well, Laurie, I have to tell you I'm taking up sculling. I'm very excited for that. >> LAUREL: I had a couple more questions -- the one on No. 21, at the bottom, where it talks about this -- your work situation and whether how many hours, et cetera, and you have the bottom one is not applicable, retired due to age. Would there be one that's not applicable due to disability? >> MEL: Due to disability. >> LAUREL: That way one wouldn't be looking for work, but one -- yeah. >> LAURIE: That's good. >> LAUREL: Here is one with community integration that I thought is a little bit of a reach but I said I would pass it on. It had to do -- do you have a service animal. And I think it had to do with the fact that you meet people with animals. >> MEL: Sure. >> LAUREL: And so I said I would include that and what kind. I would just pass that on. >> MEL: Well, I'm curious, do either of you have a sense for -- as far as the individuals with spinal cord injury, do many of them have service animals? >> LAUREL: I know a few. >> LAURIE: Yeah, I can probably think of three people. >> LAUREL: More and more, though, haven't you noticed of folks who have a -- who have to use a wheelchair or some sort of mobility disability, more and more have service animals that before -- used to it was primarily folks with visual impairment. But I've met quite a few and more recently in the last ten years than way before. >> MEL: Well, that's an interesting question to ask, too, because in a sense it would speak to -- it's a bit of a reach, but it would speak, too, with how many people do you live with. It's another someone to take care of or to interact with and it adds to community integration and people coming up to him or her on the street and what have you. >> LAUREL: It's a magnet for guys. >> MEL: To get women? >> LAUREL: Or vice versa. People just love -- well, just stop and talk. It's just amazing. >> LAURIE: It doesn't quite seem to work with my fish. But you can talk to him. >> LAUREL: I will say -- and I don't know if it's germane to the study, we had one of our coworkers had a service animal who she allowed to be part of our family. And it was remarkable coming to the office and being greeted by her. I mean, it was just -- you wonder if everybody in your life greeted you like that dog did, you would be a happier person all the time. But the fact was -- Laurie, I thought it increased the quality of life at the office to have her. Anyway. >> MEL: That was a great point that we hadn't thought about. >> LAUREL: At some point we're going to hit you all for a supplement to do a study of pets -- pet therapy. Not pet visiting, but actual therapeutic work with spinal cord injury folks and within the hospital. We'll cross that bridge later. >> MEL: Sounds good. >> PEI-SHU: Very good. >> LAUREL: On No. 16, back on demographics, it had to do with total household income. It was suggested that the 60,000 may be too low a threshold and especially if the total household income but at least 100,000 would be your cut off. >> MEL: And one of the things, too, some of the background on this question and the discussions behind it is, one, we realize that income is a touchy subject and we get people who don't answer it. And so one of the things even for this little demographic section we had talked about is do we have the response option for all of these questions of -- I'm sorry, don't want to answer. >> LAUREL: Oh, yeah. >> MEL: Or some of that extent of the no, we don't want to give them that out. We'd really like to get them if at all possible to answer the question and not withhold the information because we do like to know what -- you know, we'd like to see if there are racial differences, we would like to see if there are educational differences. We want to see differences as far as income and we've seen that there are differences based on all of that regarding various different things, whether it be access to health care or what have you. And so one of the things with that income question is, one, we didn't want to put a refuse to answer response option, but then also we wanted to make the response categories large enough so that people didn't feel too pigeon holed and we also didn't want to make the response options like the first or the last one too broad so that they didn't feel like, gosh, I'm making $40,000, think that's pretty good but here based on how they've broken their response cat emure it's, I'm in the lowest category. So that's really something we thought about. >> PEI-SHU: We want to please everyone. >> LAUREL: You want to either imply that a person who is a spinal cord injury can't make a tremendous living. That is a fine line, isn't it. >> MEL: What was the suggestion then to make the upper threshold -- to have the middle response option be 20,000 to 100,000? >> LAUREL: I think 20 to 60 and then 60 to 100 -- >> MEL: And then above. Okay. That's doable. >> LAUREL: But, you know, just a suggestion. Also they want to know -- the left handwrite hand -- what does that have to do -- >> MEL: Isn't that an interesting one? That was actually something that Suzanne Groah had suggested. She wanted us to ask that because based on -- she was telling us that based on their handedness, so to speak, she in her experience had seen more occurrences of tendonitis in their dominant shoulders and she said she was interested in that and then looking back at the little men where we asked them to color pain and what is it -- pain and UTI's, I think, but I think that one -- not skin breakdown, but question No. 4 where we ask about chronic pain. And she said in her experience she tends to see more pain in the dominant shoulder and more frequent tendonitis. >> LAUREL: For somebody who is left-handed? >> MEL: Well, regardless. >> LAUREL: Whichever hand it is. >> MEL: Exactly, and for those in manual chairs it tends to be more emphasized in whichever their dominant hand is. >> LAUREL: You know, I thought it was going to that study that was done some time ago, that left-handed people -- that their life expectancy is -- everything is harder and it's a right hand world. >> MEL: Right. Right. I've seen that. >> LAUREL: That's not what we're going for. >> MEL: Right. >> LAUREL: Of course if we get the responses in and there is a huge difference between right and left-handedness -- >> MEL: We'll keep that on ourselves. >> LAUREL: Laurie, I don't -- oh, gee, one last one I have is on demographics, what is your injury level? If a person doesn't know, could they indicate where their sensation ends? You know, like I can feel up to about my waist or -- >> MEL: That's interesting because some of the backgrounds with these discussions is a question I specifically remember Pei-Shu asking a lot is, well, people know? Do people know their injury level? And I guess the discussions we're say yeah for the most part people will know their injury level. >> LAUREL: Okay. >> LAURIE: Yeah, I would be surprised -- most people I know. >> MEL: That's what we were assuming. Again -- (Multiple Speakers). >> MEL: That's true. I mean if someone had just walked in and said I can only feel up to here, we would have a really difficult time saying what level it was. So I guess we are assuming since it's such -- I guess we're just assuming they would know. >> LAUREL: Well, if Lauri says yes, I think -- although one of the first things I learned when I started working with folks with disabilities, especially mobility, it's too personal to ask in a conversation what's your level. I have never figured out why, but I have never again asked it. So, let's see -- >> MEL: Hopefully that's one of the nice things as far as pilot testing when we ask the individuals with SCI at NRH, we'll be able on to ask them and see if they all know their injury level and if some of them don't we'll need to revisit that question and how to format it. >> PEI-SHU: I did ask some people and they did tell me though know exactly their level on just an anecdotal case. So keep in mind we'll continue to visit this question. >> LAUREL: Laurie, on the self-efficacy, I thought the questions were pretty -- I thought they were pretty good. Were you comfortable with them? I'm confident that I can -- and these breakdowns? >> LAURIE: Uh-huh, yeah. >> LAUREL: I think it's good. >> MEL: Good. Good. Thilo will be happy to hear that. Those questions we're using in another project, in another research project so we're anxious to see how those play out. >> LAUREL: I believe -- I was just looking over my list of things that people had posed to me and I think I have exhausted them. >> MEL: So I'm wondering then Laurel and Laurie, if you read all your questions, no one has necessarily submitted any questions as far as what we had specifically asked and if they haven't I guess I'm assuming it's all good to go? No one has any issues as far as is the length or the ordering? >> LAURIE: No, I didn't see any questions related to that. Just those that were clarifications that I asked earlier. >> MEL: Great. And for the most part it sounds like there were questions as far as comprehension, it was just more clarification. Good. >> LAUREL: What about the shopping? >> MEL: Shopping and travel. >> LAUREL: So I think -- now, if people have -- after listening to the webcast it will be archived. So people may want to provide feedback if they catch this a little bit later. Will you take feedback up to a certain day? >> MEL: Oh, gosh, we'll take it as long as they'll give it for the most part. >> LAUREL: So people with keep submitting. >> MEL: Right. That's fine. >> LAUREL: Let's see, I had another one about if people want to request a survey, they have a spinal cord injury and they don't know if they're on your E-mailing list or not, may they request a survey to complete? >> PEI-SHU: That's a very good question. Originally we designed the study as a random selection method, but then we do consider if we do not get enough responses in certain regions, we may consider to ask some additional people in a particular region. Yeah, that's what our tentative strategy, but we still hope that we will get enough responses from our random selection methods. >> MEL: So I guess also to add on to that if they are thinking they might like to participate, it wouldn't hurt for them to send us their contact information and then when the time comes and if we do need to recruit more participants, then we can get in touch with them. >> LAUREL: Okay. That's good. And they would just contact you through the telephone number or the E-mail. >> MEL: Exactly. But again knowing that because they are submitting their name we can't guarantee we will be able to include them in this study. >> LAUREL: Excellent. I think -- I think that would be it. So if people listening to the archived webcast care to send questions of clarification or have you considered this or X. or Y, even if it's two weeks from now or six months from now, please go ahead and send it in. >> MEL: Right. I think on the reality though six months from now that might be a tad late, but definitely in the next couple of weeks. Even the next couple of months we'll definitely be revising this and again keeping in mind that we're not recruiting and we're not administering this until the fall. So between now and then there will be constant revisions as the need arises. >> LAUREL: Laurie. >> LAURIE: That's it. no more questions at this time. >> LAUREL: Mel and Pei-Shu, would you like to -- other comments before we close? >> PEI-SHU: I just want to thank you -- all of you, for making it happen and we got good feedback. >> MEL: I think in general it's a pleasant surprise to see how much thoughtful responses and input that we have received and I think it's the type of thing where you look at something for so long and you work on it for so long you kind of hit a wall as far as, you know, what can be changed or what needs to be included. So it's nice to have these fresh opinions and fresh eyes look at it and all of the suggestion that is were made were really good. So we are over glad that we were able to do this and thank you for making it possible. >> LAUREL: Laurie, I think, would agree is that we're an opinionated group and not terribly shy. >> PEI-SHU: That's about your whole state, isn't it? I'm just having fun with you. >> LAUREL: If we may, we can wrap this up and again, thank you, all of you who helped us to provide feedback on this survey instrument. It's gratifying to be asked -- it's not always been the habit in the disabilities field for researchers to reach out to the consumers. Some do, but it's I think appreciated. Just want to point out a couple of things to our listeners. One is we referenced the Research and Training Center on managed health care and disability a number of times. We did a special issue of SCI life that covered a number of those topics. Mel, you had at least one article if not two. And there are still issues available, plus it's online. And it's publication of the National Spinal Cord Injury Association. So I suggest -- I would recommend you go to their website, www.nscia.org. That's Marcy Ross is now the director of that program. And it's a good website and has lots of resources and there are also I believe a partner on this project. >> MEL: Exactly. And they'll be playing again as I mentioned before a really big part as far as recruitment. So that was another area. >> LAUREL: Good partners. So if you care for a copy of the issue on managed health care, contact us at ILRU or again you might visit Marcy's website, nscia.org. >> MEL: I think theirs is actually spinalcord.org. >> LAUREL: All one word? >> MEL: Spinalcord.org I believe. >> LAUREL: Wouldn't that be amusing. Thank you. Then I'll close. These webcasts are made possible due in fact to our team of people who put it together. It's a diverse group and it's not all that easy to pull together all these various pieces. In particular, we want to thank our two people who make the technical end of it possible, and that's Marie Bryant who is our realtime captioner and Rob Dickehuth, who somehow makes it -- does this audio feed of a telephone conversation on. Our team here at ILRU -- it's Marj Gordon and Dawn Heinsohn, Sharon Finney, Rachel Kosoy, Mark Richards who helped put together the webcasts. We look forward to hearing from you. There is an evaluation form on this page and we urge you to complete it and send it in. And if you're in a mode for critiquing survey instruments, go ahead and critique it, too, and give us feedback on not just the presentation, but also the survey instrument. We'll kill all these birds at one stone. There will be a discussion forum where if you care to make comments about this webcast or make some more suggestions, it's on our discussion forum page and when you go to the website, our website at ILRU and click on ILRU projects, down the list will be the Research and Training Center on SCI and secondary conditions. You can click on that and then there is this web page that we've -- Mel, we've just initiated, haven't we. >> MEL: Yes. >> LAUREL: It has diverse information there and we would welcome your visit and any comment you care to give us. But down there will be a link to a discussion forum we hope you'll participate in that. And one last thing before we close is we have a discussion forum that's a question of the month. And this month it is what is the one assistive device that you would not want to be without? And we with welcome you coming to the discussion forum and putting down what it is that you think is the best thing in the whole world that you wouldn't want to live without in terms of assistive technology device. So for my colleagues at ILRU, thank you for joining us today. Thank you to the NIDRR for sponsoring this activity, and Mel and Pei-Shu, we thank you very much for presenting today. >> PEI-SHU: Thank you, too. >> LAUREL: We look forward to the findings of this research project and to upcoming town hall meetings. >> MEL: Definitely. >> LAUREL: So on behalf of all of us here at ILRU, thank you for joining us and good afternoon.