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ORIGINAL ARTICLE

Maintaining positive lifestyles through good self-care practices and adherence to daily regimesis a challenge for type 2 diabetes mellitus (DM2)

patients (WHO, 2003; Minet et al, 2009). People

differ in their appraisal of and ability to effectively

cope with the demands of diabetes self-care man-

agement (Minet et al, 2009), in particular due to

different personal behavioural coping mechanisms.

Patients with type 2 diabetes (DM2) nd them-selves unable to follow recommended lifestyles (a

healthy diet, regular physical exercise, twice daily

tooth-brushing, no smoking), which makes them

Impact of Empowerment on Toothbrushing

and Diabetes Management

Ayse Basak Cinara

/Lone Schoub

Purpose:To assess the impact of empowerment (health coaching, HC) on toothbrushing self-efcacy (TBSE) and tooth-

brushing frequency (TB) and their effects on diabetes management (HbA1c, physical activity) and quality of life in

comparison to health education (HE) among patients with diabetes type 2 (DM2).

Materials and Methods:The data (HbA1c [glycated haemoglobin], TB, physical activity, TBSE, quality of life) were col-

lected at baseline and at post-intervention at outpatient clinics of two hospitals in Istanbul, Turkey. Participants were

allocated randomly to HC (n = 77) and HE (n = 109) groups.

Results:At baseline, there were no statistical differences between HC and HE groups in terms of all measures (P >

0.05). At post-intervention, there was improvement in oral health- and diabetes-related variables in the HC group,

whereas only TBSE and TB slightly improved in the HE group (P< 0.05). At post-intervention among patients brushing

their teeth at least once a day, HC group patients were more likely to be physically active and to have high self-efcacy

than those in HE group (P< 0.01). TBSE was correlated with favourable HbA1c levels (< 6.5%) in the HC group and

quality of life (P< 0.05) in both groups.

Conclusion:The ndings show that HC-based empowerment towards improving self-efcacy is more effective at im-

proving toothbrushing behaviour than is HE and that interaction contributes signicantly to diabetes management in

terms of reduced HbA1c, increased physical activity and quality of life. TBSE can be a practical starting point for em-

powerment and toothbrushing can be used as an effective and practical behaviour to observe personal success in

diabetes management.

Key words:diabetes type II, health coaching, quality of life, toothbrushing, toothbrushing self-efcacy

Oral Health Prev Dent 2014;12:337-344 Submitted for publication: 13.05.12; accepted for publication: 18.04.13

doi: 10.3290/j.ohpd.a32130

aAssistant Professor, Oral Public Health Department, Institute of

Odontology, University of Copenhagen, Denmark.

bHead of Section, Global Oral Public Health Department, the De-

partment of Odontology, University of Copenhagen, Denmark.

Correspondence:Dr. Ayse Basak Cinar, Department of Odontology,

University of Copenhagen, Norre Alle 20, DK-2200 Copenhagen,

Denmark. Tel: +45-2757-6552. Email: [email protected]

more prone to DM2-related complications and poor

oral health, leading to a poor overall quality of life

(WHO, 2003; Cinar, 2008; Minet et al, 2009).

Patients with periodontitis are more likely to

have diabetes type 2 (Le, 1993; Sandberg et al,

2000; Guneri, 2004), which bears a high risk for

further complications such as cardiovascular prob-

lems (Genco et al, 2000; Marjanovic and Buhlin,

2013) and mortality at an early age (Avlund et al,2009). One method which is of major importance

for preventing the initiation or progression of peri-

odontal diseases is daily toothbrushing (Le,

2000). However, studies assessing the associa-

tion of toothbrushing frequency with glycemic con-

trol and quality of life among DM2 patients are

scarce. Bakhshandeh et al (2008) and Merchant et

al (2012) found that glycemic control was associ-

ated with twice-daily toothbrushing. Cinar et al

(2013a) found that DM2 patients who reported

less than daily toothbrushing were more likely to

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338 Oral Health & Preventive Dentistry

have unfavourable HDL and a low quality of life (Ci-

nar et al, 2013a).

Health 2020 (WHO, 2013) targets empowered

individuals, and thus empowered communities,

motivating them to respond proactively to new or

adverse situations; it is supported by people-cen-

tred health systems and health-care system inter-ventions (WHO, 2012). Health Coaching (HC) is a

self-empowerment-oriented behavioural approach

and intervention for transformation and mainte-

nance of positive health behaviours. HC facilitates

individuals in transforming their cognitive and emo-

tional functioning to adopt positive health behav-

iours by setting up personal goals and specic ac-

tion plans. The study by Cinar and Schou (2013)

has shown that HC is statistically more effective

than HE at reducing HbA1c and at improving oral

health and self-efcacy.

The present study aimed to assess the impactof empowerment, namely HC, on toothbrushing

self-efcacy and toothbrushing frequency, and their

effects on diabetes management (glycemic control,

physical activity) and quality of life in comparison to

health education among DM2 patients.

MATERIALS AND METHODS

The present study is part of a prospective interven-

tion study among DM2 patients (n = 186), random-

ly selected from the outpatient clinics of two hospi-

tals in Istanbul, Turkey. The power and sample size

is explained elsewhere (see Cinar and Schou,

2013; Cinar et al, 2013b). Eligibility criteria were:

1) conrmed DM2; 2) age 3065 years with at

least 4 functional teeth; 3) no psychological treat-

ment or hospitalisation.

Ethical approval of and written permission for

the study were granted by the Ministry of Health.

The methodology of the study has been described

previously (Cinar and Schou, 2013; Cinar et al,

2013b). Information regarding HbA1c was takenfrom the latest medical records at the hospital. Of

the patients participating, 96% (baseline visit, n =

179; nal visit, n = 178) lled out the self-assessed

questionnaires. Of 186 participants, the dropout

rate was 7% (n = 8) and the corresponding gure

for the participants who did not regularly partici-

pate in all sessions was 13% (n = 24).

The health behaviour questionnaires were trans-

lated into and back-translated from Turkish by two

native speakers to ensure comparability with the

original forms in English. The data in the present

study originate from the self-assessed question-

naires and HbA1c (glycated haemoglobin expressed

as the percentage of haemoglobin that is exposed

to glucose) that were collected at baseline and at

the end of study.

Procedure and randomisation

At the baseline visit, participants provided informed

consent and lled out questionnaires (including de-

mographic background, psychosocial and behav-

ioural variables). The last current medical reports

(HbA1c, fasting blood glucose, HDL, LDL, triglycer-

ide) were obtained from the hospital. Subsequent-

ly, all participants were invited for baseline oral ex-

amination, which was performed by two calibrated

examiners. Following the oral examination, partici-

pants were randomly allocated to either the HC (n= 77) or formal oral health education (HE) (n = 102)

group by a researcher who was blind to outcome

measures. HC and HE were described earlier in de-

tail (Cinar, 2012; Cinar and Schou, 2013).

The study included two phases (10-month initia-

tion and maintenance, 6-month follow-up). During

the 10-month initiation and maintenance, partici-

pants were invited for free periodontal cleaning and

three seminars about oral health and diabetes

management. At the end of the 6-month follow-up

phase, the same outcome measures were ob-

tained.

Outcome variables

Self-reported toothbrushing frequency as explained

earlier (Cinar and Schou, 2013) was taken from a

previous study (Cinar, 2008). Self-reported tooth-

brushing frequency, How often do you brush your

teeth?, was recorded on a 5-point Likert Scale

(never = 0, once a week or less = 1, 25 times/

week = 2, once daily = 3, twice or more daily = 4).This was dichotomised for further analysis as un-

favourable: brushing less than once a day and fa-

vourable: brushing at least once a day.

Diabetes management

Glycemic control was measured in terms of HbA1c.

Taking the target level HbA1c < 6.5% (International

Diabetes Federation, IDF) as the cut-off point, the

respective variable was obtained from the latest

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Vol 12, No 4, 2014 339

health records provided by either hospital or the

participants. Values were dichotomised into fa-

vourable = 0 and unfavourable = 1.

Self-reported physical activity, taken from an ear-

lier study (Christensen et al, 2010), was asked by a

multiple choice question Please tick the activity

that ts you best. There were four choices: 1.read, watch TV or other things in a sitting position;

2. walking, active house work at least four hours

per week; 3. jogging, running and other kind of run-

ning exercises or hard work in a garden 2-3 hours

per week; 4. tough training, competive sports more

than once a week. Responses were re-classied

into three categories by pooling the last two choic-

es into one, i.e. physically highly active, since rela-

tively few participants chose them. For further anal-

ysis, answers were dichotomised into unfavourable:

physically inactive and favourable: physically ac-

tive categories. The toothbrushing self-efcacy(TBSE) scale (Cinar et al, 2005; Cinar, 2008; Cinar

et al, 2012) was used to assess the individuals

belief in his/her competency to brush his/her teeth

daily across different challenging situations by an-

swering the question How sure are you that you

can brush your teeth. TBSE consisted of 8 items

on a ve-point Likert scale (0 = not sure at all to

5 = absolutely sure). The design and validity-relia-

bility measures of the scale have been described

previously (Cinar et al, 2005; Cinar, 2008; Cinar et

al, 2012). Sum scores for the TBSE scale were di-

chotomised by taking the means (HC: 18.5 and HE:

16.7) as the cut-offs and placing them into favour-

able: mean and above, and unfavourable: below

mean categories.

The modied version of WHOQOL-Bref (WHO,

2004), referring to the physical and psychological

domains, was used to assess the quality of life in

the present study. It included 6 items in total, 3

physical and 3 psychological, and responses

ranged on a 5-point Likert scale (items 1 and 2: 0

= not at all to 4= very extreme amount; items

35: 0 = very extreme amount to 4 = not at all;item 6: 0 = always to 4 = never). The validity and

the reliability of the scale were tested earlier (Cinar

et al, 2013a). By using the means as the cut-offs

(HC: 13.5 and HE: 13.9), the sum scores for the

modied quality of life scale were dichotomised

into favourable: mean and above, and unfavour-

able: below mean.

Data analysis

Statistical analyses were performed using SPSS v.

17 (Chicago, IL, USA). For assessment of correla-

tion and baseline similarities/differences between

HC and HE groups, the Spearman rank correlation

and independent samples t-test, respectively, wereused. Paired-samples t-tests were used for normal-

ly distributed data to assess change over time for

each group alone. Statistical signicance was set

at 0.05 for each test.

Principal component analysis (PCA) can be used

to hypothesise an underlying construct. The PCA

approach is thus used to nd a few combinations of

variables, called components or clusters, that ad-

equately explain the overall observed variation,

thereby reducing the complexity of the data (Cinar

et al, 2013b). In the present study, factor analysis

was applied to the variables by using PCA and Vari-max rotation to analyse not the associations but

the interrelationships (connected by shared back-

ground factors) and common underlying dimen-

sions among toothbrushing frequency, physical ac-

tivity, HbA1c levels and psychological variables

(self-efcacy and quality of life). These variables

were classied into discriminative clusters (latent

variables) based on factorial loadings, ranging from

highest to lowest values. Loadings below 0.25 were

extracted for ease of communication. The clusters

were named based on the variable with the highest

loading. Factors were extracted if the Kaiser crite-

rion of an eigenvalue greater than 1 was met.

RESULTS

At baseline, there were no statistical differences

between HC and HE groups in terms of the behav-

ioural, clinical and psychological measures (P 6.5%) than members

of the HE group (50% vs 87%, OR = 3.6 CI 95%

1.210.8, P< 0.05).

There were two clusters in the HC group based

on principal component analysis: oral health and

diabetes management (Table 2). The oral health

cluster was composed of the variables toothbrush-

ing, physical activity and self-efcacy, revealing

that at least once a day toothbrushing was inter-

related with being physically active and having high

self-efcacy. The oral health cluster was correlated

with the diabetes management cluster as follows:

improved self-efcacy was correlated with favoura-

ble HbA1c levels (rs = 0.25, P< 0.05) and quality

of life (rs = 0.28, P< 0.01). Favourable toothbrush-

ing was correlated with improved quality of life (rs =

0.27, P< 0.05).

Among the HE group, the oral health cluster was

composed of HbA1c, toothbrushing and self-efca-

cy, revealing that at least once a day toothbrush-

ers were more likely to have improved favourable

HbA1c and self-efcacy levels (Table 3). The oral

health cluster was correlated with the diabetes

management cluster as follows: toothbrushing fre-

quency was correlated with being physically active

(rs = 0.27) and improved quality of life (rs = 0.28,

P < 0.05). Improved self-efcacy was correlated

with quality of life (rs = 0.31,P< 0.01).

DISCUSSION

To our knowledge, this is one of the rst behav-

ioural interventions to analyse the effectiveness of

an individualised HC intervention vs health educa-

tion in terms of toothbrushing frequency and self-

efcacy and their effects on diabetes management

(physical activity, HbA1c) and quality of life. It tar-

gets internal motivation by linking behavioural goals

Table 1 Between- and within-group differences from baseline to post-intervention over 16 months*

n

Health coaching (HC) group

n

Health education (HE) group

P-values

baseline

(HCHE)

P-values

post-inter-

vention

(HCHE)Baseline

Post-inter-

vention P Baseline

Post-inter-

vention P

HbA1c (%) 70 7.5% 6.9% 0.001 92 7.8% 7.8% ns ns 0.001

Toothbrushing (%)Never or rare25 times/weekOnce a dayTwice a day

7714203432

1111870

0.001 7625233022

9224425

0.001 ns 0.001

Physical activity (%)Physically inactivePhysically activePhysically highly active

7742554

156916

0.001 6546486

484210

ns ns 0.001

TBSE(mean SD)

7118.5 11.9 29.3 8.6

0.001 7016.7 11.8 20.9 11.4

0.002 ns 0.001

Quality of life(mean SD) 68 13.5 4.2 14.9 4.5 0.003 65 13.9 4.9 13.8 4.6 ns ns ns

*The total number for each variable differs because the same participants did not answer all the questions; n for each variable represents

paired matches. ns: non-signicant.

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to patients values and personal vision of health by

the use of health coaching (HC) approach. To our

knowledge, there has not been any coaching inter-

vention in dentistry to date. HC in the present study

stems from Motivational Interviewing (MI) (Miller

and Rollnick, 2012) and self-efcacy (Bandura

1977, 1997) focusing on personal empowerment

to adopt healthy behaviours. Recent studies to im-

prove oral health behaviour by MI and social cogni-

tive theory are scarce. Freudenthal and Bowen

(2010) found that mothers in the MI group more

frequently brushed the teeth of their children. It

was also observed that children of parents who re-

ceived MI sessions about brushing twice a day

more frequently brushed their teeth over a two-year

period (Ismail et al, 2011). Clarkson et al (2009)

reported that patients receiving Social Cognitive

Theory-based intervention were more likely to im-prove their toothbrushing habits in terms of fre-

quency, duration and method.

Regular monitoring of HbA1c values is now the

principal way to measure and track long-term glyce-

mic control in diabetes (Skeie et al, 2001). The re-

sults of this study indicate that the HC resulted in

improvements in glycemic control (HbA1c) over the

16 months of the study. HbA1c levels of patients in

the HC group dropped by 7%, whereas HbA1C lev-

els in the HE group remained the same, which

agrees with an earlier study (Wolever et al, 2010).

Self-efcacy beliefs may play a key role in aware-

ness of ones own Hb1Ac levels as they are related

to engagement in positive health behaviours. Syr-

jl et al (1999) and Kneckt et al (1999) found that

high levels of dental self-efcacy beliefs were as-

sociated with better HbA1c levels among patients

with diabetes type 1 and insulin dependency. In the

present study, the HC group had a signicantly

higher improvement in TBSE beliefs compared to

the HE group at post-intervention, which may ex-

plain why the HC group had signicantly reduced

HbA1c levels.

Recent studies about the interrelation between

toothbrushing frequency and Hba1c are few. Mer-

chant et al (2012) reported that glycemic control

was positively associated with regular toothbrush-

ing among children with diabetes type 1. A study by

Syrjl et al (2002) showed that rmer intention tobrush the teeth was related to a lower HbA1c level

among patients with diabetes type 1. Among pa-

tients with diabetes type 1, those having better

TBSE and a higher frequency of toothbrushing had

better HbA1c levels (Kneckt et al, 1999; Syrjl et

al, 1999). In earlier studies, TBSE was found to be

strongly correlated with toothbrushing (Cinar et al,

2009, 2012) and awareness about ones own

Hba1c levels (Cinar et al, 2012). In the present

study, toothbrushing frequency and self-efcacy,

interrelated with each other in both the HC and the

Table 3 Factor analysis for assessing clusters of fa-

vourable toothbrushing and glycemic control (HbA1c)

among patients with diabetes type 2 in the health edu-

cation (HE) group

HE group Oral health Diabetes management

Favourable HbA1c 0.715 *

Toothbrushing atleast once a day

0.667 0.301

Being physicallyactive

* 0.857

Favourable TBSE 0.836 *

Favourablequality of life

* 0.764

The clusters in the study group, in total, accounted for 57.5% of the

total variance [composed of component 1 (oral health): 33.9% and

component 2 (diabetes management): 23.8%]). All variables were

coded as favourable vs unfavourable. Favourable: toothbrushing at

least once a day and regular physical exercise, TBSE and quality of

life ( mean) and clinical measure (favourable HbA1c < 6.5%).

*Loading below 0.25 extracted for ease of communication. The

clusters are named based on the variable with highest loading.

Table 2 Factor analysis for assessing clusters of fa-

vourable toothbrushing and diabetes management

among patients with diabetes type 2 in the health

coaching (HC) group

HC group Oral health Diabetes management

Favorable HbA1c * 0.870

Toothbrushing atleast once a day

0.890 *

Being physicallyactive

0.595 0.376

Favourable TBSE 0.635 0.313

Favourablequality of life

* 0.576

The clusters in the study group, in total, accounted for 59.1% of the

total variance [composed of component 1 (oral health): 32.0% and

component 2 (diabetes management): 27.1%]. All variables were

coded as favourable vs unfavourable. Favourable: toothbrushing at

least once a day and regular physical exercise, TBSE and quality of

life ( mean) and clinical measure (favourable HbA1c < 6.5%).

*Loading below 0.25 extracted for ease of communication. The

clusters are named based on the variable with highest loading.

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HE groups, interacted with Hba1c in different pat-

terns in these two groups. In the HC group, im-

proved TBSE was correlated with favourable HbA1c

levels, whereas in the HE group, it shared the same

cluster with HbA1c, indicating that they have com-

mon risk factors. Physical activity and toothbrush-

ing frequency shared the same cluster oral health in the HC group; this may indicate that health

behaviours which concern lifestyle share the same

cluster. An explanation for this may be that health

behaviours, including oral health, co-occur as sepa-

rate clusters, either as health-enhancing or health-

detrimental behaviours in the same individual (Do-

novan and et al, 1993; Astrm and Rise, 2001;

Cinar and Murtomaa, 2011). The contribution of

increased levels of TBSE to the maintenance of

regular toothbrushing may facilitate other lifestyle-

related behaviours, such as physical activity, which

corroborates with earlier studies which observedthat higher self-efcacy was associated with per-

forming diabetes self-care behaviours (Al-Khawal-

deh et al, 2012; Gao et al, 2013). Gao et al (2013)

found that having higher self-efcacy was associ-

ated with performing diabetes self-care behaviours

and these behaviours were directly linked to glyce-

mic control. Allen et al (2008) showed that improv-

ing self-efcacy beliefs led to a signicant increase

in physical activity and a decrease in HbA1c levels.

In light of these studies, the correlation between

TBSE and HbA1c in the present study can be ex-

plained by a mediating/intermediary role of TBSE

between lifestyle behaviours and HbA1c.

In the HE group, the clustering between HbA1c,

self-efcacy and toothbrushing may underline com-

mon chronic-disease management skills based on

empowerment. Many patients nd or feel them-

selves unable to follow recommended lifestyle

practices, which makes them more prone to diabe-

tes-related complications, poor oral health and

obesity, which in turn leads to poor quality of life

(WHO, 2003; Cinar, 2008; Minet et al, 2009).

Toothbrushing is a simple but effective and easilyadjustable health behaviour, the impact of which on

the oral environment can be observed easily and in

a shorter period of time, compared to the time pe-

riod required for visible outcomes of other health

behaviours. Observation of success in performance

of a health behaviour may increase self-condence,

which may lead to better control of HbA1c by regu-

lation of self-care practices, such as healthly diet

and adherence to medical regimes; the correlation

found between physical activity and toothbrushing

may support that. The fact that there was no im-

provement in HbA1c levels along with slight im-

provement at TBSE levels may underline the need

to increase TBSE beliefs to improve glycemic con-

trol. However, further studies are necessary to as-

sess the interrelation between glycemic control

and oral health behaviour-related measures.

Quality of life was correlated with TBSE andtoothbrushing among both HC- and HE-group pa-

tients. Cinar and Schou (2013) reported that quali-

ty of life was correlated with toothbrushing, which

agrees with other authors (Chen et al 1996; As-

trm et al, 2006). The interaction between oral

health behaviour-related measures and diabetes

management (HbA1c, physical activity) in the HC

and HE groups may contribute to the quality of life.

Further studies are required to elucidate the com-

plex interaction and contribution patterns found in

this study. For now, however, it is noteworthy that

oral health-related measures are interrelated withdiabetes management and quality of life. Improve-

ment in these measures can lead to better diabe-

tes management. In HE group, a signicantly higher

increase in TBSE levels may be necessary before

signicant improvements in physical activity, twice

daily toothbrushing, quality of life and HbA1c levels

are attained. This emphasises that self-empower-

ment is one of the key factors in improving diabe-

tes management and the quality of life. Future

studies should explore these issues.

A limitation of the present study is the small

sample size. Due to a number of organisational

challenges (personnel, training, funding, time etc.)

it was not possible to increase the number of par-

ticipants. However, the original sample size is with-

in the range of sample sizes of other studies in the

eld, as discussed previously. Even though the

sample is small and not representative of the gen-

eral population of DM2 patients in Turkey, it may

serve as a model for further studies. To our knowl-

edge, this study is the rst of its kind which analy-

ses the interrelation of toothbrushing and self-ef-

cacy for diabetes management and quality of life bycomparing health coaching and health education.

As discussed earlier (Cinar and Schou, 2013), the

strengths of the study are that: 1. it has a com-

parison group (HC vs HE), 2. it has a relatively long

period of intervention (16 months including a fol-

low-up), 3. it is structured and uses internationally

accredited content of HC, and 4. it uses a validity-

reliability-tested self-efcacy measurement instru-

ment. Furthermore, all HbA1c measures were tak-

en from the records of the hospitals, eliminating

the possibility of bias from self-reports.

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CONCLUSION

Whether TBSE and toothbrushing are a cause or an

effect in relation to better diabetes management

and quality of life of patients with DM2 is a topic for

further studies. However, the present ndings show

that the HC approach based on empowerment byimproving self-efcacy is more effective than HE at

improving toothbrushing behaviour. This interaction

contributes signicantly to diabetes management

in terms of reduced HbA1c, increased physical ac-

tivity and quality of life. Maintaining health despite

diabetes requires successful daily health practic-

es. The data from this study suggest that HC un-

locks positive self-intrinsic motivation, anchoring

self-efcacy beliefs for maintaining healthy life-

styles, e.g. through toothbrushing. TBSE may be a

practical starting point for empowerment, and

toothbrushing can be used as an effective andpractical behaviour to observe personal success in

diabetes management. Further studies thus may

provide new insights into and more effective out-

comes of health promotion for diabetes patients.

ACKNOWLEDGEMENTS

We would like to express our deepest thanks to Prof. Nazif Bagriacik

(Head, Turkish Diabetes Association), Associate Prof. Mehmet Sar-

gin and Head Diabetes Nurse Sengul Isik (Diabetes Unit, S.B. Kartal

Research and Education Hospital) for all their support and help dur-

ing the research. We thank Prof. Aytekin Oguz for his help with thepreparation of the documents for the ethical approval. We also

thank Prof. I Oktay and periodontologist Duygu Ilhan for training for

clinical oral examinations, ZENDIUM for oral health care kits,

SPLENDA (TR) for the promotional tools, ChiBall World Pty Ltd for

exercise chi-balls, and to IVOCLAR Vivadent, Plandent, Denmark for

provision of CRT kits. Many thanks are due to our patients for their

participation and cooperation. The research is part of an interna-

tional project that has two phases: the Turkish phase presented

here is supported by the FDI and the International Research Fund of

University of Copenhagen. The second phase is in Denmark. It is

supported by BRIDGES, which is an IDF program supported by an

educational grant from Lilly Diabetes. We would also like to thank

Christian Dinesen (Danish Coaching Institute) for the coaching train-

ing and his continuous support in both phases of the project.

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C o p y r i g h t o f O r a l H e a l t h & P r e v e n t i v e D e n t i s t r y i s t h e p r o p e r t y o f Q u i n t e s s e n c e P u b l i s h i n g

C o m p a n y I n c . a n d i t s c o n t e n t m a y n o t b e c o p i e d o r e m a i l e d t o m u l t i p l e s i t e s o r p o s t e d t o a

l i s t s e r v w i t h o u t t h e c o p y r i g h t h o l d e r ' s e x p r e s s w r i t t e n p e r m i s s i o n . H o w e v e r , u s e r s m a y p r i n t ,

d o w n l o a d , o r e m a i l a r t i c l e s f o r i n d i v i d u a l u s e .

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