Incite, Volume 16 by Greenwood Library

incite

Journal of Undergraduate Scholarship Volume 16 2025

Longwood University

incite

Journal of Undergraduate Scholarship Volume 16 2025

Longwood University

Edited by Hannah Dudley-Shotwell

Incite Faculty Advisory Board

Corey Call

Mark Kostro

Steven Hoehner

Meg Michelsen

Greg Mole

Benjamin Topham

Sarah Porter

Timothy Ritzert

Erin Waggoner

Erin Wallace

Designer

David Whaley

Cover Image

Maggie Duncan

Printed by

Worth Higgins & Associates, Richmond, Virginia on recycled archival stocks

Duncan 8 On Mentoring

Lee Millar Bidwell

The Hujum Campaign in Uzbekistan and its Consequences by Madeline Little

20 Wet Cupping Compared to Dry Needling for Treatment of Patients with Low Back Pain: A Critically Appraised Topic by Alicia Hoffman and Megan Livesay

66 The Treatment of Subacromial Impingement Syndrome with Platelet-Rich Plasma Injections Versus Exercise Therapy: A Critically Appraised Topic by Ainslie Allred and Sabrina Robles

77 Reassessing Spinosaurus

aegyptiacus: Evolutionary, Dietary, and Ecological Insights from Recent Findings by Nicholas J. Duellman

89 Regulation of the Funeral Home Industry and WhiteCollar Crime by Trinity L. Deguzman and Melissa H. Savage

102 The Folklore of Clothing: What Do Clothes Say About You? by Margaret Dudley

113 From Policy to Practice: Advocating Systemic Reforms for Climate Change Solutions by Jocelyn Escobar

120 Complementary Medicines and Practices for Type 2 Diabetes Self-Management by Olivia Hildreth

125 Feeding and Swallowing Disorders in Children with Autism: What Caregivers Need to Know by Olivia

Hopkins

135 The Economic Impacts of Sea Level Rise on Economically Valuable Coastal Properties, Land, and Infrastructure by Benjamin Gettier

150 Recognition or Refusal? Marginalized Identity Development in Passing and The Color Purple by Lee

Kassay

158 Janus Kinase Inhibition in Autoimmunity: Upadacitinib and Ulcerative Colitis by Jade

Riddle

163 Investigating Effects of Electrode Attachment Position in Single Molecule Electronics by Ashley

Seiders

introduction

Longwood University is dedicated to developing citizen leaders, with an emphasis on independent and collaborative research and creative inquiry projects. These experiences promote curiosity, scholarship, and the ability to address future challenges. Research involvement strengthens critical thinking, fosters a deeper understanding of topics, and hones essential skills such as communication, perseverance, creativity, and problem-solving. By collaborating with faculty mentors and peers, students build a sense of shared purpose while achieving intellectual independence. Completing a research or inquiry project provides students with a rewarding sense of accomplishment, and being published in Incite, Longwood’s undergraduate journal of scholarship, is regarded as a signiﬁcant milestone.

Incite features exceptional student work that highlights academic excellence and the collaborative efforts between student authors and faculty mentors. I would like to extend my gratitude to the student

authors whose work is featured in this publication and to the faculty mentors who guided them through the research process. A special thanks also goes to the Incite faculty board and editor for their hard work in bringing this journal to life. I hope you enjoy this volume of Incite and are inspired by the incredible achievements of the students showcased within its pages.

Dr. Amorette Barber Director, Office of Student Research

from the editor

I extend my heartfelt thanks to those who contributed their time and expertise to making Incite a success this year. Many thanks to Dr. Amorette Barber (Director of the Office of Student Research) for her leadership and devotion to undergraduate scholarship at Longwood, Jamie Krogh (Archives and Special Collections Librarian) for her invaluable assistance in managing our online platform, and David Whaley (Design Director) for his thoughtful and skillful design work. Navigating the proper use of AI in student research and publishing has presented new and unique challenges this year; I am especially grateful to Brent Roberts for his help in creating new Incite policies around student use of AI.

The Incite Editorial Board dedicated many hours to reﬁning our processes over the 2024-2025 cycle. We will continue this work in future semesters to ensure an even more effective and supportive experience for students and their faculty mentors. I am deeply appreciative of their efforts in this endeavor, as well as their enthusiasm for providing thoughtful editing feedback and selecting our award winners.

I also want to express my appreciation to the university leadership for their support of student research and scholarly engagement: Dr. Lara Smith (Provost and Vice President for Academic Affairs), Dr. Roger Byrne (Dean, Cook-Cole College of Arts and Sciences), Dr. Chris Kukk (Dean, Cormier Honors College), Dr. Khawaja Mamun (Dean, College of Business and Economics), and Dr. Angela McDonald (Dean, College of Education, Health, and Human Services).

Congratulations to all of the students who published in Incite and to this year’s award winners! Your dedication to research and scholarship is truly commendable. The Incite Board and I extend our deepest gratitude to the faculty mentors who have guided students through the research, writing, and editing process. Congratulations as well to our mentor award winner, a shining example of how faculty support leads to students engaging meaningfully in the academic publishing process.

This spring, a group of Longwood students organized a “Stand Up for Science” protest on Wheeler Mall. Their leader, Jordan McPherson, said this to the crowd:

Science is for all of us. Science keeps us safe and healthy. Science is an essential component of social progress ... Students, please keep yourself informed of current events and how they might affect you. Keep having conversations with people in your classes, your friends, your roommates, your peers. Don’t fall for the “politics isn’t for me” trick — it is designed to keep us uninformed. Use your critical thinking, your research, and your intuitive skills ... We are supposed to be citizen leaders. We need to be citizen scientists. (Emphasis theirs.)

As a historian, I was struck by how this call resonates beyond science. We are supposed to be citizen leaders. We need to be citizen historians. That means engaging with history as a tool for understanding the present and shaping the future; a citizen historian takes responsibility for the narratives that deﬁne us — questioning, analyzing, and preserving the stories that inform our collective identity.

As I read and reread Incite submissions, this construction echoed in my mind: We are supposed to be citizen leaders. We need to be citizen educators. We need to be citizen ethicists. We need to be citizen ethnographers. We need to

be citizen explorers. We need to be citizen storytellers. We need to be citizen researchers. And yet, we cannot all be each of these things. Instead, we must seek commonality and intersection across our disciplines. Scholarship is a conversation, a collaboration, a shared pursuit of knowledge. Through Incite, students from many disciplines push boundaries, challenge assumptions, and contribute to a greater understanding. In the context of Incite and academic research, being a citizen leader means using scholarship as a tool for engagement. It means that whether you're a scientist, historian, educator, healthcare worker, or artist, your work contributes to public discourse and has the power to shape lives. I hope that this issue of Incite serves as a reminder that the work we do has meaning beyond the page. Let us embrace the responsibility of citizenship and continue the conversation.

Dr. Hannah Dudley-Shotwell Editor

Cormier Honors College; Department of History, Political Science, and Philosophy

artist’s statement

My current work is driven by my interest in botany and the natural world. I'm most intrigued in designs, patterns, and the beauty I see in nature and the influence nature can have on humans. Nature can bring people together. It can be a meditative environment in a world of overconsumption. In my current body of work, I am working on pieces that reflect on my rural hometown. Gardens represent the love between my mother and me, and I often reference that garden and relationship in my work. This specific piece represents a small part of a larger body of work. I drew inspiration from farmhouse wallpaper. I created this piece using handmade paper that I then pulp painted over with a vibrancy of colors, including shades of pink, yellow, blue, and white. This wallpaper piece enhances the motherly sentiment I seek to achieve in the body of work.

Maggie Duncan Cover Artist

Floral Wallpaper handmade pulp paper painting by Maggie Duncan, 2025, featured on the cover

on mentoring

A mentor offers guidance, support, and knowledge to a less experienced person to help them learn and excel in a new ﬁeld or endeavor. I am fortunate that my undergraduate experience offered many opportunities to foster mentoring relationships with faculty. I attended Maryville College, a small school in East Tennessee where students were required to complete a two-semester, faculty-guided senior project and routinely invited to participate in research with faculty. Back then, I took for granted that conducting research and building mentoring relationships with faculty was a common feature of the undergraduate experience across all campuses. In graduate school, I learned that faculty-mentored research with undergraduate students was the exception, not the rule, and I pledged to ﬁnd a job at an institution that encouraged and respected teaching and mentoring. I found that place, and thirty-four years later I’m still here.

The beneﬁts of being mentored in undergraduate research are well documented. Students who partici-

pate in mentored projects are more engaged at their university, show increases in deep learning, have greater academic success, demonstrate increased motivation to set and achieve goals, are able to work more independently, and have higher retention rates compared with similar peers who do not have such opportunities (Eby et al, 2008; Haeger & Fresquez, 2016). Mentored research also provides essential life and career skills. Designing and executing research requires communication, problem-solving, and interpersonal skills, as well as the ability be ﬂexible and adapt to unforeseen circumstances. Research is difficult and often frustrating and demands determination, perseverance, and grit, but it is also rewarding and builds mastery and self-conﬁdence.

Having reaped the beneﬁts of mentoring, I wanted to pay that gift forward to the next generation of students. However, I did not expect that being a mentor would be as transformative and rewarding as being mentored. Mentoring is a bidirectional, collaborative relationship. Mentees bring fresh ideas, perspectives, and understanding to their mentors. They challenge

mentors to reﬂect on experiences and look at problems through fresh eyes. Working with students on independent research is exciting and invigorates teaching. Faculty mentors have the privilege of watching students wrestle with frustration and hard questions and then witness their excitement as they examine the ﬁnal product and marvel at their own growth.

To the students whose work is published in this edition of Incite, congratulations. The lessons you learned working with your faculty mentor on your project will inﬂuence your life and career in countless ways. When you have the opportunity to mentor others, take it. You will gain at least as much from serving as a mentor as you have from receiving mentorship.

Works Cited

Eby, L. T., Allen, T. D., Evans, S. C., Ng, T., & DuBois, D. (2008, April). Does mentoring matter? A multidisciplinary meta-analysis comparing mentored and non-mentored individuals. Journal of Vocational Behavior, 72(2): 254-267. doi: 10.1016/j.jvb.2007.04.005

Haeger, H. & Fresquez, C. (2016). Mentoring for inclusion: The impact of mentoring on undergraduate researchers in the sciences. DBE Life Science Education, 15(3). https://doi.org/10.1187/cbe.16-01-0016

Dr. Lee Millar Bidwell Faculty Mentor Award Winner

Professor of Sociology

The Hujum Campaign in Uzbekistan and its Consequences

Madeline Little

Faculty Advisor: Yulia Uryadova, Ph.D. Department of History, Political Science, and Philosophy

AWARDED FIRST PLACE FOR HUMANITIES

In 1927, an Uzbek woman was stabbed in the face by her husband. “Let her be ugly,” he said. The woman later died from the wounds.1 Another woman had her nose bitten off by her husband.2 A farmer’s daughter was raped and murdered in her own home, and her father was told “In these times you can do anything you want to a woman, and there will be no investigation.”3 These are just a few examples of the horriﬁc violence women faced at the hands of men in early twentieth-century Uzbekistan, as a result of the Hujum campaign initiated by the Soviets in 1927. The Hujum campaign (meaning “attack”) was an attack on veils worn by Muslim women between 19271929. This campaign started in Uzbekistan, the most conservative

part of Central Asia and was led by the Zhenotdel, the women’s department of the Soviet Union. The Soviets felt that they had to liberate women in Central Asia to ﬁx what they saw as a backwards society. To the Soviets, casting off the veil would be the same as casting off the rules of the past, creating new opportunities for women and bringing in new members of the Communist party.

However, what began as the Hujum attack” on the veil as a symbol of female repression, resulted in thousands of women becoming victims to violence and even death. This research examines the impact of this campaign on Uzbek women. It uses primary accounts from women who participated in and ex-

perienced the Hujum campaign, as well as accounts from the Soviet government itself, including memoranda and reports from officials. It also uses secondary sources which analyzed the Hujum campaign and its outcomes. This research argues that Uzbek women were worse off due to the severe violence they faced as a direct cause of the Hujum campaign, and they did not see positive results until years later. Women who unveiled had to live in fear for their life, whether in the form of violence from strangers or relatives.

The Soviets believed that in order to build the ideal Communist state, women needed to be liberated from what they considered Central Asia’s backwards way of life. A true socialist state could not exist unless women were also a part of the workforce. Soviet politician Nikolai Bukharin stated in 1920 that under the new state of communism, [Women] hitherto treated like cattle have at last realized that they are human beings entitled to equal rights.”4 The Soviets wanted to continue to advance women’s place in society in both the Soviet Union and Central Asia. The Soviets felt very removed from Central Asian society, which they saw as primitive, especially in the way that women were treated. A report on the Com-

munist Party’s work for the emancipation of women, written in May of 1926, states that “[Central Asian] way of life … is in contradiction with the economic development and impedes the movement of the broad masses of women to economic independence … Conditions of seclusion … serve as an obstacle to engaging the female youth of the indigenous population in the productive labor.”5 The liberation of women was intended to serve a higher purpose of increasing the Soviet Union’s workforce.

Soviets believed that increased production was more important than women’s equality; women being available to work was the true goal. They contended that this could not happen in Central Asian society unless the Soviets stepped in to mobilize women. The Soviets viewed Central Asia as too backwards and barbaric to be able to make any changes on their own. David Northrop states in his book on Stalinist Central Asia that “the Central Asian East was seen as unenlightened and primitive, thus practically begging for the introduction of civilization and progress by a more advanced West.”6 The Soviets believed that Central Asia wanted intervention from them, and so they moved forward to “save” Central Asia.

Central Asian women were the ﬁrst to be intervened upon.

The Soviets saw Central Asian women as victims of a patriarchal, Islamic society. The women had no rights of their own, and the veil was the very symbol of their oppression. Northrop states that the Soviets believed changing the status of women would “have a ripple effect, creating social change from the ground up and leading ultimately to a thoroughgoing transformation of local culture and politics.”7 If Central Asian women could change their place and status in society, they could then begin to transform the workplace, labor force, and society overall. If the campaign was successful, this would demonstrate the Soviet Union’s newfound power, something they desperately wanted to prove.

Not only did the Soviets want to liberate women to increase the workforce, but they also wanted to prove that a Communist state worked, and what better way to do so than to modernize what outsiders viewed as a primitive society? This strategy was intended to give the Soviet Union a better hold over Central Asia. Historian Marianne Kamp states that “Unveiling in itself was not the [Communist] Party’s goal; the Party’s goal was

to transform society by diminishing traditional authority and consolidating its own authority.”8 If the Soviets were successful in undermining the clergy by attacking the veil, it would show that old ways were dying off, and the Soviet government would be able to assert more dominance over Central Asia.

The Soviet Union would be able to say that they were capable of modernizing what they saw as a backwards society.

The Soviets attacked the veil specifically because they believed it was appallingly oppressive towards Central Asian women. The veil, also called a paranja, was cloth that covered both the head and the body of the woman wearing it, and to the Soviets it was a physical manifestation of oppressive society, both literally and symbolically isolating women from public spaces. In addition, the veil carried immense religious connotations. The Soviets believed only complete destruction of the veil would allow women to be fully liberated. Yuriy Malikov states that the “Hujum was closely connected with Soviet anti-Islamic policies … The veil symbolized one’s loyalty or disloyalty to the umma.”9

If a woman was veiled, they still followed the old religion, whereas those who unveiled essentially pledged their support for the new

Soviet state. Because of this, it was harder to push for liberation in countries where the veil was not as present due to traditional norms, such as in Turkmenistan.10 The veil was a powerful and useful symbol for the Soviets, one they relied heavily on, and they truly believed it was the epitome of oppression—unveiled women in nomadic groups in Central Asia were thought to have more freedom than veiled, settled women, simply because they did not cover up.11

Ultimately, the Hujum campaign caused Uzbek women from 19271929 to lose more than they gained from Soviet interference. The Soviets felt that the liberation of women should take no longer than six months so that they could celebrate accordingly in October of 1927, the tenth anniversary of the Bolshevik revolution.12 The campaigns started on International Women’s Day, March 8th, and envisioned women throwing aside their paranjis, literally and ﬁguratively casting away the past, sometimes into a pile where they would be set on ﬁre. It was a bold strategy, and one that would end up failing due to the stress put onto the women involved in the campaign, as they would face the very real possibility of being murdered for their decision to unveil.

According to Kamp, in the sixmonth period from 1927-1928, around 235 Uzbek women were murdered for unveiling, and from 1927-1929 the total reached around 2,000 women murdered.14 There are numerous accounts of violence committed against women who unveiled, and the mere act of taking off the veil was sufficient for men to feel justiﬁed in sexually harassing, raping, killing, and mutilating women. Some women took their own lives because of this vicious behavior, which was condoned by their society and the Muslim clergy. In a primary report from the Chief of Information of the OGPU, Diakov, states that in Uzbekistan “The number of political murders in 1928 in comparison with 1926 has almost doubled…Violence due to the women’s campaign and the general activity of victims constitutes 60% of cases.”15 Typically, “women were stabbed or beaten to death,” but often they were also raped and mutilated.16 Women seen leaving meetings were raped by multiple men and usually murdered after. One woman was cut to pieces, another was killed and thrown into a well, and another had her teeth broken out and stab wounds in her mouth.17

Women were not the only victims. In the city of Shahrihon in Uzbekistan, “Hadija-xon convinced a

number of women to unveil on March 8, 1927; one week later she was murdered, and so was her husband.”18 These deaths may have been preventable had proper precautions been taken, but the Soviets essentially started a campaign in which they knew women could not defend themselves. While the Soviets did plan the meetings where they would unveil women, they did little to help women and the surrounding society transition to the new un-veiled norm.19 It was not only the murder itself that instilled fear into other women, but the way in which women were often brutally murdered, mutilated, and their corpses desecrated afterward.20

Pressure from men was something women could do nothing to contest, especially considering they had little support from the Russian government. The threat of violence discouraged more women from unveiling, and women who had unveiled felt pressure to put the veil back on. Rumors spread about women who unveiled, the most popular one being that women who chose to unveil would become prostitutes. They also implied that they engaged in sexual misconduct.21

prevent women from unveiling. Kamp states that “Rape of unveiled women became widespread, and many clergy members not only took a stand against unveiling but actively encouraged men in their communities to ‘punish’ unveiled women.”22 Muslim religious clergy in the Ferghana Valley city of Andijon preached messages to prevent women from unveiling. The messages, directed to husbands, dictated that unveiling was not only forbidden by the Quran, but also that unveiling led to syphilis.23 This message implied that unveiled women would become promiscuous or adulterous, and essentially gave husbands permission to commit violence against their wives, sisters, and mothers who chose to unveil. Being unveiled put women’s safety at an immense risk, a risk most women were not willing to take. The clergy, as well as family, played a large role in amplifying these fears.

Muslim religious clergy in the city of Andijon preached messages to

Often, women were murdered by their own husbands or other relatives, a direct result of the clergy’s interference and organizing of murders themselves.24 Men whose wives or family members chose to unveil were shamed by the people around them, including religious leaders. The clergy was therefore responsible for the rumors, the

subsequent rape of the women due to these rumors, and even murders. All of these factors led the majority of women in Uzbekistan to stay veiled or return to veiling after attending the meetings.25 Even women who initially supported the campaign often veiled again due to the harassment they faced. Had the Soviet Union intervened and actually dealt out proper punishments, the Hujum campaign may have been signiﬁcantly more successful.

Women who wanted nothing to do with the campaign were often forced to participate when police blocked off exits, preventing women from getting away from these meetings; police sometimes even removed the veils themselves.26

On the Criminal Activity of the Groups Hostile to the Emancipation of Women” report states, “[the Zhenotdel] planned to unveil 125 women in the Party Club of the Old City in Tashkent. All of them came to the meeting, but by the time of unveiling, only sixty women were still in the building, the rest of them had run away.”27

The fact that women were being forced to attend the meetings further demonstrates just how few women actually wanted to participate in the campaign. Since the Soviets could not get enough women to voluntarily

come to the meetings, they implemented forced attendance.

There was also immense pressure within the Communist party towards male members to unveil their wives. Kamp states that “Most women unveiled because of coercion. Either government representatives told them to unveil, or their husbands, under government pressure, told them to unveil.”28 Although there were certainly women who wanted to unveil, the vast majority did so under coercion, which then put them into unnecessary and preventable danger.

The campaigns took a serious mental toll on the women who participated, as well. Party members reported that women who returned from the meetings would pray with relatives, begging God for forgiveness for what they had done.29 There were also party members who did not want their wives and family members to unveil, which is why they were often forced to by the government or faced expulsion from the party.30 One report stated that a member of the party, Abdulla Tashmukhamedov, absolutely did not want his wife to go to these meetings. He “told women to go to hell, believing that serious people will not bother with such triﬂes as woman.”31 This was not an

uncommon feeling within the party, as many would have agreed with Tashmukhamedov’s statement. Although men were encouraged to bring their wives to the meetings, few did.32

The Soviets were very aware of the Uzbek’s feelings towards the Hujum campaign. It was not at all a secret that Uzbeks were mostly opposed to the unveiling campaign, and that if they followed through, it would probably create hostile attitudes of all Muslims to the Soviet power.”33 However, the Soviets were not concerned about this because, as previously stated, the ulterior motive was to undermine the power of religious authorities, regardless of the effect it had on the women who would ultimately pay the price for the Hujum campaign. Overall, the campaign was very poorly planned as the Soviets had no way of protecting unveiled women from the violence they were sure to face afterwards. Intimidation worked very well against women who could do nothing to defend themselves from their attackers, or even from those who threatened them. The only choices women had were to follow the Soviet state or to remain veiled, the latter being the obvious choice as the Soviets offered ideas, but no way of implementing them correctly. Because of how poorly

managed the Hujum campaign was, women who unveiled often faced cruel fates.

Soviet interference ultimately changed the way Uzbek women lived. While this paper has explored many of the negative consequences, there were also positives. The goal of the Hujum campaign was not entirely about the removal of the veils, although that is the most recognizable aspect of it. Kamp states that the campaign also sought to increase the numbers of girls in school and women in End Illiteracy courses, to enforce laws against [polygamy] and the marriage of minors, to bring women into workplaces and promote them in the Party and government, … and to explain to women their rights.” It took a long time for these changes to be implemented, but the Soviets did make these changes happen eventually.34

Reports from the Soviet Union itself should be analyzed with caution; however, a report from Malikov acts as support to the claim that women had some participation within the workforce at the time. According to a report from the Tashkent Okrug Commission on the improvement of working and living conditions, the Labor Exchange of the Communist party provided jobs for around

208 Uzbek women, and around 5,426 Uzbeks had visited the Labor Exchange after its creation. This demonstrates direct Soviet interference in supplying women in Central Asia with jobs, which should be viewed as a positive overall. The Soviet Union’s abrupt implementation of the Hujum campaign had horrible consequences for women at the time, but may have sped up the process of progress and modernization for women.35

There were also Central Asian women who did want to unveil, and who ultimately led the way for unveiling to become more popular decades later. Still, these women too acknowledged the terror that other women experienced during the campaign. In her book, Kamp interviews multiple women who lived through and supported the Hujum campaign. Rah-Bar Oi, who unveiled on International Women’s Day, stated that she eagerly threw her paranji off on March 8th.36 She acknowledged that some women chose to put their veils back on right after the meeting, but that “everyone unveiled eventually … It continued for a long time, ten years. After that, being unveiled was widespread.”37 This indicates that the Hujum campaign was responsible for allowing women to go unveiled in the future. There were

also Central Asian women such as Mafrat-xon, who Kamp wrote about, who stopped unveiling for their safety but eventually joined the Komsomol, becoming an activist for others to unveil.38 Not every woman in Central Asia opposed the removal of the veil, although it should be noted that the vast majority did. The state would eventually dissolve the Zhenotdel, claiming that women had already been liberated (although they certainly had not), but laws were still enforced that supported and protected women.39 Even though women suffered at the time, those who participated broke ground for women of the future to choose how they dress. However, the cost of that progress cannot be minimized: women were made to fear for their lives, and many lost their lives in the end.

The Soviet Union felt it was their job to liberate women, and to do so they targeted the veil in Central Asia. They also wanted to show that communism did, in fact, work, and could be used to speed up the modernization process of other civilizations. However, implementation of the Hujum campaign in Uzbekistan put women in a worse and more dangerous position. Women who unveiled had to live in fear for their lives, whether in the form of violence from strangers or relatives.

Because of this, women faced worse conditions than they had before Soviet interference, with over 2,000 women losing their lives from the start of the campaign in 1927 to the end of the campaign in 1929. The failure of the Hujum campaign would cause the Zhenotdel to completely dissolve as it struggled to gain support from the Government, due to the Soviet Union seeing no point in continuing a program which had been met with such violence and anger from the people it was intended for.40 It was not until much later that women started to see the positive effects of Soviet interference, such as universal education and basic healthcare. The Hujum campaign certainly sped up the process of modernization but only at the cost of innocent women’s lives. Overall, the Hujum campaign was a failure and did not show positive effects in Uzbekistan until many years later.

Russian History, Accessed April 4, 2024, https://soviethistory.msu.edu/1917-2/the-new woman/the-new-woman-texts/russian-bolshevism-and-the-working-women/.

5. Yuriy Malikov, Modern Central Asia: A Primary Source (London: Lexington Books, 2020), 211.

6. Douglas Northrop, Veiled Empire: Gender and Power in Stalinist Central Asia (Ithaca: Cornell University Press, 2004), 35.

7. Ibid., 77.

8. Kamp, The New Woman, 185.

9. Malikov, Modern Central Asia, 203.

10. Adrienne Edgar, “Emancipation of the Unveiled: Turkmen Women under Soviet Rule, 1924-29,” The Russian Review, 62, no. 1 (2003): 133. http://www.jstor.org/ stable/3664562.

11. Ibid., 134.

12. Northrop, Veiled Empire, 83.

13. Ibid., 84.

14. Kamp, The New Woman, 186.

15. Diakov, “Report on Terror in the Villages of Uzbekistan. January 1928,” Making Central Asia Soviet Texts. Seventeen Moments in Russian History, Accessed April 4, 2024, https://soviethistory.msu.edu/1929-2/making-central-asia-soviet/making-central-asiasoviet-texts/terror-in-uzbek-villages-of-uzbe kistan/. Diakov’s report details the increase in political terror in 1928 in comparison to 1926, blaming the Hujum campaign for parts of this.

Notes

1. Marianne Kamp, The New Woman in Uzbekistan: Islam, Modernity, and Unveiling under Communism. (Seattle: University of Washington Press, 2006), 162.

2. Ibid., 160.

3. Ibid., 196.

4. Nikolai Bukharin, “Russian ‘Bolshevism’ and the Working Women. July 31, 1920,” The New Woman Texts, Seventeen Moments in

16. Kamp, The New Woman, 197.

17. Ibid., 197.

18. Ibid., 194.

19. Ibid., 186.

20. Ibid., 187.

21. Ibid., 197.

22. Ibid., 193-194.

23. Ibid., 197.

24. Malikov, Modern Central Asia, 221.

25. Kamp, The New Woman, 170.

26. Malikov, Modern Central Asia, 218.

27. Ibid., 220.

28. Kamp, The New Woman, 176.

29. Malikov, Modern Central Asia, 220.

30. Ibid., 219.

31. Ibid., 213.

32. Ibid., 216.

33. Ibid., 214.

34. Kamp, The New Woman, 215.

35. Malikov, Modern Central Asia, 213.

36. Kamp, The New Woman, 158.

37. Ibid., 159.

38. Ibid., 169.

39. Ibid., 217.

40. Ibid.

Bibliography

Bukharin, Nikolai. “Russian ‘Bolshevism’ and the Working Women. July 31, 1920.” The New Woman Texts. Seventeen Moments in Russian History. Accessed April 4, 2024. https://soviethistory.msu.edu/1917-2/thenew-woman/the-new-woman-texts/russianbolshevism-and-the-working-women/.

Diakov. “Report on Terror in the Villages of Uzbekistan. January 1928.” Making Central Asia Soviet Texts. Seventeen Moments in Russian History. Accessed April 4, 2024. https://soviethistory.msu.edu/1929-2/making-central-asia-soviet/making-central-asiasoviet-texts/terror-in-uzbek-villages-of-uzbekistan/.

Edgar, Adrienne Lynn. “Emancipation of the Unveiled: Turkmen Women under Soviet Rule, 1924-29.” The Russian Review, 62, no. 1 (2003): 132–49. http://www.jstor.org/ stable/3664562.

Kamp, Marianne. The New Woman in Uzbekistan: Islam, Modernity, and Unveiling under Communism. Seattle: University of Washington Press, 2006.

Malikov, Yuriy. Modern Central Asia: A Primary Source Reader. Contemporary Central Asia: Societies, Politics, and Cultures. London: Lexington Books, 2020.

Northrop, Douglas. Veiled Empire: Gender and Power in Stalinist Central Asia. Ithaca: Cornell University Press, 2004.

AI Statement

No AI tools were used in this process.

Wet Cupping Compared to Dry Needling for Treatment of Patients with Low Back Pain: A Critically Appraised Topic

Alicia Hoffman & Megan Livesay

Faculty Mentor: Jenn Cuchna, Ph.D. Department of Health, Recreation, and Kinesiology

AWARDED

FIRST PLACE

FOR EDUCATION, HEALTH, AND HUMAN SERVICES

Abstract

Clinical Scenario: Low back pain (LBP) is a widespread health issue. LBP affects many people, and the prevalence is increasing rapidly, mostly affecting females. The most commonly prescribed treatment for LBP is therapeutic exercise through physical therapy; however, other treatment options such as dry needling and wet cupping are available. Dry needling is a minimally invasive procedure used to release tension and enhance blood flow in the muscles. Wet cupping uses suction cups along with superficial incisions to remove toxins from the blood and to improve blood flow to the muscles and skin. Clinical Question: In the general population with low back pain, how does wet cupping

compared to dry needling affect pain levels when used in conjunction with therapeutic exercise?

Summary of Key Findings: Four articles met the inclusion criteria, two of which investigated dry needling, and two investigated wet cupping. All studies compared results to a control group, and in all four studies, the intervention group showed a greater decrease in pain levels in patients with low back pain. All articles received a minimum of 6 on the PEDro scale.

Clinical Bottom Line: Evidence shows that both dry needling and wet cupping are effective in treating LBP. Strength of Recommendation: The overall body of evidence used to address the clinical question supports a grade B strength of recommendation.

Clinical Scenario

Low back pain (LBP) is a very common health problem that creates burdens for individuals in social, physical, and economic settings (Hoy et al., 2012). This health problem can be hard to live with, and it can cost someone their job (Hoy et al., 2012). LBP is not taken as seriously as it should be at times because individuals who experience LBP think it is normal, they are just aging, or that it is not seen as an immediate threat, so it is not prioritized (Dickson & Trivedi, 2019). However, LBP can have a signiﬁcant impact on well-being, work, and quality of life (Hoy et al., 2012). In 2020, approximately 619 million people globally were affected by LBP, and in 2050, a projected 843 million people will be affected by LBP (Ferreira et al., 2023). Looking at all age groups, it is clear that females are affected more by LBP than males, especially in females 75 and over (Ferreira et al., 2023).

Many individuals who experience LBP are prescribed physical therapy as treatment because it helps to relieve symptoms and prevents further discomfort (Hayden et al., 2012). However, the purpose of this investigation was to look at alternative therapies available for the treatment of LBP. Two promising

interventions from the literature in the treatment of LBP are dry needling and wet cupping.

Dry needling (DN) is a relatively new treatment option for patients with LBP. Therapists need to have a continued education certification to be able to give this therapy (Upstream Rehab Institute, 2020). DN is a minimally invasive procedure where a needle is inserted directly into myofascial trigger points (Hu et al., 2018). DN is also beneficial in increasing blood flow, stimulating nerve fibers, and releasing tension in muscles in the back (Hu et al., 2018). Research shows that DN alleviates pain intensity and functional disability in patients with LBP (Hu et al., 2018).

Wet cupping is a treatment also known as bleeding cupping (Tagil et al., 2014). Wet cupping drains the excess fluids and toxins in the body as well as helps bring blood flow back to the skin and muscles (Tagil et al., 2014). To perform wet cupping, a therapist leaves a cup on for about three minutes for a mild suction; after they remove the cup, they use a small scalpel to make tiny superficial incisions (Ansorge & Whitbourne, 2024). There have been studies that show that wet cupping is effective for treating LBP (Kim et al., 2009). Our goal is to ex-

plore the two therapies in the treatment of improving low back pain.

Focused Clinical Question

In populations with low back pain, how does wet cupping compared to dry needling in their effects on pain levels?

Search Strategy and Criteria

Terms Used to Guide Search Strategy

• Patient/client groups: Men and/or women with LBP

• Intervention: Wet cupping

• Comparison: DN

• Outcomes: Pain

Sources of Evidence Searched

• Google Scholar

• PubMed

Inclusion and Exclusion Criteria

Inclusion Criteria:

• Studies that looked at LBP

• Studies that investigated DN

• Studies that investigated wet cupping

• Studies that were considered level 2 evidence on the Oxford Center for Evidence-based Medicine (OCEBM) scale from 2011

• Limited to publications from

2014 to 2024 in the English Language

Exclusion Criteria:

• Any study that did not use pain as an outcome measure

• Studies that did not have a control group

• Studies that just looked at DN

• Studies that included regular cupping

Evidence of Quality Assessment

The quality assessment that was used to appraise the included articles was the Physiotherapy Evidence Database (PEDro) scale (PEDro, 1999). The PEDro scale is an 11-item checklist used to evaluate study design and methodological quality with criteria to determine internal and external validity (PEDro, 1999). The two articles used in the research for wet cupping scored a 9/11 on the PEDro scale (Mardani-Kivi et al., 2018; AlBedah et al., 2015). The two articles used in the research for DN scored a 10/11 on the PEDro scale (Karimi et al., 2016; Martín-Corrales et al., 2020).

Summary of Search and Key Findings

The authors searched the literature for studies published in the past 10 years comparing pain levels following the use of DN or wet cupping in individuals with LBP. The search identiﬁed 540 potential studies, with four meeting the inclusion criteria following full-text review. All of these studies randomly assigned individuals to the intervention of choice group (DN or wet cupping) or the control group (Table 1). Table 2 includes the relevant ﬁndings from the four included studies.

I: Summary of Best Evidence

Table

Table 2: Characteristics of Included Studies

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Abbreviations: LBP, low back pain; VAS, Visual Analogue Scale; PT, Physical Therapy; DN, dry needling; MTP, myofascial trigger point; NRS, numerical rating scale; ODQ, Oswestry Functional Disability Questionnaire; RMQ-S, Roland-Morris Questionnaire Spanish; FABQ-S Fear Avoidance Beliefs Questionnaire Spanish; PPI, present pain intensity; PPT, pressure pain threshold

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Table 2: Characteristics of Included Studies (continued)

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• The literature search was conducted to only include high quality evidence that investigates reducing pain levels by wet cupping versus DN in conjunction with therapeutic exercise to reduce pain levels.

• A total of four studies were included in this critically appraised topic paper (CAT). All four of the studies were RCT and incorporated some type of blinding.

• Of the four studies used, two studies scored a 9/11 on the PEDro scale (Mardani-Kivi et al., 2018; AlBedah et al., 2015), and two studies scored a 10/11 on the PEDro scale (Karimi et al., 2016; Martín-Corrales et al., 2020).

• Mardani-Kivi et al. (2018) implemented a four-week protocol with wet-cupping for 20-minute increments, repeated ﬁve times per visit. There was both an

intervention and control group for this study, with the control group practicing conventional treatments. This study showed that both groups provided a decrease in pain to the patient; however, the wet-cupping group showed a signiﬁcantly larger decrease in pain.

• AlBedah et al. (2015) implemented a two-week protocol for the wet cupping (intervention) group, and a four-week protocol for the control group. Wet-cupping sessions were three sessions per week for two weeks. At baseline, both groups showed similar results with a slight decrease in pain levels; however, after two and four weeks, the wet-cupping group showed a larger decrease in pain levels compared to the control group.

• Karimi et al. (2016) implemented 10 45-minute physical therapy sessions every other day with thermal modalities. This study had a control group and a DN group. The DN group had ﬁve sessions of DN done at the end of the second, fourth, sixth, eighth, and tenth sessions. This study showed a decrease in

both groups; however, the DN group showed a decrease in pain intensity, and disability score was signiﬁcantly more than the control group.

• Martín-Corrales et al. (2020) implemented a DN or sham DN session with therapeutic exercise two days a week for four weeks investigating if DN used with therapeutic exercise can reduce pain levels. The exercises consisted of double leg bridge, hip clam exercise, prone heel squeezes as well as side lying hip abduction with internal rotation. The DN group showed that it reduced pain three months after the treatment. This study did not show any signiﬁcant differences.

Results of Quality Assessment from Best Available Evidence

This paper includes four level two randomized control trials (RCT) classiﬁed under the 2011 Oxford Center of Evidence-based Medicine (OCEBM) Levels of Evidence. Level 2 on the OCEBM Level of Evidence Scale is reserved for well-designed RCTs, prospective studies, or costanalysis studies (OCEBM, 2011). These studies were selected based

on their relevance to the research investigation and were used to help answer the focused clinical question.

Clinical Bottom Line

Based on the best available research, DN with therapeutic exercise is effective for decreasing pain levels, and wet cupping alone decreases pain with no complications. DN is effective in decreasing pain levels when used in conjunction with therapeutic exercises. Therefore, the research indicates, DN and wet cupping are both effective for treating LBP.

Strength of Recommendation (SOR)

Collectively, the body of evidence included to answer the clinical question aligns with the strength of recommendation of grade B. SOR is an overall assessment grade, typically letter grades, that is based on volume, quality, nature, and reliability of the evidence used within the individual study (McKeon & McKeon, 2018).

Implications for Practice, Education, and Future Research

Therapeutic exercise is the most common treatment option for patients who experience low back

pain, however it is typically prescribed in isolation (Hayden et al., 2012). Most people with low back pain tend to have pain that lasts a minimum of three months that goes away but returns more than twice a year (Hayden et al., 2012). It is important to look at other treatment options in conjunction with therapeutic exercise to help minimize the amount of pain that patients with low back pain experience.

DN is a commonly used treatment modality in physical therapy. The DN studies showed that DN is effective with therapeutic exercises for reducing pain and decreasing disability in patients with LBP. DN is a minimally invasive treatment modality. Future research should focus on comparing DN and wet cupping in conjunction with therapeutic exercise to determine which intervention is more effective for LBP beyond the therapeutic exercise alone. Additionally, studies should investigate the long-term outcomes of DN after the follow up to see how it continues to relieve pain and decrease disability.

Wet cupping is a common treatment modality used in physical therapy. The wet cupping studies showed that it reduces pain with no issues; it is a cost-effective option.

The wet cupping studies used in this CAT shows that wet cupping can independently contribute to reducing pain levels; however, there should be future research comparing if wet cupping is effective in reducing pain and decreasing disability alone or in conjunction with therapeutic exercises.

Ferreira, M. L., de Luca, K., Haile, L. M., Steinmetz, J. D., Culbreth, G. T., Cross, M., Kopec, J. A., Ferreira, P. H., Blyth, F. M., Buchbinder, R., Hartvigsen, J., Wu, A.-M., Saﬁri, S., Woolf, A. D., Collins, G. S., Ong, K. L., Vollset, S. E., Smith, A. E., Cruz, J. A., … March, L. M. (2023, June). Global, regional, and national burden of low back pain, 1990–2020, its attributable risk factors, and projections to 2050: A systematic analysis of the global burden of disease study 2021. The Lancet Rheumatology, 5(6). https://doi.org/10.1016/s26659913(23)00098-x

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Ansorge, R., & Whitbourne, K. (2024, July 9). Cupping therapy and its beneﬁts. WebMD. https://www.webmd.com/balance/cuppingtherapy

Dickson, D., & Trivedi, K. (2019, July 3). 5 signs your back pain might be an emergency: Back and spine: Orthopaedics and rehab: UT southwestern medical center. Back and Spine | Orthopaedics and Rehab | UT Southwestern Medical Center. https://utswmed.org/medblog/5-signs-yourback-pain-might-be-emergency/

Hayden, J. A., Cartwright, J., van Tulder, M. W., & Malmivaara, A. (2012, April 18). Exercise therapy for chronic low back pain. Cochrane Database of Systematic Reviews. https://doi.org/10.1002/14651858.cd009790

Howick, J., Chalmers, I., Glasziou, P., Greenhalgh, T., Heneghan, C., Liberati, A., Moschetti, I., Phillips, B., Thornton, H., Goddard, O., & Hodgkinson, M. The Oxford Levels of Evidence 2. Oxford Centre for EvidenceBased Medicine.https://www.cebm.ox.ac.uk/ resources/levels-of-evidence/ocebm-levelsof-evidence

Hoy, D., Bain, C., Williams, G., March, L., Brooks, P., Blyth, F., Woolf, A., Vos, T., & Buchbinder, R. (2012, May 25). A systematic review of the global prevalence of low back pain. Arthritis; Rheumatism, 64(6), 2028–2037. https://doi.org/10.1002/art.34347

Hu, H.-T., Gao, H., Ma, R.-J., Zhao, X.-F., Tian, H.-F., & Li, L. (2018, June 1). Is dry needling effective for low back pain? Medicine, 97(26). https://doi.org/10.1097/md.0000000000 011225

Karimi, A., Mahmoudzadeh, A., Rezaeian, Z., & Dommerholt, J. (2016, January 1). The effect of dry needling on the radiating pain in subjects with discogenic low-back pain: A randomized control trial. Journal of Research in Medical Sciences, 21(1), 86–93. https://doi.org/10.4103/1735-1995.192502

Kim, J.-I., Lee, M. S., Lee, D.-H., Boddy, K., & Ernst, E. (2011, June 23). Cupping for treating pain: A systematic review. Evidence-Based Complementary and Alternative Medicine, 2011(1), 1–7. https://doi.org/10.1093/ ecam/nep035

Mardani-Kivi, M., Montazar, R., Azizkhani, M., & Hashemi-Motlagh, K. (2018, November 27). Wet-cupping is effective on persistent nonspeciﬁc low back pain: A randomized clinical trial. Chinese Journal of Integrative Medicine, 25(7), 502–506. https://doi.org/10.1007/ s11655-018-2996-0

Martín-Corrales, C., Bautista, I. V., MéndezMera, J. E., Fernández-Matías, R., Achalandabaso-Ochoa, A., Gallego-Izquierdo, T., Nuñez-Nagy, S., & Pecos-Martín, D. (2020, November 7). Beneﬁts of adding gluteal dry needling to a four-week physical exercise program in a chronic low back pain population. A randomized clinical trial. Pain Medicine, 21(11), 2948–2957. https://doi.org/ 10.1093/pm/pnaa279

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Tagil, S. M., Celik, H. T., Ciftci, S., Kazanci, F. H., Arslan, M., Erdamar, N., Kesik, Y., Erdamar, H., & Dane, S. (2014, October 13). Wet-cupping removes oxidants and decreases oxidative stress. Complementary Therapies in Medicine, 22(6), 1032–1036. https://doi.org/10.1016/j.ctim.2014.10.008

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AI Statement

In the development of this article, the authors utilized Open AI’s ChatGPT as a tool to assist in removing and reducing excessive jargon, mainly for Table 2. The authors provided the AI with all the included studies’ characteristics and then asked it to remove unnecessary words.

No additional AI tools were used in the writing of this article.

Optimization of eDNA Air Sampling via 3D Printed Fan

Gabrielle Quaresma

Faculty Mentor: Amanda M. Starr, Ph.D.

Department of Biological and Environmental Sciences

AWARDED FIRST PLACE FOR NATURAL SCIENCES

Abstract

Environmental DNA (eDNA) is DNA that is found in the environment shed from living organisms. Such organisms include bacteria, which can carry antibiotic resistance. Bacteria with antibiotic resistance can be harmful to human and animal health. Research has been conducted on eDNA from soil and water environments, but there has been less focus on the eDNA from air. Assessment of air eDNA using 3D printed devices has aided in ecological and species diversity studies making research more portable and cost-effective. Sequencing eDNA to determine microbial communities within an environment has also become a more cost-effective method and is able to provide

quick and accurate information on species diversity. This research utilized small and large 3D printed devices to attach ﬁlter media to a computer fan as a way of collecting air microbes. A total of nine methods were tested to determine which would yield the most extracted DNA and best sequencing data. The most effective wash method was growing the ﬁlters on an LB agar plate, then washing in 1X PBS. DNA concentration and quality were assessed using Nanodrop, Qubit, and 16S PCR. Following assessment, samples were prepped and barcoded using either the end ligation sequencing kit, rapid PCR barcoding kit, or 16S barcoding kit. The library was then sequenced on a Flongle on a MinION device by Oxford Nanopore Technologies.

The highest DNA quality and diversity of species identified in sequencing came from growth of HVAC filters on LB agar, which was extracted with the Monarch Spin gDNA Extraction Kit and library prepped with the 16S barcoding kit. Establishing a method to accurately measure air microbiome communities provides the scientific community a protocol to reduce preliminary costs for experimentation. This also allows for the establishment of researching other air microbiome questions, such as surveying for antibiotic resistance levels within air communities.

Introduction

Environmental DNA (eDNA) is free floating DNA that is found in soil, water, and air (Larsson 2022). The microbial communities made up by eDNA floating in the air can also be called the air microbiome. The air microbiome can influence human health by affecting the human gut microbiome, the respiratory microbiome through the transmission of pathogens and multidrug resistance, and early life including immune, metabolic, and neurological developments (Valles and Francino 2018, Naumova and Kabilov 2022, Vieceli et al. 2023, Dujardin et al. 2020). The air microbiome can also be used in ecology to survey

for various cryptic or endangered species to better understand the diversity of an ecosystem; this method was established using 3D printed fans in a zoological setting and ﬁeld setting (Garrett et al. 2023, Clare et al. 2022).

Air sampling is of growing interest as a method to: 1) measure biodiversity of species and 2) assess air quality which could negatively impact human health or the environment (Clare et al. 2021). Most sampling approaches involve the use of large and expensive equipment, making it less accessible to perform research on a limited budget (Dommergue et al. 2019). Recent studies have experimented with more portable designs utilizing a battery and air collection with a pump or fan onto various filter media, to monitor vertebrate, invertebrate, and bacterial species (Lynggaard et al. 2022, Littlefair et al. 2023). 3D printing has become more available at universities and colleges, allowing customization of devices, such as a 3D printed filter holder, making it much more affordable. To recover DNA from the filters, methods vary by each sampling device, filter material (such as car cabin air filters), and DNA extraction methods (Dommergue et al. 2019, Hurley et al. 2019, Johnson et al. 2019). Ways of collecting air microbes have included using

pumps or computer fans to pull air through the filter and collect microbes on filter media. Researchers have prioritized quiet devices that would not disturb organisms when surveying for species diversity and power to ensure a significant amount of air can be pushed through the fan (Clare et al. 2021, Garret et al. 2023).

Whole genome sequencing methods have been used in the microbiology ﬁeld and are of growing interest to ecological and biodiversity research (Ruppert et al. 2018). This method of research allows a sample of eDNA to be barcoded and sequenced, allowing identiﬁcation of all species present (Park et al. 2023). Companies like Oxford Nanopore Technologies have created devices like the Flongle, used in this research, which provides size and cost effective ways to sequence samples in a short amount of time.

The aim of this project was to collect air samples from Longwood University’s campus to establish an air sampling technique and determine what microorganisms were present. This research developed methods of collecting air eDNA from Longwood University’s campus using a 3D-printed fan device and heating, ventilation, and air

conditioning filters (HVAC filters). Different methods experimented with included filter washes, growth on media, DNA extraction kits, and DNA library preparations.

Materials and

Methods

3D Printed Filter Holder

Files for small and large 3D printed ﬁlter-holding apparati were modiﬁed from Garrett et al. 2023, constructed from polylactide plastic (PLA) and printed on the Creality CR-10S Pro V2 3D printer (Shenzhen Creality 3D Technology Co. Ltd, Shenzhen, China).

Air Sampling Prep and Procedure

The sampling location was Longwood University’s Campus (37.301,78.396). Fan ﬁlters (Quartz and HVAC) were autoclaved, and fan device pieces (including 3D printed parts, zip-ties, and computer fans) were sprayed with 70% ethanol and sanitized under UV for 10 minutes under sterile conditions. Two sampling devices of each size were assembled and wrapped in aluminum foil in sterile conditions. Fans were powered with a SinKeu portable power bank with an AC outlet.

The ﬁrst method of sampling used two small 3D printed devices which

attached a Millipore Sigma Quartz Fiber Membrane Filter to a fan. The fan used was a 40mm x 20mm dual ball bearing brushless blower fan 12V with 0.12A with a speed of 7500 rpm, pressure of 10.56 mmH2O, 1.48W, and airﬂow of 3.87 CFM. Sampling was done for one hour in the morning, and temperature, wind speed, and humidity were recorded at each location.

With the larger fan design, sampling was done with both Quartz and MERV-13 HVAC ﬁlters. The fan used was a 120mm x 32mm dual ball bearing brushless blower fan 12V with 240V AC plug with a max 1A and speed of 3000 rpm, air pressure of 1.14mm H2O, 11W, and 36 CFM. Sampling was done for one hour, and temperature, wind speed, and humidity were recorded.

Filter Wash Procedures

For the first wash method, Quartz filters were removed with sterile forceps and placed into 10 mL of 1X Phosphate Buffered Saline (PBS) and incubated with rotation overnight at 56℃ (SQ). For the larger fan device, Quartz filters were cut into 1 cm2 strips and placed in 300 μL STET buffer (sodium chloride, Tris-HCl, EDTA, and Triton X-100) and 20 μL Proteinase K and was incubated at different conditions of

56℃ overnight (LQ_STETKON), 37℃ for 30 minutes (LQ_STET37_30).

The first wash method with HVAC filters involved cutting them into strips which were added to 20 mL STET buffer and 20 μL Proteinase K and incubated at 56℃ overnight (LH_STETON). HVAC filters were also washed with 20 mL STET buffer and 10 mg/mL of lysozyme and incubated at two different temperatures: 37℃ for 30 minutes (LH_STETL37_30) and 56℃ for 30 minutes (LH_STETL56_30). For the first growth method, HVAC filters were cut into fourths with sterile scissors. They were then placed on brain heart infusion agar (BHI) and incubated at 37℃ for 24 hours (LH_BHI_PBS_HMW). Growth was additionally done on Luria Broth (LB) agar plates and incubated at 23℃ for 1 week (LH_LB_PBS_gDNA_R and LH_LB_PBS_gDNA_16). All of the growth method filters were removed from agar plates and 20 mL PBS buffer and rotated at 56℃ for 60 minutes.

Extraction Method

Filters were removed after wash and incubation and centrifuged for 20 minutes at 2500 xg to form a pellet for extraction. For all methods except LH_LB_PBS_ gDNA_16, the Monarch High Molecular Weight (HMW) DNA Extraction

Kit (New England Biolabs, Ipswitch, MA, USA) was used according to the manufacturer's protocol.

For LH_LB_PBS_gDNA_16, the pellet was resuspended in 300 μL PBS and separated into two tubes, each 150 μL. To this 50 μL Tissue Lysis Buffer and 10 μL of 25 mg/mL lysozyme was added and incubated for 5 minutes at 37℃. About 0.5 mL of glass beads were added and the samples were vortexed for 1 minute then iced for 1 minute. This bead beating procedure was repeated 5 times, then 100 μL from each were combined, and extraction ﬁnished using the Monarch Spin gDNA Extraction Kit (New England Biolabs, Ipswtich, Ma) according to manufacturer’s guidelines.

DNA Quantiﬁcation and PCR

Genomic DNA from all wash methods was quantiﬁed with a nanodrop and Qubit Fluorometer 3.0 (Thermo, CA, USA) with the Qubit dsDNA HS Assay Kit (Thermo, CA, USA) according to manufacturer’s guidelines.

PCR with 16S primers was completed with each sample to verify the presence of bacterial DNA. The following was added into a PCR tube: 2 μL DNA extract from each sample, 1 μL each Forward (27F 5’

AGAGTTTGATCMTGGCTCAG 3’) and Reverse (1429R 5’ GGTTACC TTGTTACGACTT 3’) primers at an initial concentration of 10 μM, 25 μL Taq 2X Master Mix (NEB), and 21 μL water. PCR was done using the following parameters: 94 ℃ 4 min, 40 cycles of: 94℃ 30 sec, 50℃ 30 sec, and 72℃ 1 min, and 72℃ 7 min ﬁnal extension. Gel electrophoresis using 2% agarose with 5 μL 10 mg/mL ethidium bromide was used to run each PCR product.

Sequencing Methods and Analysis

Sequencing from extracted genomic DNA was done on a Flongle device (Oxford Nanopore Technologies, Oxford, UK). The library was prepped for the sample SQ 16S rRNA using the ligation sequencing kit (SQK-LSK109; Oxford Nanopore Technologies, Oxford, UK). Extracted genomic DNA was barcoded using the rapid PCR barcoding kit 24 (SQK-RPB114-24; Oxford Nanopore Technologies, Oxford, UK) or 16S barcoding kit (SQK16S114-24; Oxford Nanopore Technologies, Oxford, UK).

Barcoded libraries sequenced on a MinION Mk1B using the Flongle adaptor (FA-01683; Oxford Nanopore Technologies, Oxford, UK) for 24 hours using the MinKnow software 24.06 (MiKNOW Core

6.0.15) with Bream 8.0.13, configuration 6.0.19, with pore scan every 1.5 hours and live basecalling with Dorado 7.4.14, a high-accuracy model v4.30 400 bps, with a minimum q score of 9. Reads were analyzed using EPI2ME software from Nanopore following the wf-metagenomics workflow with Kraken2 for taxonomic identification from libraries utilizing the rapid PCR barcoding kit or wf-16S workflow using the NCBI 16S, 18S, 28S, and ITS databases for taxonomic identification (Oxford Nanopore Technologies, Oxford, UK). Alpha diversity was calculated in Microsoft Excel and genera from each condition were converted to eigenvalues to standardize differences between samples using statskingdom.com.

A Principle Component Analysis (PCA) was completed to compare the six different sequenced methods and determine genera that caused the groupings using statskingdom.com.

Results and Discussion

Nine different techniques were compared within this study. They varied by fan size, filter type, filter preparation methods, DNA extraction methods, and library preparation (Figure 1). To evaluate these methods, filters were run on the Longwood Campus location for 1

hour, the filter was prepared, DNA extracted directly from the filters or from filters grown on LB or BHI media, checked for DNA concentration and quality, 16S rRNA PCR was done to confirm bacterial DNA was present, DNA library was prepped, and libraries were sequenced. The concentration and quality of DNA was assessed between all conditions using a Nanodrop and Qubit. The 6 techniques which contained the required DNA concentration and quality were prepared for sequencing using either the ligation sequencing kit (SQK-LSK109), rapid PCR barcoding kit 24 (SQK-RPB11424), or 16S barcoding kit (SQK16S114-24) from Nanopore and sequenced on a MinION Mk1B using the Flongle adaptor (FA-01683).

Figure 1. Techniques used to sample air from Longwood Campus with modifications in fan size (large or small), filter material (quartz or HVAC), growth or no growth of the filter onto media (LB or BHI), filter wash methods, DNA extraction methods: Monarch HMW DNA Extraction Kit for Tissue (HMW) or Monarch Spin gDNA Extraction Kit (gDNA), DNA sequencing library prep methods: ligation sequencing kit (16S End ligation), rapid PCR barcoding kit 24, or 16S barcoding kit from Nanopore or X indicating

not library prepped or sequenced, and the naming for each method used.

Quality of DNA Assessed by Nanodrop, Qubit, and PCR

The campus air samples were processed by nine different extraction methods, abbreviated SQ, LQ_STETKON, LQ_STET37_30, LH_STETKON, LH_STET37_30, LH_STETL56_30,

LH_BHI_PBS_HMW, LH_LB_PBS_gDNA_R, and LH_LB_PBS_gDNA_16 (Figure 1). The DNA from each condition was quantiﬁed and checked for quality through Nanodrop and Qubit readings. Nanodrop was not a reliable method for quantifying highmolecular weight DNA with an

FIGURE

average concentration of 1.54 +/2.52 ng/μL and a minimum value of -1.4 ng/μL and a maximum value of 5.8 ng/μL (Table 1). The Monarch Spin gDNA Extraction Kit (NEB) did show the highest concentration values with 82.1 ng/μL (Table 1).

High quality DNA to run through Nanopore sequencing is recommended to have a minimum DNA concentration of 1-5 ng/μL, 260/280 value of 1.8-2.0, and 260/230 value of 2.0-2.2.

The Qubit 3.0 was able to validate the presence of dsDNA in three

samples with a concentration range of 16.2+/- 19.8 ng/μL with a minimum of 1.53 ng/μL and maximum of 38.7 ng/μL (Table 1).

The 260/280 values ranged from 0.96 +/-1.8 with a minimum value of -1.94 and maximum value of 3.26, and the 260/230 values ranged from -5.55 +/- 14.5 with a minimum value of -37.89 and maximum value of 1.76 (Table 1). The LH_LB_PBS_gDNA_16 and LH_LB_PBS_gDNA_R samples contained the best 260/280 and 260/230 values.

Table 1. DNA quality and concentration measurements using Nanodrop and Qubit for each technique in Figure 1.

A 16S rRNA PCR was run to validate the presence of bacterial DNA that would be ampliﬁed in PCR regardless of DNA concentration, 260/280, or 260/230 values. Samples which produced a PCR product were independent of low DNA quality (Figure 2). Therefore, those samples which produced a PCR product were determined to be viable for sequencing.

Figure 2. PCR products for 16S rRNA for different extraction methods mentioned in Figure 1 run on 2% agarose at 120V for 30 minutes and were stained with ethidium bromide.

The majority of the methods that included HVAC filter material with STET Buffer washes with Proteinase K or Lysozyme produced no PCR product and were not sequenced, except for LH_STET37_30. The HVAC filters with growth on LB agar or BHI agar, and washed with 1X PBS at 56oC for 1 hour consistently produced DNA with good concentrations. The method that produced the best concentration and quality of DNA was the use of HVAC filters in the large fan grown on LB agar at 23oC for 7 days, washed with 1X PBS at 56oC for 1 hour and DNA extracted from the cellular pellet using the Monarch Spin gDNA Extraction Kit (NEB).

Nanopore Sequencing Comparisons

DNA from extraction methods which produced a 16S rRNA PCR product were assessed for DNA quality and quantity and used for sequencing with varying library preparations (Figure 1). Total number of bases, passed reads, and N50 were highest in samples which were grown on LB at 23oC for 7 days, DNA extracted for cellular pellet using the Monarch Spin gDNA Extraction Kit (NEB), and library

prep of 16S barcoding kit (LH_LB_PBS_gDNA_16) (Table 2).

The second highest total number of bases, passed reads, and N50 was in the sample which was grown on LB at 23oC for 7 days, DNA extracted for cellular pellet using the Monarch Spin gDNA Extraction Kit (NEB), and library prep of rapid PCR barcoding kit (LH_LB_PBS _gDNA_R) (Table 2). All other methods produced below 25Mb

of data with less than 11 Mb of data passing a Q score of 9 (Table 2). Based on this data, the best sequencing method would be

utilizing the 16S barcoding kit, with the rapid PCR barcoding kit coming in second.

Table 2. Nanopore results using a Flongle with MinION Mk1B from various techniques mentioned in Figure 1.

Genera Diversity Comparisons Between Sequencing Methods

The gamma diversity was calculated to be 135, representing the total number of genera identiﬁed among all sampling techniques (Figure 3). Alpha diversity based on genera was also calculated, and those samples which were grown on LB at 23oC for 7 days, DNA extracted for cellular pellet using the Monarch Spin gDNA Extraction Kit (NEB), and library preps of 16S barcoding kit (LH_LB_PBS_gDNA_16), and

rapid PCR barcoding kit (LH_LB_PBS_gDNA_R) produced the largest number of unique genera, 84 and 42, respectively (Figure 3A). The methods which did not utilize growth on media or used the Monarch HMW DNA Extraction Kit for Tissue (NEB) and library prep with rapid PCR barcoding kits yielded fewer than 10 genera each (Figure 3A). The exception was the quartz ﬁlter, which utilized the 16S rRNA PCR product and ligation sequencing kit yielding 27 genera (Figure 3A).

Figure 3. A) Alpha diversity based on genera for each technique sequenced from Figure 1, B) PCA Analysis of each for each technique sequenced from Figure 1, and C) PCA based on unique genera inﬂuences differences between techniques sequenced from Figure 1.

Genera were standardized and eigenvalues were calculated to determine the variation between the six different methods that were sequenced (statskingdom.com). A PCA analysis comparing the methods produced 3 unique groupings. These included group 1) the quartz filter with 16S rRNA ligation (SQ), 2) HVAC filter samples which were grown on LB at 23oC for 7 days, DNA extracted for cellular pellet using the Monarch Spin gDNA Extraction Kit (NEB), and library preps of 16S barcoding kit (LH_LB_PBS_gDNA_16), and rapid PCR barcoding kit (LH_LB_PBS_g DNA_R), and 3) HVAC or Quartz filter samples with or without growth on BHI agar at 37oC, filter washes STET buffer with lysozyme or proteinase K, DNA extracted using the Monarch HMW DNA Extraction Kit for Tissue (NEB), and sequencing with the rapid PCR barcoding kit (Figure 3B). The genera which helped to differentiate the 6 methods included: Bacillus, Escherichia, Homo, Micrococcus, Staphylococcus, Vibrio, Viridibacillus, and unknown species (Figure 3C). These species are linked to environmental microbes, human-associated microbes, and humans themselves (Da Costa et al. 2013). The lack of Homo in 16S sequencing is understandable since these are prokaryotic specific primers.

Conclusions

Nine methods were used to collect microbes and DNA from the air, extract DNA from filters, prepare DNA libraries, and sequence DNA collected on Longwood Campus. Genomic DNA from original small fans did not produce DNA viable for sequencing. After all of the comparisons, the method with the best performance based on DNA concentration and quality, breadth and depth of sequencing coverage, and higher diversity was the method using HVAC filters on large fans with filters grown on LB at 23oC for 7 days, DNA extracted from cellular pellet using the Monarch Spin gDNA Extraction Kit (NEB), and library prepped with the 16S barcoding kit (LH_LB_PBS_gDNA_16). In addition to producing the best performance in data, this method overall is least expensive ($119/sample) as compared to the other five sequenced methods per sample (Table 3). While this method does produce the largest prokaryotic diversity, the potential for eukaryotic and viral organism identification is not possible. The second method of choice would be using HVAC filters on large fans with filters grown on LB at 23oC for 7 days, DNA extracted from cellular pellet using the Monarch Spin gDNA Extraction Kit (NEB), and library prepped with

the rapid PCR barcoding kit (LH_LB_PBS_gDNA_R). The rapid PCR barcoding kit does allow for potential identification of eukaryotic, prokaryotic, and viral organisms and is of equal cost to the LH_LB_PBS_gDNA_16 method. There is bias in the Rapid PCR Barcoding Kit as it randomly cuts using the transposase enzyme (Chen et al. 2024). The last potential library method that could be utilized is the Nanopore 24 native barcoding kit, which would allow for full DNA sequences to be labeled and potentially identify eukaryotic, prokaryotic, and viral organisms as well. This method is what was used for the SQ sample library and would be the most expensive at roughly $235/sample (Table 3). Depending on the level of data being sought, the overall recommended method would be HVAC filters on large fans with filters grown on LB at 23oC for 7 days, and DNA extracted from cellular pellets using the Monarch Spin gDNA Extraction Kit (NEB). The library method could then be modified depending on specific interests. This established method would allow for researchers to minimize monetary expenses when determining which extraction and sampling method was best for them. With the preliminary work completed to determine species diversity and abundance, other

research questions can be explored, such as prevalence of virulence traits (ex. Antibiotic resistance). Areas that can still be explored include determining a method best to identify the eukaryotic and viral communities within air sampling.

Table 3. Costs per sample for each technique mentioned in Figure 1. The costs include fan printing, fans, ﬁlters, battery pack, media/plates, extraction kits, library preparation kits, and Flongle for sequencing. Costs do not include plastics, buffers, or the MinION Mk1B.

Acknowledgements

The author thanks Dr. Dale Beach and Jade Riddle for their assistance in experimental design and with laboratory equipment and the Longwood Office of Student Research for funding. The author would also like to thank Dr. Scott Starr from Hampden-Sydney College for modifying 3D print ﬁles and 3D printing ﬁlter-holding apparati.

Da Costa PM, Loureiro L, Matos AJ. 2013. Transfer of multidrug-resistant bacteria between intermingled ecological niches: the interface between humans, animals and the environment. International Journal of Environmental Research and Public Health. 10(1):278-94.

Dommergue A, Amato P, Tignat-Perrier R, Magand O, Thollot A, Joly M, Bouvier L, Sellegri K, Vogel T, Sonke JE, Jaffrezo JL, et al. 2019. Methods to investigate the global atmospheric microbiome. Frontiers in Microbiology. 10:243.

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AI Statement

No artiﬁcial intelligence (AI) was used in the process of writing or reviewing, experimental design, experimentation, or data analysis for this manuscript.

Beyond the Classroom: A Qualitative Study of Teacher Attrition and Retention

Serenity Allen and Laina Pfountz

Faculty Mentor: Lee Millar Bidwell, Ph.D. Department of Sociology, Anthropology, and Criminal Justice

AWARDED FIRST PLACE FOR SOCIAL

SCIENCES

Abstract

Public schools across the United States increasingly experience difﬁculty attracting and retaining teachers, which disrupts students’ education and creates greater workplace stress for educators (Loehrke, 2024; Nwoko et al., 2023; Robbins, 2023). The purpose of this qualitative study is to investigate the lived experiences of current teachers, analyze the challenges they face that may contribute to attrition, and examine their suggestions for change. We conducted 18 semi-structured interviews with K-12 public school teachers. Teachers reported that unsupportive school leadership, lack of parental support, low pay, work overload, and burnout are factors that lead to attrition. We recommended

that school leaders, teachers, and policymakers should strengthen teacher preparation curriculums, develop structured mentoring for new teachers, and provide loan forgiveness programs to make teaching a more desirable, rewarding profession.

Public education in the United States is experiencing a shortage of its most critical resource: qualiﬁed teachers. Data from the U.S. Bureau of Labor Statistics indicate a steady decline in employment in the teaching profession since the 1970s, with teaching currently at “its lowest levels of employment in 50 years” (Huynh, 2024, para.1). The Learning Policy Institute estimates that in 2024, at minimum, 406,964 positions, representing 1 in 8 teaching

positions nationwide, are either vacant or ﬁlled by teachers who are not fully qualiﬁed (Tan, Arellano, & Patrick, 2024). The shortage creates additional workload and stress for continuing teachers, leads to overcrowded classrooms with increased discipline and classroom management problems, and is correlated with lower student achievement and academic performance (Blizard, 2021; Ramos & Hughes, 2020; Robbins, 2023).

The teacher shortage is caused by difficulty both attracting and retaining teachers in the profession. Eighty-six percent of public schools report trouble hiring teachers (Teachers of Tomorrow, 2024). Kraft and Lyon (2024, p. 6) report that, interest in the teaching profession among high school seniors and college freshman [sic] has fallen 48% since the 1990s, and 40% since 2010,” resulting in over 100,000 fewer prospective teachers earning their license between 2006 and 2021. In addition to declines in the pool of potential applicants, teachers are leaving the profession altogether, a phenomenon known as attrition.” Carver-Thomas and Darling–Hammond (2019) report that 30% of teacher turnover is due to individuals voluntarily leaving the job prior to retirement (Carver-Thomas & Darling-Hammond, 2019). In fact,

8% of teachers leave the profession every year (Loewus, 2021).

This study investigates the lived experiences of current teachers, the challenges they face that may contribute to attrition, and their suggestions for change. Using a qualitative approach, we conducted 18 in-depth interviews with K-12 public school teachers. During these interviews, teachers described responsibilities, challenges, rewards of their jobs, and suggestions for how to attract and retain teachers in the profession. Our ﬁndings suggest that the concerns of today’s teachers, including lack of support, work overload, low pay, and burnout, parallel previous literature. While much of the literature examines single, speciﬁc factors affecting teacher attrition, our study provides a comprehensive overview of the complex factors that may contribute to the nationwide teacher shortage. By acknowledging that a multifaceted approach to the problems in education is necessary to create real change, the results of the study indicate that a range of micro- and macro-level solutions are required to reduce teacher attrition.

Literature Review

Researchers identify a myriad of explanations for why so many

teachers leave the profession and fewer choose to pursue the profession altogether. Lack of support from administrators, parents, and the larger culture; work overload; low pay; and burnout are some of the most commonly cited reasons for the teacher shortage (Robbins, 2023).

Lack of Support

One of the primary causes of teacher attrition among K-12 teachers is a lack of support and respect for teachers and the teaching career (James, 2024). This lack of support can come from administrators, parents, and the community at large. Effective, supportive administrators, especially principals, are essential for teachers’ job satisfaction and morale (James, 2024). When teachers are already facing a variety of other challenges within their career, they look for support from their administration. It is the job of school administrators to help teachers be effective by encouraging, acknowledging, and communicating well with them. A good administrator provides high-quality preparation, mentoring, and induction programs for new teachers which aid in those teachers forming long-lasting careers with less chance of attrition (Gull & Rush, 2024). School leaders

should also provide professional learning experiences and be a leadership example that is supportive towards all teachers (CarverThomas & Darling-Hammond, 2019). Clearly, a good administrative team affects how likely a teacher is to stay in the ﬁeld.

When the administration is not supportive of teachers, however, it becomes another factor in their decision to leave the ﬁeld entirely. Inefficient principals are one of the most signiﬁcant factors affecting teacher attrition in public schools (Holmes et al., 2019). Teachers do not necessarily dislike their administrators personally, but they may disagree with administrators’ policies, programs, decisions and actions, or lack thereof (Ramos & Hughes, 2020). Teachers must trust and feel comfortable approaching the administration with any problems they may be facing in the classroom. Simply put, “School administrators can make or break a teacher” (Robbins, 2023, p. 257).

Lack of support from parents also contributes to teacher attrition. Often, parents do not respect teachers as professional educators, going so far as to threaten or even physically attack teachers (Garcia & Weiss, 2020). Parents who constantly challenge teachers’

authority and decisions also can destroy morale, leading to attrition (Robbins, 2023).

Finally, the decline in respect towards teaching as a profession in the broader society contributes to high levels of teacher attrition. According to Kraft and Lyon (2024, p. 5-6) “Perceptions of teacher prestige have fallen between 20% and 47% in the last decade to be at the lowest levels recorded over the last half century.” Teachers do not feel appreciated or supported in the hard work they do and often are given very little control over what, or how, they teach (Garcia & Weiss, 2020; Turner & Cohen, 2023). Few people outside the ﬁeld of education understand the amount of effort and resilience it takes to be a teacher. When teachers’ work is taken for granted, devalued, and even attacked, they become discouraged and seek more rewarding, or at least better paying, careers (Garcia & Weiss, 2020).

Work Overload

Work overload is another factor contributing to teacher attrition. Over half of teachers work more than 60 hours a week, with almost 20% of teachers reporting that they work over 70 hours a week (Hopkins, 2023). Teachers recognize that

they are often overwhelmed with too many tasks which they must accomplish in a short period of time, and they do not receive the compensation that would be expected for this amount of effort (Blad, 2024). The amount of time teachers spend on their jobs is well over their contracted hours (NEA, 2018). However, for teachers to do their job and do it well, they often must put in more time than is technically required of them. Teachers may be afraid to complain, ask for help, or say no when asked to take on more responsibility and ultimately assume an unhealthy workload, leading to teacher burnout and eventually attrition (Swisher, 2022).

Low Pay

Low pay also contributes to the teacher shortage. Teachers make far less than other college graduates, a fact sometimes referred to as the wage penalty” (Allegretto, 2023). Public school teachers make 21% less than other professionals in similarly degreed occupations (Hopkins, 2023), even accounting for their shorter work year (Singleton & Roberts, 2023). Although teachers’ salaries vary across states and localities, (Darling-Hammond et al., 2023; Turner & Cohen, 2023) with those working in rural areas being paid far less than suburban and

urban areas (Oyen, 2019), inﬂation and the economic impact of COVID19 have led to a decline in teachers’ real earnings nationwide (Allegretto, 2023; Walker, 2022). As Allegretto (2022, p.1) states, “Simply put, teachers are paid less…than their non-teaching college-educated counterparts, and the situation has worsened considerably over time.” As a result, 59% of teachers report that they have to work more than one job to make a livable income (Garcia & Weiss 2020), 29.15% of teachers report that they are often stressed by economic concerns, and many teachers cannot afford to live in the area where they teach (Singleton & Roberts, 2023). Ramos & Hughes (2020) contend that teachers’ low-income is one of the most signiﬁcant contributors to teacher attrition.

Burnout

Teacher burnout is one of the strongest predictors of attrition (Madigan & Kim, 2021). The World Health Organization deﬁnes burnout as a “‘state of vital exhaustion’” as a result of working conditions that is characterized by low energy, exhaustion, increased mental distance from or negativity toward one’s job, and “reduced professional efficacy” (cited in Drayton, 2021, p. 11).

As Drayton (2021, p. 12) explains,

Burnout is related to poorly managed stress in the environment, rather than weakness on the part of susceptible employees.” The demands of the profession, including bureaucratic policies aimed at improving education, excessive workload, and work-life imbalance, help explain why teachers report higher rates of burnout than workers in other professions (Nwoko, 2023).

While new teachers face a variety of challenges when starting their career, veteran teachers suffer from similar struggles and start to get burnt out (Tompkins, 2023). Loewus (2022) writes that the only reason many teachers stay is because of the love they have for their students, which is often why they initially chose the teaching career. However, many teachers leave the profession when their love for their students is no longer enough, especially when it means sacriﬁcing their mental health.

Research Methods

Current teachers are in the best position to describe the challenges of the profession that may drive them to leave and to offer suggestions for ways to address these challenges. The data for this study were collected by students in an Honors Sociology of Education class (SOCL

320) in the spring semester of 2024. Each of the 18 students in the class conducted one semi-structured interview with a K-12 public school teacher with whom they had no personal connection. Teachers were sent a recruiting email explaining the purpose of the study, the interview procedures, and how the conﬁdentiality of the data would be protected. Informed consent statements were included in the recruiting email and were also read prior to each interview.

Interviews lasted an average of 52 minutes, with a range of 20 to 220 minutes. Of the 18 respondents, 15 were women. Most respondents taught grades K-5 (67%): 13% taught middle school: and another 13% were high school teachers. The majority of teachers (53%) reported working in rural areas. Respondents ranged from ﬁrst year teachers to 32-year veterans; the average number of years respondents taught was 15 years.

The interview questions were split into 3 main categories: Background Questions, Essential Questions (which included subcategories of what attracts teachers to the profession, stressors, and attrition/solutions), and Closing Questions (see Appendix). These speciﬁc questions were formed from information gath-

ered from students’ literature reviews that were compiled together and then collectively agreed upon after lengthy class discussions. The Honors Sociology of Education class had several weeks of preparation in which students learned interviewing techniques to avoid asking leading or biased questions and how to add probes during interviews in order to encourage respondents to offer more thorough answers.

The interviews were recorded using a variety of web-based programs, automatically transcribed, and edited for accuracy. Using a grounded theory approach (Strauss, 1987; Strauss & Corbin, 1990), coding was conducted manually in a three-step process. First, each student researcher individually coded their interview by reading through the transcribed interview and highlighting main themes related to factors that attract and retain teachers in the profession, factors that contribute to attrition, and suggested solutions. Next, the student researchers worked in teams of ﬁve to ﬁnd common themes between their interviews. Finally, the class worked together as a group to narrow down the list of common themes and compiled a code book. The code book was used to categorize responses regarding contributors to teacher attrition, reasons teachers

chose to stay in the ﬁeld of education, and advice they had for improving the system.

Findings

Respondents identiﬁed stresses and challenges in the profession that parallel those found in the literature review. Teachers reported that unsupportive school leadership, lack of parental support, low pay, work overload, and burnout contribute to overwhelming stress and are factors that lead to teacher attrition.

Role of School Administration

One common theme the respondents referred to as a reason for teacher attrition is feeling unsupported by their administrators. Administrative support can be categorized into micromanaging, lack of respect, and “not having the teachers’ backs.” Micromanaging involves administration controlling every part of a teacher’s job instead of supporting the executive decisions teachers make in choosing their own teaching strategies and role in the classroom. This can be seen as being too supportive. Teacher 17 said, “… The support is actually leaving, leaving me alone and knowing that I'm doing my job and not micromanaging.” This teacher also commented that teachers

desire “that pat on the back” from their administrators, but in a school where micromanaging takes place, teachers do not receive this sort of support from their administration. Instead, they get told how to do their job and do not have the power or the freedom to teach their students the way they would like.

Furthermore, there is also a perceived lack of respect from the administration. Administrators have power over teachers, and this power, in turn, is experienced by some teachers as being abused in harmful ways which results in a feeling of disrespect. As Teacher 9 shared, sometimes administrators do not know how to talk to their teachers and use disrespectful tones and language that can lead to teachers to feeling less appreciated. Teacher 10 said,

Even our admin, they don’t treat us like we’re professionals; we are just another body in here and they can … act like they can ﬁll the spot. So, it’s just I don’t know why you wanna do it or why you gonna stay.

As this respondent indicated, teachers need to feel valued in order to stay in the career and withstand the many daily challenges they face. When teachers perceive a lack of professional respect from

their own administration, they feel they have less of a support system and are more likely to leave when things get tough.

Finally, teachers identiﬁed “not having their backs” as a type of lack of administrative support. Many of the teachers had similar statements to Teacher 6, who shared the feeling that “there’s not support for me personally.” Teacher 9 stated that teachers in her school felt like they had to tell their administrators “You need to back us, not the kids.” As these quotes illustrate, teachers expressed a need to feel their administration supports them, even though they acknowledged that this is not always the case. These responses suggest that not feeling comfortable with or supported by administration is a factor that could lead to teacher attrition. The responses also indicate the importance of quality leadership in schools to ensure other professionals and staff are acting appropriately and to run things in a way that creates a partnership with the teachers. For example, Teacher 2 stated, “The administration, chieﬂy the principal, sets everything else in motion… Good principals keep good teachers, bad principals burn us out.”

Lack of Parent Support

A second theme from our respon-

dents was a lack of support from parents. This can be split into two categories: parents who are not involved enough in their children’s education, and parents who are overinvolved. For example, Teacher 9 said, “It’s partially the school’s fault. They don’t really want the parents in the building, and I like having parents involved.” Parents who do not actively keep up with their children’s education, and school administrators who keep them from being involved, can be problematic when students start struggling with something or need to practice skills at home. In other schools, teachers face the opposite problem. Parents can interfere with the teachers trying to do their jobs by being overinvolved as illustrated by Teacher 17 who said, “Some people say that they’d want to work at an orphanage because kids have no parents and there will be nobody bothering them.” Teachers need a good balance where the parents are involved and care but also respect the authority of the teacher.

Low Pay

Almost every teacher respondent mentioned pay. Speciﬁcally, that it is too low for what they do. Teacher 4 said, “I think teachers are making at least 20,000 a year less than they should be, and that's a struggle.”

Teacher 13 remarked, "The pay is laughable at best.” Teachers mentioned that other careers are paid the correct amount for their level of professional training and degree requirements while also getting raises; they, however, are not. For example, Teacher 15 stated, “My husband makes double what I make, and he does half the work that I do, maybe even less than half.”

Some teachers, especially young and single teachers, are not making enough to support themselves and have to pick up second or even third jobs to make ends meet.

Teacher 7 said, “I have a second job because my salary does not pay for the loans that I had to take out for the degree that I had to have for my job.” Further, when starting a family, couples often select one parent to stay home and take care of the children, especially with the extremely high cost of childcare. Since teachers have such a low salary, they are usually the ones to stay home, leading to more teacher attrition. Teacher 2 illustrated this by saying, “But, if you have a household and you decide that one parent is going to stay home, you generally pick the parent that makes the least amount of money, and guess what, that is the teacher.”

work long hours, and still do not get paid enough to live comfortably alone. Teacher 6 said that they shouldn’t have a full-ﬂedged career and still need a roommate.”

Combined with the other stresses, the pay just is not enough to keep teachers from leaving the ﬁeld.

As Teacher 15 put it, “I don't want to discourage you, but if I could go back to school, I think I would have done something different just because of the pay honestly.”

Work Overload and Burnout

The amount of time teachers spend on their jobs is well over the seven hours in their contracted workday. Our respondents consistently said that they could not get everything done without working overtime, outside of school hours. Teacher 11 said, “Things get piled on you. But just know you are not going to be able to get [it] all done. You will have a continuous workload.” In addition to their classroom instruction, lesson planning, and grading, teachers must attend meetings and sometimes cover others’ classrooms. They also help children handle stress they bring from home.

Teachers have college degrees,

Teacher 4 explained, “It's less and less teaching, more and more parenting and counseling. We are not qualiﬁed for those positions. And it makes it harder and harder for us to

actually educate when we have to parent.” Their days are so busy that one teacher even reported she does not get the opportunity to hydrate or go to the bathroom.

To manage this tremendous workload, teachers stay late, go in early, or go to work on weekends. Teacher 6 reported going into work almost every weekend. Although they did not regret their decision, they acknowledged that this was “1000% not sustainable.” Furthermore, these job demands may affect teachers’ family life. Teacher 12 said, “A lot of teachers in my grade are working to have families and saying that they just can't do it and that the time commitment is impossible.” Teacher 7 agreed, stating, “It [schoolwork] all comes home with me. Like I don’t get it done during the day … I feel like they’re taking my purpose.”

Work overload and lack of worklife balance contribute to burnout. The stress, exhaustion, and frustration associated with burnout are evident in the following sentiments: It’s just not natural to do what we are asked to do on a daily basis for [so] long” (Teacher 5) and “A lot of it [teaching] is overwork. Just you know, I’m doing too much and I’m not getting enough back” (Teacher 16). Teacher 3 said, “I have told every single one of my children ‘don’t be

a teacher.’ Don’t be a teacher because it’s too hard. It’s too much stress.”

Solutions

Searching for solutions to teacher attrition can be challenging because the ongoing cycle of the teacher shortage contributes to increased teacher workload, burnout, and eventually more attrition. As Robbins (2023, p. 332) puts it, “Now American education is caught in a catch-22: To ﬁx the school system, we need more educators, but to attract more educators, the system must change.” Given the many, complex factors that contribute to attrition, there is no single solution; instead, a multifaceted approach is necessary to reduce attrition and increase retention (Garcia & Weiss, 2020). Suggestions for ways to reduce attrition point to actions that school leaders, teachers, and policymakers can take to make teaching a more desirable, rewarding profession.

What can school leaders do?

School administrators play an important role in retaining teachers. Teachers want to know that administrators trust, respect, and support them. Principals demonstrate trust and respect in teachers by not

micromanaging teachers’ work, giving them control over what happens in the classroom, listening to their ideas, and encouraging open communication. Furthermore, principals can support teachers by enforcing consequences for student misconduct and effectively addressing problems caused by parents and students (Robbins, 2023). Principals should emphasize to parents the importance of reinforcing education and teaching children behavior management skills at home and insist that parents communicate with their child’s teacher in a respectful and civil manner. As school leaders, principals should regularly remind parents that when they work in tandem with teachers, treating the relationship as cooperative rather than contentious, children receive a higher quality education (Ramos & Hughes, 2022).

Additionally, administrators have the power to allocate resources that can signiﬁcantly reduce teachers’ stress. One of the easiest and least expensive resources to provide teachers is time. School officials should ensure that teachers have enough protected school-day planning time to fulﬁll that job within their paid contracted school hours” (Robbins, 2023, p. 331). Administrators can increase time in the day for teachers to complete their

core responsibilities by creating a master schedule that allows time for teachers to regularly collaborate on lesson planning, replacing meetings with e-mails, assigning additional support staff to reduce tasks that do not directly involve teaching or supporting students (such as covering bus, cafeteria, and hall duties), offering individualized professional development days that give teachers the opportunity to work on their unique goals, and offering ﬂexible late arrival and early departure times for teachers to address family responsibilities (Anderson 2019; Handley & Donnelly, 2024; Tadros & Faulkner, 2023).

School leaders also need to ensure that teachers have the resources they need to teach their classes so that teachers do not have to spend their personal money on supplies. Furthermore, teachers need access to reliable technology for routine tasks such as taking attendance and scheduling meetings (Anderson, 2019). Experienced teachers are among the most valuable resources in a principal’s arsenal. As Teacher 2 explained,

[In teacher preparation programs] you only go into student teaching and all you do is teach. That is all you do. You do not go to all the committee meetings, you do not sit

in on the IEP meetings, you do not sit in on the grading, you do not have to do the parent communication, you do not have to do all those other things that are requirements of a teacher.

Administrators have a responsibility to connect new teachers to mentors who offer advice on how to manage these tasks, as well as how to effectively address student behavior, build lessons, achieve work-life balance, avoid burnout, and communicate assertively (Gull & Rush, 2024).

What can teachers do?

Although teachers are not responsible for ﬁxing macro-level problems in education, there are actions they can take to help avoid burnout. To keep a healthy balance between their professional and home life and to avoid work-overload, teachers should prioritize responsibilities, set clear boundaries between work and personal time, and be willing to be assertive when they simply cannot take on a task that has little impact on student outcomes (Education Support, 2024). As Teacher 4 explained, “The To-Do list is never going to be done. And you have to know that and quit trying [to ﬁnish it] and instead take care of yourself on weekends.” Other interviewees offered similar advice on how to

avoid burnout and achieve work-life balance. Teacher 17 said, “Make sure your home life is home. One of my personal goals every year is to hardly ever bring stuff home to grade.” Teacher 16 advised new teachers to “Honor your contract hours. It is hard not to take [work] home with you. Deﬁnitely try to have plans after work… [so you are] not just like staying after work and getting stuff done for ages.”

Teachers can reduce workload by developing lesson plans using shared online resources, AI, and collaboration with colleagues, rather than creating them from scratch (Education Support, 2024; Robbins, 2023). Taking care of personal well-being by maintaining time for hobbies, friends, and family, and reaching out for support when feeling overwhelmed is necessary to protect mental and physical health (Education Support, 2024). Finally, Robbins (2023) suggests that teachers maintain a sense of humor to keep perspective and diffuse stress.

What can policymakers do?

Policymakers can address the macro-level problems that contribute to the teacher shortage by improving teacher preparation programs and expanding creative recruiting and ﬁnancial strategies.

The recently released National Academy of Education (2024, p. 15) report states that teacher preparation programs (TPPs) are essential to “recruit, prepare, and retain a qualified and diverse teacher workforce, generating a supply of teachers that is responsive to demand to ensure that all students are taught by well-prepared, culturally responsive teachers.” Educational policymakers must ensure that TPPs provide teacher-candidates with knowledge of learners and learning, knowledge of subject matter and curriculum, and knowledge of teaching; skills in reflection, listening, curriculum design and instruction, observation, and analysis, and dispositions that influence the teacher-student relationship, such as empathy, cultural competence, and social-emotional capacities (National Academy of Education, 2024, p. 54).

One of the most effective ways to prepare teachers for the job is to strengthen teacher education programs to ensure that they have signiﬁcant experience in the classroom. As Teacher 1 explained,

Teacher prep programs do not show enough of what teaching is … . I would rather three credits of a college classroom go toward students being in a [K-12] classroom [where student teachers] see the day-today …, see how teachers are dealing

with it, see how the good teachers balance all of those things that are not part of teaching.

This teacher went on to suggest that college leaders and school district leaders could collaborate to establish a teacher preparation program in which student teachers participate in practicum for three years at the same school, being given progressively more experience and responsibility and “at the end of that you are hired. No interviews. No nothing.” They argued that such a program costs very little and would give schools “this great pool of teachers” who understood the demands of the profession. Whether this or another approach is adopted, it is essential that TPPs create educators who are likely to last in their career, resulting in less attrition.

High quality teacher preparation programs also emphasize recruiting a more diverse workforce. Currently, just 7% of public school teachers are Black and 9% of public school teachers are Hispanic–and even these low numbers are in danger of dropping” (Robbins, 2023, p. 332). With an overwhelming majority of teachers, especially in elementary school, being white women, the increasingly diverse classroom is not well represented by their teachers. Not only are students who can see

themselves reflected in their teachers more likely to perform better in school, but promoting diversity in the teaching profession can help draw in more teachers to the field, bringing with them differing points-of-view and cultures to which more students can relate (National Academy of Education, 2024). Teacher preparation programs that promote diversity, inform the public of the importance of representation in the field of teaching, and draw in future teachers from a variety of backgrounds improve the education students receive and lessen the teacher shortage.

Another way to recruit more teachers is through “Grow Your Own” (GYO) programs, which seek to recruit community members to teach in local public schools through partnerships between school districts, community-based organizations and colleges” (Wood, 2022, para. 3). The primary focus of most GYO programs is to introduce high school students to the teaching profession, although these programs also assist paraeducators, substitute teachers, and mid-career changers in gaining teaching licensure through an abbreviated certiﬁcation process (Cardoza, 2023; Wood, 2022). These programs can be successful in recruiting teachers

whose demographic characteristics reflect those of students in the community and increase the teacher workforce in general. However, studies show that teacher attrition rates of GYO-prepared teachers are generally higher than those of teachers who went through college programs because GYO participants generally have less coursework and fewer hours of student teaching than traditionally prepared teachers (CarverThomas & Darling-Hammond, 2019). The benefits of GYO programs in recruiting and retaining teachers can be improved by increasing the amount of student teaching and practice before sending professionals into the field (CarverThomas & Darling-Hammond, 2019).

Certainly, policymakers must address the dismal pay for teachers in many communities. Increasing teachers’ salaries obviously would make the profession more attractive and could slow attrition (Robbins, 2023). However, other ﬁnancial incentives such as scholarships and loan forgiveness programs can be developed or expanded as well. Scholarships make pursuing a teaching degree more attainable for a broader group of students. As Garcia (cited in Wood, 2022, para.16) explains, “By providing ﬁnancial assistance upfront,

teachers…are able to graduate with less debt, which is an important consideration given that in some states they may only be earning $40,000 a year starting out.”

Implementing policies like “Arizona State University’s Mary Lou Fulton Teachers College, which offers state-funded full-tuition scholarships to students who commit to teaching in the state for the number of years of their scholarship,” (Robbins, 2023, p. 332-333) would increase the number of educators and reduce the teacher shortage.

Loan forgiveness programs eliminate all or some student loan debt. While a few loan forgiveness programs for educators exist, they are quite limited (Carver-Thomas & Darling-Hammond, 2019). Expanding federal and/or state funding for loan forgiveness programs for educators would give teachers greater ability to live off their teaching salary without taking second jobs or being forced to have roommates to share rent. Furthermore, the opportunity for new teachers to receive loan forgiveness, no matter where they choose to teach, would encourage more people to enter the teaching profession and stay.

Implications and Conclusion

The teachers interviewed for this

study offered valuable insights into the factors that contribute to attrition and suggested important ways to improve the workplace for educators. The small, convenience sample used in this study limits the generalizability of the ﬁndings, although the challenges respondents reported mirror the existing literature. Additionally, with only 18 participants, we cannot make comparisons between different demographic groups, such as rural and urban teachers. Future research with large random samples of teachers would allow quantitative analysis of how variables such as race, ethnicity, gender, level of teaching experience, and school location affect teacher attrition. Since our study included teachers at all grade levels, we suggest additional studies gather more nuanced data comparing elementary, middle, and high school educators to offer targeted remedies for attrition. Finally, greater attention in research is needed to understand factors that contribute to teacher retention and professional commitment.

The key to reducing the teacher shortage is to understand the reasons teachers are leaving the ﬁeld in the ﬁrst place. This study pinpointed four reasons that a sample of 18 teachers argued factor into teacher attrition: problematic

school administration, lack of parental support, low pay, and work overload/burnout. These factors drive teachers away from the profession because they create additional demands on top of an already challenging and time-consuming job. As Teacher 12 explained, "Education is forever changing but sometimes when it changes it's not for the better of the teachers. They think that it's helping the students, but in reality it's causing the teachers more stress." Implementing changes such as strengthening school leadership, reducing teacher workload, offering strong mentoring programs, improving teacher preparation programs, increasing teacher pay, and devising ﬁnancial incentives could alleviate many of these stressors and foster greater workplace satisfaction. Teachers would then be free to focus on their passion: making an impact on their students’ lives.

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AI Statement

No AI tools were used in any portion of the research, writing, or editing of this paper.

Appendix

Interview Guide

Opening: Thank you so much for agreeing to be interviewed. As I explained before, the

students in the Honors Sociology of Education class I’m taking at Longwood University are interested in learning about your teaching experiences, the rewards and challenges. We want to better understand what attracts people to teaching, why some may choose to leave the profession, and ways to improve the teaching profession.

Background Questions

Tell me about your teaching career.

1. How long have you been teaching?

2. How long have you taught at your current school? Have you taught at other schools? If so, please tell me about where else you’ve taught.

3. What grade and/or subject(s) do you teach?

4. Where did you go to college? What did you major in?

5. Do you have additional degrees or certiﬁcations, endorsements, or licensures?

I’d like to hear about the characteristics of your school, including the community it’s located in and the students it serves.

1. Would you describe your school as rural, suburban, or urban?

2. What factors inﬂuenced your decision to choose to work at this school and what motivates you to stay?

Essential Questions

What attracts teachers to the profession? What is it like to be a teacher?

1. Why did you decide to become a teacher?

2. What does a typical work day look like from the time you get up until the time you go to bed? (Prompt: Can you describe some of the teaching responsibilities at your current school in addition to lesson planning and grading tasks, such as grade level or department chair, working on IEPs and 504 plans, attending meetings, and other paperwork?)

3. What do you ﬁnd most rewarding about teaching?

4. What do you ﬁnd most challenging about teaching?

Potential Stressors

1. Please describe the types of support that you receive from or would like to receive from administrators, colleagues, and parents that aid you in being the most effective and satisﬁed teacher.

2. How do you perceive your salary in relation to your workload as a teacher? To what extent, if any, do you believe teachers’ salaries affect teacher retention and attrition?

3. What advice do you have for how teachers can maintain a healthy work-life balance?

Attrition & Solutions

1. Based on your experience, what are some of the factors that inﬂuence teachers to leave the profession within your district?

2. Have you ever considered leaving the teaching profession?

a. If so, why?

b. If not, what factors keep you inspired to stay in the profession?

3. If you could change your job and/or the public's perception of teachers, how would you do it?

4. What would you suggest be done in order to attract teachers to the profession and to keep them from leaving?

Closing

Is there anything else you would like to share about being a teacher that I haven’t asked about?

The Treatment of Subacromial Impingement Syndrome with PlateletRich Plasma Injections Versus Exercise Therapy: A Critically Appraised Topic

Ainslie Allred and Sabrina Robles

Faculty Mentor: Jenn Cuchna, Ph.D.

Department

of Health, Recreation, and Kinesiology

Abstract

Clinical Scenario: Subacromial impingement syndrome (SAIS) can be caused by a compression of the ligaments in the shoulder, affecting the rotator cuff, scapula, and bursa, causing pain and loss of function. Platelet-rich plasma (PRP) injections use a patient’s own plateletconcentrated growth factors to aid in tissue healing, pain reduction, and improve range of motion. Physical or exercise therapy can help rehabilitate the shoulder through strengthening exercises, thermal therapeutic modalities, and stretching. Clinical Question: In patients with shoulder impingement syndrome, do platelet-rich plasma injections decrease pain levels more effectively and efficiently than tra-

ditional physical therapy? Summary of Key Findings: Four articles met the inclusion and exclusion criteria and investigated PRP injections and/or exercise therapy as a treatment for SAIS. Three studies compared PRP injections to physical or exercise therapy, and one study investigated PRP injections with exercise as a valid treatment for SAIS. All articles supported the use of PRP injections combined with an exercise protocol. Clinical Bottom Line: There is moderate evidence to support the use of PRP injections in conjunction with exercise therapy in the treatment of SAIS. Strength of Recommendation: The grade of B is based on the Strength of Recommendation Taxonomy.

Clinical Scenario

Shoulder impingement syndrome, or more accurately, subacromial impingement syndrome (SAIS), is caused by a compression of the rotator cuff ligaments and tendons in the space between the humeral head and the acromion, acromioclavicular joint, and coracoacromial ligament (Horowitz & Aibinder, 2023). SAIS comprises 48% of all shoulder complaints, being the most common shoulder disorder (Dhillon, 2019). SAIS can occur in a variety of ways resulting from structural issues in the bursa, rotator cuff, or acromioclavicular joint, or from functional issues with weakness of the rotator cuff and scapula (Escamilla et al., 2014). The condition presents with pain in the anterolateral acromion area and can travel down to the mid-humerus, often felt at night due to pressure on the shoulder or when reaching overhead (Koester et al., 2005). Management of the condition is usually conservative: physical therapy, pain relief through non-steroidal anti-inflammatory drugs, and corticosteroid injections are the most popular options (Koester et al., 2005). Most treatments surround pain management and recovery of function and strength, but newer treatments such as platelet-rich plasma injec-

tions may offer a new approach to improving pain and mobility.

Platelet-rich plasma (PRP) consists of a collection of growth factors involved in the tissue repair process that are shown to accelerate healing when the platelet concentration is at least 1,000,000 platelets/μL in 5 mL of plasma (Foster et al., 2009). Clinical studies have been carried out on PRP usage in a variety of orthopedic conditions, especially ones relating to chronic tendinopathies and acute ligamentous and muscle injuries (Foster et al., 2009). PRP can be helpful in reducing pain and improving range of motion in shoulder impingement patients who experience rotator cuff tendinopathy and ligamentous issues (Nejeti et al., 2017). PRP could improve healing by decreasing disability levels for patients with shoulder impingement syndrome when compared to conservative physical therapy alone.

Non-operative rehabilitation programs can focus on rehabilitating the primary structure causing pain in the shoulder through rest, strengthening muscles and tendons to reduce wear, and regain pain-free mobility. Clinicians can personalize treatment plans for patients and target the individual problem structures as well as focus treatment on

patient-speciﬁc goals (Escamilla et al., 2014). Using a variety of treatment types could offer a more wellrounded treatment that produces better outcomes for patients. Horowitz and Aibinder reference a protocol that uses a combination of 5 categories of treatment (2023). Within this physical therapy rehabilitation protocol, modalities include heat and cold, joint and soft tissue mobilization through manual therapy, range of motion exercises focusing on the glenohumeral joint and scapula, ﬂexibility exercises through stretching, and strengthening of the rotator cuff and stabilizing scapular muscles (Horowitz & Aibinder, 2023). An analysis is needed to determine if PRP injections are more effective than physical therapy in treating subacromial impingement syndrome.

Focused Clinical Question

In patients with shoulder impingement syndrome, do platelet-rich plasma injections decrease pain levels more effectively and efficiently than traditional physical therapy?

Summary of Search, “Best Evidence” Appraised, and Key Findings

• A literature search was conducted

to locate studies with level II evidence or higher that investigated the effect of PRP when included in conservative treatment programs for patients with SAIS.

• A total of 5 studies were found during the initial search, with 4 being included in the ﬁnal analyses.

Out of the 4 studies, 3 were randomized controlled trials (Pasin et al., 2019; Nejati et al., 2017; Ziroglu & Sahbaz, 2024) and one was a prospective interventional study (Saurav et al., 2022).

• Of the 3 randomized controlled trials, 2 studies earned a Physiotherapy Evidence Database (PEDro) score of 6/10 (Pasin et al., 2019; Nejati et al., 2017) and one earned a 5/10 (Ziroglu & Sahbaz, 2024).

All 3 studies compared PRP injections included in conservative treatments to conservative treatments without PRP.

• The prospective interventional study received a 19/22 on the Strengthening the Reporting of Observational studies in Epidemiology (STROBE) checklist (Saurav et al., 2022).

• Pasin et al., (2019) compared PRP injections, corticosteroid injections, and physical therapy over an 8 week period and found that PRP

injections were more effective in reducing pain and disability level. PRP injections were also more effective in the long period for treating SAIS.

• Nejati et al., (2017) compared PRP injections and exercise therapy with follow-ups at the 1, 3, and 6-month period and found that both treatments reduced pain, increased range of motion (ROM), and increased shoulder function. Both treatments showed improvement but exercise therapy proved to be more effective in the outcomes measured in the 1st and 3rd months.

• Ziroglu & Sahbaz (2024) implemented an 8-week exercise therapy (ET) program where one group received 2 separate PRP injections and one completed the isolated ET. The ET focused on shoulder ROM, stretching, and shoulder strengthening. The PRP injections were given 3 days prior to the start of the ET and again after 4 weeks. Both isolated ET and the combination of PRP and ET were effective at treating SAIS in relation to pain, function, and quality of life. Combining ET with PRP was superior at decreasing resting and night pain, increasing shoulder abduction and forward ﬂexion , and increasing the degree of shoulder abduction.

• Saurav et al., (2022) included patients who had clinically diagnosed SAIS and failed to respond to conservative treatment receive a PRP injection. Patients followed up the injection with shoulder active ROM exercises and then rotator cuff strengthening exercises, with a follow up at 6 and 12 weeks. From pre to post injection, there was a decrease in visual analog scale (VAS) and Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) scores, as well as an increase in shoulder ﬂexion and abduction. PRP injections in combination with ET can signiﬁcantly reduce pain, improve ROM, and improve overall function in patients with SAIS.

Clinical Bottom Line

There is moderate evidence to support the use of PRP injections in conjunction with ET in the treatment of SAIS. Most evidence suggests that PRP injections are more effective in reducing pain in patients with SAIS. There is some contradicting evidence that suggests isolated ET is more effective; however, PRP injections were still effective as a treatment.

Strength of Recommendation

There is “grade B” evidence that ET combined with PRP injections provides greater improvements in pain for those diagnosed with SAIS over isolated ET in accordance with the Strength of Recommendation Taxonomy (Ebell et al., 2004).

A grade of “A” suggests strong evidence, a “B” suggests moderate evidence, and a “C” suggests weak evidence in support of the clinical question. A grade of B was decided as all four studies determined that PRP injections were effective in treating SAIS, despite one study concluding that ET was equally effective, since PRP injections were still concluded as a valid treatment. This grade was assigned to the evidence presented as limited published comparisons of the two treatments are available.

Search Strategy

Terms Used to Guide Search Strategy

• Population: men or women diagnosed with shoulder impingement syndrome, subacromial impingement syndrome

• Comparison: conservative physical or exercise therapy with no PRP injection

• Outcome: pain

Sources of Evidence Searched

• Google Scholar

• PubMed

Inclusion and Exclusion Criteria

Inclusion Criteria

• Studies that looked at PRP injections and/or physical or exercise therapy in patients with SAIS

• Studies that included patients diagnosed with SAIS

• Studies with pain as an outcome measure

• Level 2 evidence or higher (2009 CEBM)

• Studies within the last 10 years (2015-2024)

• Limited to English Language

Exclusion Criteria

• Intervention: platelet-rich plasma injection

• Studies that did not include PRP injections

• Studies looking at shoulder pathologies that were not SAIS

Results of Search

A total of four relevant studies were located and categorized as shown in Table 1 (based on the Oxford Centre for Evidence-Based Medicine (2009)).

Summary of Studay Designs of Included Articles

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Best Evidence

The studies in Table 2 were identiﬁed as the best evidence in accordance with our predetermined inclusion and exclusion criteria for this critically appraised topic. These studies were selected because they were all level 2 evidence or higher, used pain as at least one of their outcome measures, and/ or compared conservative rehabilitation therapy with PRP injections for SAIS.

Table 1

Implications for Practice, Education, and Future Research

The aim of this CAT was to determine if the combination of PRP injections with ET has greater pain reduction in patients with SAIS versus isolated ET. The 4 studies examined in this CAT present slightly conﬂicting evidence regarding the superiority of the effect of PRP injections on SAIS (Pasin et al., 2019; Nejati et al., 2017; Ziroglu & Sahbaz, 2024; Saurav et al., 2022). Two of the articles showed superiority of the combination of PRP injections with ET compared to ET alone, with PRP injections being more effective at decreasing pain, improving ROM and functionality, and decreasing disability (Pasin et al., 2019; Ziroglu

& Sahbaz, 2024). However, it is important to note that out of these two studies, one did not provide information on the number of participants that completed the study and completed all follow up assessments post-injections (Pasin et al., 2019). One study showed equality between PRP injections and isolated ET, with PRP injections showing no signiﬁcantly greater improvement over ET alone (Nejati et al., 2017). However, the PRP patients did not participate in exercise therapy for 6 months after both injections were administered. The fourth study, a prospective interventional study, gives further evidence to support the use of PRP injections in SAIS treatment to combat the conﬂicting

evidence presented (Saurav et al., 2022).

Despite the conﬂicting and limiting existing evidence, it can be determined that PRP injections have value in treating SAIS as compared to ET alone. Although one study showed a lack of superiority of PRP in reducing pain, the evidence still supported that PRP injections were effective in reducing pain and other outcome measures, just with a lack of greater impact over ET alone (Nejati et al., 2017). Regardless, all studies suggest attempting ET alone before utilizing PRP injections in treatment due to risk and costs associated with the injections (Pasin et al., 2019; Nejati et al., 2017; Ziroglu & Sahbaz, 2024; Saurav et al., 2022). Isolated ET should be attempted and completed without signiﬁcant improvements before PRP is used in conjunction.

Furthermore, the articles in this appraisal have limitations in both generalizability and method of PRP injection administration. It is important to note the inconsistencies in PRP protocol across studies, as well as the ET program duration, including number of injections, amount of PRP per injection, amount of time between injections, and amount of time between injections and ET. In Pasin et al (2019), researchers

took 8.5 mL of blood to produce 4 mL of PRP which was injected and then followed by 8 weeks of an exercise protocol. Nejati et al (2017) administered two injections, once at the beginning of the study and the second injection 1 month after the ﬁrst injection. Researchers collected 25 mL of blood to produce 5 mL of PRP, with 1 mL being used for platelet counting and 4 mL for the injection (Nejati et al., 2017). PRP

injection patients then did not participate in exercise therapy for 6 months. In Ziroglu & Sahbaz (2024), 2 PRP injections were given, the ﬁrst being 3 days prior to the ET program and the second being after 4 weeks. For these injections, 10 mL of blood was taken and centrifuged once for 8 minutes, with 5-6 mL of PRP being injected. The ET program lasted a total of 8 weeks. In Saurav et al (2022), one PRP injection was given before the ET program was started. For these injections, 7.5 mL was taken and centrifuged twice for 10 minutes, with 2 mL of PRP being injected. There was no information provided on the lengthen of the ET program.

Further research should be conducted on the effectiveness of PRP injections for the treatment of SAIS over extended periods of time. Research should focus on looking at SAIS across all demographics and

the effectiveness of PRP injections in large study groups. Extended follow-up times should also be considered, as long-term effects of PRP injections are unclear. Increasing follow up times to up to a year allows for investigation of the longterm effects on muscle health, maintenance of functionality, and to identify any possible long term adverse effects. Future research should aim to develop a standardized protocol for PRP injections in relation to SAIS, including number of injections, amount of PRP per injection, and amount of time between injections. In addition, there should be a standardized ET program that follows PRP injections that is utilized across studies to help determine true effectiveness and superiority of PRP injections.

The evidence suggests that PRP injections are most effective when administered in conjunction with ET, so clinicians should consider adding PRP injections to their patient’s ET treatment protocol to better reduce pain in patients with SAIS. While not all the studies compared PRP injections with ET or physical therapy, all of the studies did ﬁnd PRP injections to be effective. Our clinical recommendation is to administer PRP injections with ET, only after isolated ET proves to be ineffective or lacks the improvements

the patient desires. However, clinicians should also consider the cost and possible risk of complications that comes with injections of any kind and educate the patient about all effective treatment options. This CAT should be reviewed in 2 years to determine if additional best evidence has been published that can aid in answering this clinical question.

References

Dhillon, K. S. (2019, November). Subacromial impingement syndrome of the shoulder: A musculoskeletal disorder or a medical myth?. Malaysian Orthopaedic Journal, 13(3), 1–7. https://doi.org/10.5704/MOJ.1911.001

Ebell, M. H., Siwek, J., Weiss, B. D., Woolf, S. H., Susman, J., Ewigman, B., & Bowman, M. (2004, February). Strength of recommendation taxonomy (SORT): A patient-centered approach to grading evidence in medical literature. The Journal of the American Board of Family Practice, 17(1), 59-67. https://doi.org/ 10.3122/jabfm.17.1.59

Escamilla, R. F., Hooks, T. R., & Wilk, K. E. (2014, February 28). Optimal management of shoulder impingement syndrome. Open Access Journal of Sports Medicine, 5, 13–24. https://doi.org/10.2147/OAJSM.S36646

Foster, T. E., Puskas, B. L., Mandelbaum, B. R., Gerhardt, M. B., & Rodeo, S. A. (2009, November). Platelet-rich plasma: From basic science to clinical applications. The American Journal of Sports Medicine, 37(11), 2259–2272. https://doi.org/10.1177/ 0363546509349921.

Horowitz, E.H. and Aibinder, W.R. (2023, May). Shoulder impingement syndrome. Physical Medicine & Rehabilitation Clinics, 34(2), 311-334. https://doi.org/10.1016/ j.pmr.2022.12.001

Koester, M.C., George, M.S., and Kuhn, J.E. (2005, May). Shoulder impingement syndrome. The American Journal of Medicine, 118(5), 452-455. https://doi.org/10.1016/ j.amjmed.2005.01.040

Nejati, P., Ghahremaninia,A., Naderi, F., Gharibzadeh, S., & Mazaherinezhad, A. (2017, May). Treatment of subacromial impingement syndrome: Platelet-rich plasma or exercise therapy? A randomized controlled trial. Orthopaedic Journal of Sports Medicine, 5(5) 1-9. https://doi.org/10.1177/23259671177 02366.

Pasin, T., Ataoğlu, S., Pasin, Ö., & Ankarali, H. (2019, March 28). Comparison of the effectiveness of platelet-rich plasma, corticosteroid, and physical therapy in subacromial impingement syndrome. Archives of Rheumatology, 34(3), 308–316. https://doi.org/ 10.5606/ArchRheumatol.2019.7225

Saurav, S., Aggarwal, A. N., Shahi, P., Kamal, S., Bansal, K., & Singla, S. (2022). Efficacy of single injection of platelet-rich plasma in shoulder impingement syndrome. Cureus, 14(6), e25727. https://doi.org/10.7759/ cureus.25727

Ziroglu, N., & Şahbaz, Y. (2024, October 8). Clinical effects of additional platelet-rich plasma application to exercise therapy in patients with subacromial impingement syndrome: A double-blind randomized controlled trial. Orthopaedic Journal of Sports Medicine, 12(10), 1-9. https://doi.org/10.1177/ 23259671241276368

AI Statement

The authors declare that no AI was used in the writing of “The Treatment of Subacromial Impingement Syndrome with Platelet-Rich Plasma Injections Versus Exercise Therapy: A Critically Appraised Topic.”

Reassessing Spinosaurus aegyptiacus: Evolutionary, Dietary, and Ecological Insights From Recent Findings

Nicholas J. Duellman

Faculty Mentor: Richard Franssen, Ph.D.

Department of Biological & Environmental Sciences

Abstract

Spinosaurus aegyptiacus, a large theropod from the late Cretaceous, has been the subject of recent paleontological debate. This paper discusses multiple aspects of the evolution of Spinosaurus aegyptiacus, the ongoing taxonomic debate surrounding Spinosaurus aegyptiacus, and the phylogeny of Spinosauridae. This paper also examines the debated synonymous taxa within the Spinosaurus genus. Additionally, the dietary habits of S. aegyptiacus are examined, revealing adaptations that indicate a piscivorous diet, supported by unique dental structures. Furthermore, the current biomechanical debates are outlined, contrasting the "aquatic pursuit predator" model with the

emerging hypothesis of a "wading ambush predator." As research progresses, the understanding of S. aegyptiacus will evolve further, as evident with the reconstruction and ecological understanding from information in the past three decades. Paleontologists have debated the ecological nature of spinosaurids since the discovery of Spinosaurus aegyptiacus a century ago. The emergence of fossil evidence and research from the past 30 years has driven the paleontological community to accept Spinosaur ecology as that of both terrestrial and semi-aquatic.

Introduction

Spinosaurus aegyptiacus is a large theropod from the late Cretaceous

within the family Spinosauridae. It is estimated that Spinosaurus grew to a maximum length of 14 meters and a body mass of 7.4 tons (Sereno et al., 2022). The Spinosauridae family is generally classiﬁed by conical teeth, longer snouts, proximal orbital-nare, and respectively longer neural spines (Ibrahim et al., 2014, Rayﬁeld et al., 2007, William & Richard, 2017). Since the discovery of Spinosaurus aegyptiacus in 1915 by Dr. Ernst Stromer in the Bahiriya formation in Egypt (Stromer, 1915), there has been much paleontological debate about the nature and ecology of Spinosaurus and its relatives. Recent paleontological discoveries emerging within the past three decades have spawned new debate surrounding the ecology of Spinosauridae. The current understanding of Spinosauridae is that it was riparian, ranging from terrestrial to semi-aquatic depending on genera.

Spinosauridae had a wide distribution, with fossils discovered in North Africa, Iberia, England, South America, and Southeastern Asia (Allain et al., 2012, Barker et al., 2021, Buffetaut et al., 2002, Mateus et al., 2022, Rauhut et al., 2019, Sereno et al., 1998). Paleontologists have developed arguments on the ecology, phylogeny, and biomechanics of Spinosaurids, despite a fragmented

fossil record. However, this has spawned a new international debate surrounding the ecology of Spinosaurus aegyptiacus — “shallow water wading” versus “aquatic pursuit predator.” Most recent evidence suggests that Spinosaurus aegyptiacus suits the “shallow water wading” ecological theory as opposed to the debated “aquatic pursuit predator” hypothesis.

Phylogeny

Classiﬁcation of Spinosaurs has been difficult due to a fragmented and shallow fossil record. This has in turn made phylogenic reconstruction equally if not more difficult for paleontologists. It is accepted that Spinosauridae family is subdivided into two clades, Baryonchinae and Spinosaurinae. Within this subdivision, these subgroups are classiﬁed by the differences in their dentary composition. Spinosaurinae have straight conical teeth and Baryonychinae have more teeth, which are slightly curved compared to those of Spinosauridae (Serrano et al., 1998, Figure 1). Spinosauridae is most closely related to Megalosauridae, another family of large theropods.

Paleontologists have identiﬁed two Spinosaurus species, those being Spinosaurus aegyptiacus and

S. marocannus, both of which were discovered in North Africa. In addition, two separate species of Spinosaurids have been identiﬁed, Sigilmassasaurus brevicollis and Oxalaia quilombensis. Advanced genetic analysis has opened debate over whether these species are synonymous with Spinosaurus aegyptiacus (Kellner et al., 2011, Evers et al., 2015, Taquet & Russell, 1998, Russel, 1996). Paleontologist Serjoscha Evers and his team examined Dale Russel’s 1996 publication, “Isolated Dinosaur bones from the Middle Cretaceous of the Taﬁlalt, Morocco,” in which he described two species

of Spinosaurids: S. marocannus and Sigilmassasaurus brevicollis. In 2015, Evers published a reassessment of the Russel paper: “A reappraisal of the morphology and systematic position of the theropod dinosaur Sigilmassasaurus from the ‘middle’ Cretaceous of Morocco” and suggested that these two species are in fact the same species, with reappraisal of dorsal and cervical vertebrae supporting Evers’ claims (Figure 2). Paleontologist Robert S. H. Smyth and his team published their reassessment, which further builds upon Evers et al., arguing the complete rejection of Oxalaia

Ecology

Paleontologists Alan Charig and Angela Milner ﬁrst described Baryonyx walkeri in 1986 and later theo-

(Kellner et al., 2011), stating that Sigilmassasaurus and Oxalaia are synonymous with Spinosaurus aegyptiacus. Smyth further suggested a review of all autapomorphies within Spinosaurs, arguing that discoveries should attempt to link into declared species, rather than paleontologists attempting to declare a species of a fragmented tooth fossil. The paper also suggested Oxalaia and Spinosaurus aegyptiacus supported the theory of Cretaceous faunal interchange between North Africa and South America.

rized it to be a piscivorous dinosaur in 1997, suggesting it was “living in the vicinity of a sub-tropical delta.” The anatomical structure of the skull shape, conical teeth, and elongated premaxilla and maxilla supported the piscivorous diet theory even further. Baryonyx walkeri was found in the Wessex Formation in England, the same formation where additional taxa were discovered, Ceratosuchops inferodios and Ripovenator milnerae, which share similar anatomical features (Barker et al., 2021). Spinosaur fossil remains suggest a generalist diet, with ranges from terrestrial herbivores, prehistoric ﬁsh and sharks, and pterosaurs (Buffetaut et al. 2004). Conical teeth and elongated jaw bones support snatching and piercing prey, as opposed to other theropod teeth, which suggest cutting and ripping with blade-like teeth. Furthermore, S. aegyptiacus is theorized to have been a niche predator, evolved to have specialized uneven teeth distributions in the premaxilla, maxilla, and dentary (William & Richard, 2017).

Spinosaurus aegyptiacus lived in the late Cretaceous, in modern day Morocco, which suggests the Spinosaurids potentially evolved to suit the semi-aquatic niche. This development into a semi-aquatic niche is further supported with specialized

anatomical adaptations for hunting prey. Late Cretaceous Morocco was generally a coastal swampy wetland ecosystem, home to several large herbivorous hadrosaurs and sauropods. Two large apex predators roamed this ecosystem as well, Spinosaurus and Carcharodontosaurus (Ibrahim et al., 2020). Carcharodontosaurus saharicus possessed serrated teeth as opposed to conical teeth and could reach 12.5 meters long (Figure 1). Paleontologist Nazir Ibrahim and his team described the paleoecology of the Kem Kem formation in Eastern Morocco where S. aegyptiacus and other sympatric theropods have been uncovered, noting that numerous ﬁsh fossils and potential brackish-freshwater ﬂoodplain deposits allowed for such diversity surrounding piscivorous behavior (Ibrahim 2020, Cavin et al., 2010).

The premaxilla and dentary of S. aegyptiacus and other spinosaurid taxa are convergent to the Pike Conger, as described by Romain Vullo and his team in 2016, further suggesting a piscivorous diet. Vullo suggests that the derived traits such as elongated rostrum, deep notch posterior to the premaxilla, and heterodonty and enlarged teeth indicate similar feeding behaviors (Figure 3). Vullo describes how these derived traits are not

exhibited in their sister groups, which share much less specialized characteristics. The derived traits suggest feeding kinetics that are suited for piercing prey, further providing evidence towards the suggested theory of riparian lifestyle and dominantly piscivorous behavior in S. aegyptiacus.

The Papo Seco and Wessex formations (Portugal and England) where Iberospinus and B. walkeri remains have been discovered further support the development of S. aegyptiacus specialization. These discoveries predate S. aegyptiacus by roughly 30 million years, however similar patterns of behavior and anatomy are present in these discoveries. Paleontological and sedimentation analysis indicate Papo Seco to have been an open estuary, supported further by ﬁsh

fossil remains appearing proximal to Iberospinus (Figueiredo et al., 2023). The Wessex formation has additionally been indicated to have been a mixture of ﬂood plain and ﬂuvial environment, as evident by sedimentation analysis of the early Cretaceous, with low productivity unable to support large herbivorous species (Insole & Hutt, 1994). Despite their distant relative relation to S. aegypaticus, the fossil evidence and paleoecology of B. walkeri and Iberospinus support the early development of the specialized ecological niche that S. aegypaticus possessed.

Current Debate Surrounding

Spinosaurus aegyptiacus

In 2014, a team of researchers, consisting of Paul Sereno, Nizar Ibhrahim, Matteo Fabbri, David Martill,

and Nathan Myhrvold published a paper titled, “Semiaquatic adaptations in a giant predatory dinosaur”, supervised by Dawid Iurino at the University of Rome. The team reported their ﬁndings from a partial S. aegyptiacus skeleton from the Kem Kem formation from the late Cretaceous. They examined the skull, axial column, pelvic girdle and limbs, with missing bones extrapolated, tomography scans performed on neotype, and isolated Spinosaurus aegyptiacus bones combined with computer models of the 1915 Stromer holotypes. This paper reconstructed S. aegyptiacus to be approximately ﬁfteen meters long. Skull analysis revealed concentrated neovascular foramina which housed pressure receptors, synonymous with crocodilians, hypothesized to facilitate detection of movement in water.

In this paper, the team described procumbent interlocking teeth and hypothesized the utilization for predating on fish. The horizontal cervico-dorsal hinge was hypothesized to facilitate better head and neck movement, contributing to specialized hunting patterns. Short centra and neural arch articulations were described to facilitate powerful tail movement, which is found in extant species of bony fish. Spinosaurus aegyptiacus was believed to have a lower center of mass, requiring forearms for terrestrial movement. Lengthened pedal digits and flattened ungual, like non-perching shorebirds, facilitated the hypothesis towards swimming capability. The paper also cited a 2014 paper (Amson et al.) describing the gradual shift of bone density of aquatic lifestyles in extinct sloths, with 40% higher bone density increase in

Spinosaurus aegyptiacus compared to other theropods.

The current debate on Spinosaurus aegyptiacus behavior began in 2022, with paleontologist Paul Serrano leading a team of researchers that included Nathan Myhrvold. This publication was in response to two years of publications from paleontologists Nizar Ibrahim, David Martill, and Matteo Fabbri who continued the hypothesis supporting the aquatic pursuit predator model. Ibrahim and his associates continued to publish about tail locomotion, subaqueous foraging, and taphonomic evidence in support of the pursuit predator theory (Beevor et al., 2021, Fabbri et al., 2022, Ibrahim et al., 2020). Serrano’s 2022 publication, Spinosaurus is not an aquatic dinosaur, rejected the past two years of Ibra-

him's research, addressing the aquatic hypothesis and claiming that their analysis had gaps. Sereno postulates that evidence suggests S. aegyptiacus was as a “bipedal ambush piscivore.” Sereno developed a 3D model and mathematically showed that S. aegyptiacus could not have produced enough force to dive and indicating other biomechanical issues which would prevent it from living the lifestyle suggested by Ibrahim in a 2020 publication (Ibrahim et al., 2020). He showed that Spinosaurus aegyptiacus could wade in shallow water and bipedal on land, with its forearms not being used. Sereno argued that Spinosaurus aegyptiacus fossil remains have been found in two inland basins, far from a marine coastline and compared it to both extinct and extant secondary aquatic vertebrates. Serreno ﬁnally

concluded with phylogenetic analysis supporting the “bipedal ambush piscivore” theory, with the earliest spinosaurids having piscivorous adaptations. Sereno’s paper agrees with the same general understanding that paleontologist Hone and Thomas R. Holtz published in 2021, citing that Spinosaurus aegyptiacus ambushed large ﬁsh within riverine and shallow coastal waters.

Conclusion

Paleontologists have debated the ecological nature of spinosaurids since the discovery of Spinosaurus aegyptiacus nearly a century ago. Fossil evidence and research from the past 30 years has pushed the paleontological community to widely accept a mixed terrestrial and semi-aquatic lifestyle and spawned a new international debate surrounding the ecology of Spinosaurus aegyptiacus. It seems that Spinosaurus aegyptiacus ﬁts the “wading shallow water ambush predator” ecological theory as opposed to the debated “aquatic pursuit predator” theory. Spinosaurus aegyptiacus was initially described over a century ago, and the past three decades of paleontological development has led to reopened debate and new understanding of the paleoecology and phylogeny of

Spinosaurus aegyptiacus. Spinosaurus aegyptiacus was a large piscivorous theropod from the Late Cretaceous, living in present day North Africa. The palaeoecological reconstruction has shifted from a terrestrial theropod to a semiaquatic theropod, and debate stems further into behavior and hunting strategies of the species. Paleontological evidence suggests Spinosaurus lived as an ambush predator along the riverbeds and coastlines of the late cretaceous North Africa. Additionally, paleontological discoveries and computational rendering developments will only continue to further this debate. Paleontologists Sean Smart and Manabu Sakamoto suggest that further research regarding post cranial data, dentary classiﬁcation, and phylogenetic analyses of Spinosaurus are potential further investigations. The paleontological debate surrounding the ecology of Spinosaurus is unique, and it signiﬁes how fossil discoveries truly drive paleontological studies. The understanding of Spinosaurus is limited, even with advanced technologies and teams of researchers debating every intricate detail of this animal. Paleontologists are left with the limited available fossil records until future discoveries are made. Spinosaurus represents a specialized animal which evolved slowly over time to

adapt to the changing ecosystem of the late Jurassic to the late Cretaceous, with S. aegyptiacus representing the culmination of evolutionary traits adapted for a piscivorous lifestyle.

References

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Barker, C.T., Hone, D.W.E., Naish, D., Cau, A., Lockwood, J.A.F., Foster, B., et al. 2021. New spinosaurids from the Wessex Formation (Early Cretaceous, UK) and the European origins of Spinosauridae. Scientiﬁc Reports 11: 19340.

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Fabbri, M., Navalón, G., Roger, Pol, D., O’Connor, J., Bhullar, B.S., et al. 2022. Subaqueous foraging among carnivorous dinosaurs. Nature 603: 852–857.

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Hone, D.W.E. & Thomas R. Holtz, J. 2021. Evaluating the ecology of Spinosaurus: Shoreline generalist or aquatic pursuit specialist? Palaeontologia Electronica 24: 1–28.

Ibrahim, N., Maganuco, S., Dal Sasso, C., Fabbri, M., Auditore, M., Bindellini, G., et al. 2020. Tail-propelled aquatic locomotion in a theropod dinosaur. Nature 581: 67–70.

Ibrahim, N., Sereno, P.C., Dal Sasso, C., Maganuco, S., Fabbri, M., Martill, D.M., et al. 2014. Semiaquatic adaptations in a giant predatory dinosaur. Science (New York, N.Y.) 345: 1613–1616.

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AI Statement

In the development of “Reassessing Spinosaurus aegyptiacus: Evolutionary, dietary, and ecologocial insights from recent ﬁndings” for Incite, artiﬁcial intelligence (AI) tools were not used.

Regulation of the Funeral Home Industry and White-Collar Crime

Trinity L. Deguzman and Melissa H. Savage

Faculty Mentor: Virginia R. Beard, Ph.D.

Department of Sociology, Anthropology, and Criminal Justice

Abstract

This paper examines the impact of institutional and industrial level factors on the incidence and prevalence of white-collar crimes in the funeral industry. The analysis of 21 cases of criminal offenses in the funeral home industry between the years of 1987 and 2024 highlight patterns of improper body disposal, embezzlement, forgery, and illegal organ harvesting. Most offenses occurred in small family-owned businesses. Crimes were typically uncovered as a result of customer complaints, not as a result of regular inspections and monitoring by the state. It can be noted that regulation in the United States is poor and that acts are more often motivated by individual gain than business gain. Finally, the paper concludes by recommending avenues for future research and

suggestions for regulatory changes in the industry.

Introduction

Practices within the funeral industry have become a topic of concern due to the ethical and criminal violations that have occurred. Convictions discussed in research have found instances of improper disposal of remains, exploitation of vulnerable consumers, failure to provide consistent pricing, and improper handling of bodies. Criminal practices by funeral homes can include exploitation of vulnerable customers, failure to provide consistent pricing, and improper handling of bodies. In the Sunset Mesa Funeral Home case, a mother and daughter stole and sold bodies over the course of 10 years reaching a total of 560 victims. Over the years they developed a donor

service to sell human remains resulting in the improper disposal of bodies by the funeral home (U.S. Attorney’s Office, District of Colorado, 2023). The funeral home industry in the United States provides families with essential services during one of the most sensitive times in their lives. Like other businesses and industries, the funeral home industry has regulations in place that ensure ethical practices and protect customers. While federal and state regulations like the Funeral Rule enforced by the Federal Trade Commission (FTC) aim to address these issues, inconsistent enforcement restricts consumer protection and ethical compliance. Further, signiﬁcant variation among state laws and regulations leads to inconsistent oversight geographically. This paper seeks to conduct an exploratory study of the intersections of white-collar crime and the funeral industry as it is related to the regulatory methods of industry control and to situate the ﬁndings within the industrial and institutional theories of business crimes.

Literature Review

Funeral Home as a Business and Crime within the Business

The funeral industry is a commercial business in the United States that

operates with the goal of economic profit. As research notes, funerals represent the third greatest expenditure in an individual's life (Beard & Burger, 2017; Beard & Burger, 2020; Gottschalk, 2019). In recent decades, social and economic forces have changed the funeral home industry, moving significantly towards more cremations and fewer traditional funerals. In 2024, the average cost of the traditional funeral, including embalming, viewing, casket, and burial was noted as $8,300.00, where the average cost of cremation was $6,280.00 (National Funeral Directors Association, 2024). Because of the cost difference and the social and economic changes, more individuals are opting for cremation as a method of body disposal. In 2015, 46% of all body disposals were through cremation (Beard & Burger, 2020). By 2045, it is projected that around 80% of disposals will be cremations (National Funeral Directors Association, 2024). As a result of these market changes in the industry, funeral homes must modify their business plan to avoid economic decline or closure. This can be challenging, and while many funeral homes have innovated in pro-social ways to address the market changes (Beard & Burger, 2017), others have adopted deviant, fraudulent, and criminal activities to increase their profit margins (Clayton, 2022).

Consumers rely heavily on funeral undertakers as specialists in a field where most lack awareness of the processes and regulations. The profession and service are one in which the methods and products monetized for sale are performed away from public view. These factors make consumers vulnerable to potential criminal acts committed by those in positions of trust. For example, some funeral directors have exploited the grieving state of the mourning individuals and used this vulnerability to coerce them into spending more on funeral expenses than they would if they were fully aware of the rules and regulations of selling in this sector (Gottschalk, 2019; Wasik, 1995; Gentry et al., 1995). Some unscrupulous funeral homes have taken advantage of this. For example, in 2021 a lawsuit was filed against Service Corporation International, a large funeral services corporation, for falsely marketing their products including their refund policies on pre-needs burial plan purchases and burial and cremation benefits. As a result of their actions, SCI was found responsible and ordered to pay a twenty-four million dollar civil fine and additional customer restitution to those who elected to cancel their pre-needs plans (State of California, 2024).

Regulation or Lack of Regulation for the Funeral Industry and Issued Related

Due to social concerns, the Federal Trade Commission proposed the Funeral Act in 1982, and it was amended in 1984. This act acknowledges that families who have lost a loved one and are in the stages of grief and mourning are at a heightened vulnerability and can be more easily taken advantage of at this time. The rule requires that consumers be informed of their rights to choose, know what is and is not required, and receive a price list of all available services before they select and sign a contract either in person or over the phone (Gottschalk, 2019’ Jeras et al., 2024). While this regulation is in place, its enforcement lacks the deterrent effect as the yearly randomized undercover inspections by the Federal Trade Commission's of funeral homes are conducted through a phone call designed to uncover violations of the Funeral Act’s rules (Bureau of Consumer Protection, 2019). Without the FTC staff physically being on the premises, this limits what the agency can regulate (Bureau of Consumer Protection, 2024). In addition to the off-site regulation of the funeral industry at the federal level, the remaining forms of regulation occur at the

state level and are centered on board examinations and speciﬁc licensing or continuing educational requirements for funeral directors and the regulation of funeral services including the selling of caskets and other funeral merchandise (Lares & Lehenbauer, 2019; Solley, 2022).

Therefore, the regulation is present but is not efficient at preventing and uncovering crimes such as financial abuse of the elderly and their living and annuity trusts (Finberg, 2002) enforcement disparities, and consumer abuse through non-disclosure of prices and requirements as mandated by the 1994 Funeral Act (Finberg, 2002; Champney, 2016, Champney, 2019, Gentry et al., 1995; Kopp & Kemp, 2007; Robinson, 2016; Rugg & Jones, 2021; Selk, 2018). In addition to this, there have been instances where funeral directors did not abide by the deceased’s or family's wishes regarding the disposal of their remains and instead sought profit through the sale of bodies or body parts to brokerage firms (Champney, 2016; Champney, 2019; Rugg & Jones, 2021; Robinson, 2016). Thus, despite licensing and regulatory mechanisms in place, issues of deviant, fraudulent, and criminal activity have and still do occur in the industry (Champney,

2016; Champney, 2019; Rugg & Jones, 2021; Robinson, 2016). The question remains as to whether there are industry and market-level factors that contribute to the motive and opportunity to engage in these acts. Utilization of theoretical work developed to explain whitecollar crime and previous research conducted on these theories can help to provide the framework for understanding these phenomena.

Theoretical Grounding

The actions committed by funeral directors mentioned above occurred during legitimate business opportunities and were conducted for business or personal gain; they fit the definition of white-collar crimes. Theoretically, white-collar crime has been studied at the macro level. Focusing on widespread patterns within the economy, industries, or industrial sectors and how factors within these areas influence the motive and opportunity to engage in criminality to meet organizational or personal goals (Kennedy, 2020).

One macro-level theory is the industrial theory of white-collar crime. This theory focuses on the economic conditions in which industries are operating and the impact of competition for resources

between industries within the same market sector during variable economic conditions (Kennedy, 2020). This theory predicts that when economic conditions are negatively impacting the profit margins of a corporation, they will have an increased motive to engage in corporate offending to keep their business profitable. Tests of this theory, however, have found mixed results. While some have indeed found that in constricted economic conditions, incidents and prosecutions of white-collar crime increase in line with the original argument, others have found that incidents and prosecutions also increase during economic booms (Braithwaite, 1985). Explanations of these findings center on the resource-poor versus research-rich environment and the differing motivations for crime inspired by each. Specifically, in research-poor environments, the motivation is the need to sustain the profitability or viability of the business whereas in resource-rich environments the motivation is greed and the ability to profit substantially (Taub, 2020). While the findings are mixed, the support for the resource-poor argument lends support for the use of this theory as an explanation for the motive to engage in white-collar crime within the funeral industry which has experienced market declines due to

economic and social changes over the past several decades (Beard & Burger, 2020).

At the business industry level, the institutional theory argues that the lack of regulation of a market sector or business provides the opportunity for white-collar crime to occur. Previous research on the lack of regulation within a market or industry has found support for the argument as a predictor of criminality. For example, the “Roaring 20’s,” a decade of significant financial gain due to the lack of regulation that allowed for speculative trading and under-regulated investment trusts that became overleveraged, led to a stock market crash that ushered in the Great Depression (Klein, 2009). The Watergate Scandal too has been noted as partially resulting from a lack of regulation and oversight. During this time period, there was no regulation on campaign financing, which allowed the use of political campaign donations to fund Nixon’s activities, and there was a lack of oversight of the intelligence and policing agencies that Nixon utilized to further his political agenda (Ervin, 1980). As Calavati & Pontell (1990) observed in the Savings and Loan scandals, deregulation created conditions ripe for unethical practices. Similarly, in the funeral industry, the lack of

uniform regulatory standards across states fosters an environment where white-collar crime can thrive (Sparrow, 1996). Each of these incidents has led to at least the call for if not the enactment of increased oversight and regulation to prevent these incidences of criminality from re-occurrence (Calavati & Pontell, 1990; Ervin, 1980; Klein, 2009; Sparrow, 1996). Within the funeral industry, this theory can be seen through the issue of improper disposal of remains. As Selk (2018) notes, the funeral industry is weak in regulation and enforcement of industry rules, and these conditions have created inadequate oversight and opportunities for violations such as this to occur. Additionally, the lack of uniformity in regulatory standards across states regarding the funeral industry has created environments where white-collar crime is more likely to occur (The Conference, 2023). Together, the industrial theory of white-collar crime and the institutional theory of white-collar crime provide the motive and opportunity for white-collar crime to occur in the funeral industry as the market is experiencing declines and the industry is under-regulated (Kennedy, 2020). Though these are broad statements about the conditions in the funeral industry, previous research has also indicated signiﬁcant variation by state, local-

ity, and even among individual funeral homes as to the level of regulation and oversight that occurs. Using data from a content analysis of newsprint articles related to crimes in the funeral industry, this study hypothesizes that these crimes are more likely to occur in funeral homes where there are industrial and institutional factors that provide the motive and opportunity for criminal acts to occur.

Data and Methods

An internet search using the speciﬁc keywords “Crimes Committed by Funeral Directors” through the Google Search platform was conducted. Google Search is widely used to analyze websites based on the relevance of the user’s topic that is searched. Google was used due to its variety of news articles, YouTube videos, and much more. Results were limited to crimes occurring only in the United States and a date range of January 1, 1987, through October 2024. Once the returned data was cleaned to eliminate repeated articles and non-relevant material, the data was analyzed utilizing a rubric where the coding of categories was assessed using intercoder reliability to ensure that the data analysis exhibited consistency of coding decisions among researchers. The coding

rubric used to conduct the research included the location of the incident, date uncovered, location (urban, suburban, and rural), independently or corporate-owned, family-owned or chain, type of crime, elements of the crime, single or multiple people involved, how the crime was discovered, and any previous civil or criminal sanctions. Limitations with coding included not every case identifying how the crime had been discovered, several cases did not state an exact date of when the crime was uncovered, what the outcome of the crime resulted in, and the motivation behind the crimes committed. There were no inter-coder disagreements between the researchers.

Results

Descriptive Statistics

After cleaning the original returned results, the ﬁnal sample included 21 cases of funeral home crimes over a 37-year period. This section describes the descriptive statistics of the study categories. These are also presented in Table 1. The crimes included improper disposal of bodies, embezzlement and/or forgery, and the illegal harvesting of organs. From the 21 funeral homes examined, there were ﬁfteen incidents of improper disposal of

bodies, three incidents of embezzlement and forgeries, and three incidents of illegal harvesting of organs. A mode year was calculated to determine the year that had the highest prevalence of crimes committed. The analysis indicated that this was 2024, when three incidents were recorded. The range of victims was also calculated. The results indicate that there was a significant range of victims with the lowest case having one victim and the highest having 16,000, thus the range was 15,999. In the case of 16,000 victims, which is a significantly higher number of victims than other discovered crimes in the data set, Lamb Funeral Home located in California was discovered to have improperly disposed of 16,000 corpses. The funeral home had at their disposal two cremation ovens and was discovered to have burned at least two bodies at a time and at times up to six to eight at a time during the same retort firing, an action that is against the law and regulations of crematory use (Time, 1988). The states represented in the study included California, Colorado, Florida, Georgia, Illinois, Indiana, Massachusetts, North Carolina, Ohio, and Pennsylvania. The mode of states was Pennsylvania, which had the highest representation of incidents at seven. While research into the legal and regulatory

mechanisms in place in the state of Pennsylvania indicates that there is an established board of examiners, legal statutes, and regulatory mechanism to police the industry, there has been concern noted that this is more representative of having a law on the books rather than the law in practice. Thus, in Pennsylvania, there appears to be a signiﬁcant lack of oversight of these agencies (Vella, 2019). Research into the variation in crime among states to any further degree, however, has not been conducted.

The overall conclusion is that lack of regulation and oversight has allowed individual operators to engage in white-collar crimes, so the reasoning for state-level variation is not yet solved. Still, it could be a relevant topic for future research and policy initiatives.

The main points of interest in analyzing the data centered on whether the crime was committed individually or collaboratively, whether the uncovering of the

crime was reactive or proactive, and whether the funeral home was a corporate-owned or a familyowned entity. Table 2 presents the data related to these topics. The analysis indicated that sixteen of the offenders committed their crimes individually, while five worked in collaboration. This finding suggests that increases in regulation and oversight should focus more specifically on those that target occupational-level white-collar offenders in this industry rather than broad-scale market-based regulation. The analysis of proactive versus reactive discovery of the crime analyzed whether the criminal acts were uncovered through active policing and regulation of the funeral home or whether the criminal acts were uncovered through a reactive reporting of strange, odd, or concerning behavior or actions by individuals not associated with policing agencies or regulatory agencies. The analysis indicated that all the discoveries were reactive. The commonalities included

anonymous tips, relative complaints, the discovery of forged doctor's signatures, customer complaints, and local coroner's discovery of bodies. Interestingly, there were also some non-similar findings in how these acts were uncovered. Four of the crimes were reported by a former employee who reported foul smells to police, in two cases the state licensing board was notified by customers regarding economic crimes, one was discovered by police after a search warrant was issued due to a report of operating without a license, and finally, two were discovered accidentally while eviction orders were being served.

This ﬁnding suggests that increases in proactive oversight of funeral homes could potentially either deter these individuals from committing these crimes or discover the actions in a more prompt time frame to avoid numerous victimizations. An additional analysis that was conducted indicated that twenty-one of the funeral homes that committed white-collar crimes

were family-owned; meanwhile, zero corporate-owned funeral homes were detected in the analysis. This suggests that the crimes are more likely to occur in small businesses that lack the oversight imposed on larger corporations.

Discussion and Conclusion

In sum, crimes committed by funeral directors are more likely to occur in small, family-owned funeral homes, tend to be committed for personal gain, and tend to be discovered through reactive reporting rather than proactive investigation and regulation. The theoretical grounding for the study centered on two macro-level theories of white-collar crime: the industrial theory, and the institutional theory. The industrial theory argues that economic and market-level forces, particularly resource-scarce conditions, provide the motive for white-collar crimes to occur. In this study, the ﬁnding that most of the offenses were committed for

personal gain rather than corporate or business gain does not lend support for this theory as an explanation of the motivation for funeral home-related crimes. Instead, individual-level motivations are driving the actions. The institutional theory focuses on the regulation and oversight within an industry and the impact of the presence or absence of such regulation on the opportunity for white-collar crimes to occur (Kennedy, 2020). The findings of this study lend support to this argument given the solitary nature of most offenses and the reactive rather than proactive nature of crime discovery. Overall, the arguments of the study are partially supported. Despite lack of support for the industrial level theory in this study, a change in the overall economic climate in total or specifically for small businesses leads to a fluctuation in these findings. The longterm trends of crimes in this field during multiple different economic conditions in the market could be a future direction of research.

While the study provides partial support for the arguments investigated, there are certain limitations that must be addressed. First, the study sample size was small, which may restrict the general applicability of its ﬁndings. Second, the study relies on news articles instead of of-

ficial reports or records from police departments. The use of this source as data can have several potential issues. First, the media often focuses on the most sensational of cases and therefore, the use of this as the primary form of data could result in selectivity bias where crimes of lesser notoriety that would still be classified as whitecollar crimes in the funeral home go unreported. Second, there is a potential that in larger metropolitan areas there is a higher concentration of journalists vying for a sensational story and, therefore, crimes such as these are more likely to get press coverage. Conversely, in smaller rural areas, it could be that the crimes are over-reported due to a lack of sensational crimes in these areas. In either case, the overarching concern is over or underreporting of crimes due to geographic location. Additionally, the study lacked in-depth historical data on the regulations of the funeral homes included in the study. Future research should expand upon this initial topic to utilize larger sources of data that can be correlated to measures of oversight. One significant finding that was not hypothesized in the study was the finding that more incidents were related to individual level motivations for personal gain rather than organizational benefit. Future research

should also examine this finding. Finally, these findings can inform policy. The literature review noted that the predominant oversight in the industry is related to the mandates of sharing price lists with consumers in the Funeral Rule, and that checks of this rely mostly on telephone calls rather than in-person inspections. Because of the hidden nature of the industry and the findings of this study that most discoveries of white-collar crime in the funeral industry occur through reactive means, it is suggested that mandating regular, unannounced inspections and providing whistleblower protections for other employees who may take note of illegal actions be implemented. This could reduce reliance on reactive reporting and increase both proactive investigation and deterrence. Overall, this research finds that there are situational and occupational factors that influence the commission of profit-driven crimes within the funeral industry. The findings of this study have noted that the lack of oversight and regulation are consistent factors that provide the opportunity for motivated offenders to engage in these acts that can have significant financial and emotional impacts on their victims. Due to the harm associated with these acts, the recommendation is to use this information to address

the lax system of reactive response to provide a better opportunity to prevent white-collar funeral home crimes from occurring.

References

Beard, V. R., & Burger, W. C. (2017). Change and Innovation in the Funeral Industry: A Typology of Motivations. OMEGAJournal of Death and Dying, 75(1), 47-68. https://dx.doi.org/10.1177/0030222815612605

Beard, V. R., & Burger, W. C. (2020). Selling in a Dying Business: An Analysis of Trends During a Period of Major Market Transition in the Funeral Industry. OMEGA-Journal of Death and Dying, 80(4), 544-567. https://dx.doi. org/10.1177/0030222817745430

Bureau of Consumer Protection. (2019). Undercover inspections of funeral homes in nine states and Washington, D.C. press funeral homes to comply with Consumer Protection Law. Federal Trade Commission. https://www.ftc.gov/news-events/news/ press-releases/2010/03/undercover-inspections-funeral-homes-nine-states-washingtondc-press-funeral-homes-comply-consumer

Bureau of Consumer Protection. (2024). FTC sends warning letters to funeral homes after ﬁrst undercover phone sweep. Federal Trade Commission. https://www.ftc.gov/newsevents/news/press-releases/2024/01/ftcsends-warning-letters-funeral-homes-after-ﬁ rst-undercover-phone-sweep#:~:text=The% 20Federal%20Trade%20Commission%20is,F uneral%20Rule%20on%20these%20calls

Calavita, K., & Pontell, H. N. (1994). The State and White-Collar Crime: Saving the Savings and Loans. Law & Society Review, 28(2), 297–324. https://doi.org/10.2307/3054148

Champney, T. H. (2016). The Business of Bodies: Ethical Perspectives on For�Proﬁt Body Donation Companies. Clinical Anatomy, 29(1), 25-29.

Champney, T. H., Hildebrandt, S., Gareth Jones, D., & Winkelmann, A. (2019). Bodies R Us: Ethical Views on the Commercialization of the Dead in Medical Education and Research. Anatomical Sciences Education, 12(3), 317-325.

Clayton, P. J. (2022). Small Business Fraud: The Death of African American Funeral Homes. Doctoral dissertation, Northcentral University. https://www.proquest.com/openview/9e2df1ffe055c9ad5f7f286dd236c41f/1? pq-origsite=gscholar&cbl=18750&diss=y

Gentry, J. W., Kennedy, P. F., Paul, K., & Hill, R. P. (1995). The Vulnerability of Those Grieving the Death of a Loved One: Implications for Public Policy. Journal of Public Policy & Marketing, 14(1), 128-142https://www.jstor.org/ stable/pdf/30000385.pdf?casa_token=C4R9 -Ycd0mQAAAAA:neMUHpjenBPPLaw1Bh3 OSI8kJ67vFR7Edq1XdlQtr5xJ835uuao4RebR 4UdyWrcHqFCCD_XXqpmx7Lm6zSLGD6IrOi 9tV82jvMq2MvDFQke-HCSqeY0

Gottschalk, A. (2019). Giving Up the Ghost: How the Funeral Rule and State Licensing Boards Are Failing to Protect Consumers from Underhanded Undertakers. Elder LJ, 27, 423. https://heinonline.org/HOL/LandingPage?handle=hein.journals/elder27&div=18&i d=&page=

Heras, G. de las, Miller, T., Puig, A., & Lazarus, A. (2024, March 4). The FTC funeral rule. Consumer Advice. https://consumer. ftc.gov/articles/ftc-funeral-rule

Horton, K. E. (2003). Who's Watching the Cryptkeeper: The Need for Regulation and Oversight in the Crematory Industry. Elder LJ,11, 425 https://theelderlawjournal.com/wpcontent/uploads/2015/02/Horton.pdf

Kennedy, J. (2020, September). Organizational and macro-level corporate crime theories. Wiley. https://onlinelibrary. wiley.com/doi/abs/10.1002/97811187 75004.ch12

Kopp, S. W., & Kemp, E. (2007). The Death Care Industry: A Review of Regulatory and Consumer Issues. Journal of Consumer Affairs, 41(1), 150-173.

News. National Funeral Directors Association (NFDA). (2024). https://nfda.org/news/statistics

Robinson Jr, G. B. (2016). Regulating Death: Occupational Licensing and Efficiency in the Death Care Industry. Loy. Consumer L. Rev., 29, 343. https://lawecommons.luc.edu/ cgi/viewcontent.cgi?article=1986 &context=lclr

Rugg, J. J., & Jones, S. (2021). Care of the Body in Funeral Directing Services. https://eprints.whiterose.ac.uk/178971/1/COT B_Oct_7_2021.pdf

Solley, E. A. (2022). Death Will Have His Day: Overly Restrictive Funeral Director Licensing

Statutes Harm the Public and Violate the Constitution. Wake Forest L. Rev., 57, 829.

Sparrow, M. K. (2019). License to steal: how fraud bleeds America's health care system. Routledge.

The Conference. (2023). Regulations in Funeral Service Licensing. The International Conference of Funeral Service Examining Boards. https://theconferenceonline.org/licensing-requirements/

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U.S. Attorney’s Office, District of Colorado. (2023, July 5). Sunset Mesa Funeral Home operators sentenced to federal prison for illegal body part scheme. U.S. Department of Justice. https://www.justice.gov/usaoco/pr/sunset-mesa-funeral-home-operatorssentenced-federal-prison-illegal-bodypart-scheme

Vella, V. (2019, April 19). Pa. Funeral-Home Inspections: A dead system?. https://www.inquirer.com/philly/news/20151009_Pa__funer alhome_inspections__A_dead_system_.html #:~:text=In%20order%20to%20operate%20le gally,t%20completely%20shocked%2C%20he %20said

Wasik, J. (1995). Special Report: Fraud in the Funeral Industry. Consumers Digest, 34(5). https://www.jewish-funerals.org/wpcontent/uploads/2011/07/condigest 1995_09.pdf

AI Statement

Artiﬁcial Intelligence was not used in this project.

The Folklore of Clothing: What Do Clothes Say About You?

Margaret Dudley

Faculty Mentor: Mark Kostro, Ph.D.

Department of Sociology, Anthropology, and Criminal Justice

Abstract

Clothing embodies beliefs and knowledge passed down through generations, inﬂuencing individuals' behaviors in response to external factors. Erving Goffman's theory of self-presentation, as outlined in The Presentation of Self in Everyday Life, is relevant to this topic, with his dramaturgical concepts offering valuable insights. Additionally, Russell W. Belk's article "Possessions and the Extended Self" connects possessions to consumer behavior, which can be directly applied to clothing. The relationship between clothing folklore, Goffman’s dramaturgical metaphor, and Belk's extended self theory is explored through interview data, focusing on themes like superstition, sexuality, and status.

The Folklore of Clothing

Erving Goffman, in his book The Presentation of Self in Everyday Life, states that “All the world is not ... a stage, but the crucial ways in which it isn't are not easy to specify.”1 Goffman uses dramaturgy to compare individuals to actors and their efforts to present themselves tailored to their audience. Dramaturgy is the sociological perspective of analyzing behaviors through the analogy of stage performance. The performance that Goffman refers to is the way in which we present ourselves to the world, as if it were a stage. Much like this idea of outwards presentation, in “Possessions and the Extended Self,” Russell W. Belk discusses how possessions can become part of the self. Anything that

is owned is a part of the self, which makes objects intrinsic to identity.2 Clothes in this case are “expressive equipment” which are utilized by the wearer to change or reinforce any perceptions that someone else may have of them. The focus of my analysis is how each informant uses their clothing as “expressive equipment” and what can be inferred about their beliefs surrounding superstition, sexuality, and status.

Clothing is the outermost layer that others see. Most clothing choices are intentional, internal or externally influenced, but there are unconscious reasons as to why individuals make the clothing choices they do. A person’s background, including their upbringing and beliefs, is reflected in the clothing they choose to wear. In this essay, I will analyze the various ways folklore influences clothing and explore how individuals feel about the garments they wear. To do this, interviews are used, as well as online examples of clothing folklore, and the ideas that Erving Goffman and Russell W. Belk discuss were used to create a deeper understanding.

Throughout history, clothes have been used in necessary ways, like warmth, protection, or modesty. However, in many contexts, clothes function to communicate notions of

identity, usually through signaling perceived status.3 This practice has become deeply embedded in Western culture. An increase in social stratiﬁcation leads to the development of means to display the differences between social classes, like the implementation of differently valued clothes at a societal level. Without consciously knowing it, societies hold ideologies of what clothes someone is supposed to wear based on their background. Those ideas then impact how people wear their clothes and what their families tell them they should wear. For this project, the folklore of clothing can be categorically analyzed based on four things: superstition, sentiment, status, and sexuality.

Methods of Collection and Analysis

The interview subjects were chosen based on my connections within the LGBTQ community. The topics of interview questions evolved from the beginning idea that clothes had value. Initially, the questions were more focused on superstition, but as the interviews and background research progressed, it became apparent to me that clothing meant more than just that. Folklore can encompass beliefs, stories, and sayings, which led to the development of the other categories of analysis.

Beliefs and prejudices about how clothing represents sexuality can be passed generationally. Certain elements of sentimentality can be passed down by older generations expressing what clothes mean to them. Along with that, clothes also represent a status symbol for people, and that belief is passed on to children from a very young age. These categories became apparent when thinking about the subjects individually, but I believe they can be applied to a broader sample.

Interview 1 Background

My ﬁrst informant was a 20-yearold woman who lives in Virginia, attends Longwood University, and is a part of the LGBTQ+ community. She grew up in Northern Virginia in a lower socioeconomic family with her mother, father, and brother. Her household had liberal views. Her attitude towards clothes is extremely positive; she often describes herself as a “fashionista.” Attitude towards clothing is an integral part of this analysis, as it is an indicator of beliefs that this person has about the clothes themselves.

Interview 2 Background

The second informant is a 21-yearold woman from Virginia and is also a part of the LGBTQ+ community.

For most of her childhood, she attended church with her family. She states that her conservative upbringing had a signiﬁcant impact on the input she received regarding her wardrobe and the meaning she attaches to clothing.

Superstitions

At the beginning of the interview with Informant 1, I asked her what kinds of superstitions her family told her about growing up. Her response:

Um, so every time during the winter that it was forecasted to snow … ten percent, twenty percent, didn’t even matter, my grandma would always tell us to wear our pajamas inside out that night. Um, and that was something that everyone said. My parents said it, my grandparents said it, and me and my brother just stuck to that.

Diving deeper into this belief of turning clothes inside out, I wondered if it had something to do with the location where she grew up, or more speciﬁcally where her grandmother grew up. Informant 1 said, “I mean she grew up in Hampton [Virginia], where there was no snow and I think we all really wanted snow all the time.” Because weather is uncontrollable, people

tend to manipulate things they can control, like clothing, to change the outcome of the uncontrollable event.

Online research has shown other examples of this phenomenon of turning clothes inside out, but like the informant’s example, it was used to control uncontrollable events. Folklore writer Icy Sedgewick described how Yorkshire women, for example, would turn their smock inside out to give their male partners good luck on their journey at sea and safe return. Because the sea is unpredictable in nature, the turning of the smock was the only thing the women could control to have power over the journey’s outcome. In many areas of humankind, domination over nature is seen as a divine right, so when something in nature like the ocean or the weather is too powerful to overcome, humans ﬁnd a way to try and inﬂuence it.4

Many other superstitions have been passed down throughout history, especially through sports. Clothing has been used by athletes to inﬂuence the outcomes of their games. Serena Williams would not change her socks during a tournament; Michael Jordan wore his college basketball UNC shorts underneath his Bulls shorts; Jason Giambi wore a gold thong

to be better at batting.5 As demonstrated by these examples, clothes can hold power in many different contexts. While an athlete's performance largely depends on their personal skill, superstition helps mitigate factors beyond their control and provides a rationalization when things go wrong.

Informant 1 shared the importance of clothes in their role in enhancing her own abilities during various parts of her life, whether it be a big presentation or a job interview. She said:

If I want to be super conﬁdent when I go and talk in public … even when my professors are like, don’t dress professional, I still do because it makes me feel so much better about myself … I feel prettier, I feel taller … clothing has always been something that has enhanced … life for me.

For Informant 1, the outﬁts that she puts together are part of a larger ritual when preparing for notable events where she needs to perform at her best. By dressing up for presentations, she controls outside perceptions before she even begins speaking; thus, making her more conﬁdent overall.

Informant 1’s deep connection to clothes and their importance to her life made me wonder where such a belief came from. When asked, Informant 1 responded, “I full handedly believe that there is love within clothing … wearing my mom’s clothes, my grandma’s clothes … even my dad’s clothes, like, taking his sweater or something.” We discussed the comfort that clothes worn by loved ones can bring and the value that they must hold for both her and her family. The conversation naturally transitioned into talking about handme-downs, especially what her family communicated to her about them. She said, “From day one, my parents and my grandparents were like, handing down clothes is meaningful and shopping for secondhand clothes is meaningful.” Growing up in a lower socioeconomic household, shopping at thrift stores was the primary way that she got “new” clothes. For many, there exists a stigma that comes along with shopping at second-hand stores; however, her family embraced this part of their lives, trying to create good memories, even though they struggled ﬁnancially. Informant 1 fondly shared a story of secondhand shopping with her grandmother, having mini fashion shows

in oversized dresses, and laughing with one another as they strolled the aisles. Because of this, she has a positive association with already loved clothing and continues to share that appreciation with others because it is such an integral part of her upbringing.

Lived experiences in clothes can also inﬂuence their value. The user waxedmintﬂoss on the website Reddit says, “If I want to relive a memory, I won’t wash what I wore that day... conversely if I feel like a vibe is ruined, I will change and put those clothes in the laundry even if they didn’t get dirty yet.” Informant 1 agrees with this, but in the context of wearing clothes from a loved one. She agreed with me that, “It sort of feels magical, like you’re using their life experience in my everyday life, and it gives [you] comfort.” While clothes can be comforting, they can also be carriers of powerful emotions, sometimes painful ones. One redditor, Key_Surprise_8652, said:

I haven’t worn the dress, sweater, or shoes that I wore to my parents’ funeral again and I probably won’t ever but I don’t know for sure. All I know is that right now even the thought of it makes me uncomfortable! ... My sister told me she threw out the pajamas she was wearing

when she found out. I can’t even remember what I was wearing, everything felt so surreal and disorienting.

Another redditor, ResponsibleShop-400, details their own experience with loss and how it created superstition revolving around clothes:

My mom died in 2001. In 2015, when I was moving I ﬁnally threw out the shirt I was wearing the day she died and the outﬁt I wore to her funeral. I hadn't worn any of the clothing I associated with her death. Still, I felt like I needed to hold on to it until I really made myself think about it. The clothes were a physical representation of memories and I was holding on to them to feel close to her, but really they just upset me. I really struggle with this, holding on to ordinary mundane things that I associate with memories of my parents as if my keeping them will bring them both back.

Clothes have also been used to bring new people into individual’s lives, speciﬁcally love interests. For example, in the 19th century, there was a practice of women trying to get men’s attention by leaving their nightdresses inside out on a bush; their future husband would be the person to turn it right side

out.6 This practice includes both superstition and love. Most people say that love is uncontrollable; you cannot help falling in love with someone, it just happens. But the most uncontrollable part of falling in love is timing. Throughout the course of history, women have been pressured to ﬁnd husbands, sometimes at young ages. Practices of love divination were a natural reaction to this pressure, giving the women a sense of control and that they were doing everything they could to ﬁnd a husband. Love has taken on new forms such as sharing clothing with a partner, which is thought to be a romantic gesture. In Belk’s “Possessions and the Extended Self,” he suggests that gifting other people possessions can be used to “extend the self” or display control over someone.7 By this, he means that the way in which we regard the object changes; it becomes permanently associated with the giver and can become an extension of the giver’s identity imposed on the recipient of the gift. In other words, while sharing clothes is a romantic gesture in some cultures, it can also function as claiming someone as a possession.

Status

From the beginning of my interview with Informant 2, I could see a clear

difference between her and Informant 1’s attitudes towards clothes. She told me all about how much control her parents had over her wardrobe and how that impacted her views about herself and still inﬂuences how she dresses today. Many of her experiences with parents verbally communicating their expectations of what she should be wearing and maintaining an appearance of looking 'nice'. To them, looking ‘nice’ was dressing to avoid accusations of not being ﬁnancially stable from people in their social circle.

This idea piqued my interest: How can appearance reﬂect folk beliefs? It’s not just the clothes themselves, but the reasons behind wanting them to look a certain way—reasons that, in this case, are rooted in insecurities. I asked Informant 2 about the origin of this perception anxiety, and she said:

On my dad’s side, my grandparents grew up hella poor, so they were like ﬁve kids, and they all lived in a single room cabin … My grandpa, was very much the type of person to be like, I don’t want anybody to know who I truly am, like deep down.

This anxiety continued for Informant 2’s nuclear family, as they experienced ﬁnancial insecurity and

did not want others to perceive them as struggling. This belief is something that many people have about their appearance. Clothing is a form of expression that some people use to signal status or try to mask that they are insecure about. This societal construct has deep roots in Western culture, especially with the onset of capitalism and increased stratiﬁcation between socioeconomic classes. Valued beliefs like “being poor is bad” and “being rich is good,” while somewhat subconscious, perpetuate these insecurities and promote people to take measures to change perceptions of their wealth.

The perceived status of clothes has also been used as an instrument of social change. In the 1960s, Civil Rights Activists would wear their Sunday Best” to the marches to challenge negative stereotypes about African Americans.8 According to Richard Thompson Ford, a Standford legal scholar, their dress code created intentional pushback against white supremacy in its attempt to keep African Americans at the bottom of society.9

Abena L. Moon, a Professor of History at Coppin State University, suggests that in the years after the Civil War, African Americans had to always dress in opposition to white people’s negative stereotypes

because “a person who was untidy or unruly was also underserving of equality.10

Sexuality

Appearance can be impacted many aspects of a person’s identity. One of the more noteable topics discussed with Informant 2 was sexuality. This discussion began with me asking how where she grew up impacted what she was told about clothes. She responded:

I mean I honestly think it just stems from homophobia … “Girls can’t wear men’s clothes;” “You can’t shop in the men’s clothing.” But I like the way it ﬁts better on me. Necessarily, I don’t think it comes down to where I live, just because Williamsburg can be really diverse.

Over the course of the interview, it became clear that it was not necessarily where she grew up that impacted this experience, but her own family’s ideologies about gender and sexuality. While society has progressed in many ways in breaking gender stereotypes and moving towards equality, there are still many ideologies that control what people wear, even subconsciously. Because of these societal beliefs about what a girl should wear, her parents told her that she needed to

conform to those standards. Informant 2 now wears basic clothes, usually black skinny jeans and a black T- shirt with minimal modiﬁcations. In contrast to the experience of Informant 2, Informant 1 reported the use of clothes to emphasize her sexuality growing up rather than suppress or not draw attention to it. Much of this difference can be attributed to the distinctions in their families’ ideologies about gender and sexuality, and it contributes to the idea that ideology is a part of the presentation of self.

How the Presentation of Self Applies

Using the comparison to a performance, Erving Goffman states that “‘front’… [is] part of the individual’s performance which regularly functions in a general or ﬁxed fashion to deﬁne the situation for those who observe the performance.”11 The folk beliefs about economic status and clothing that Informant 2’s family relate to concerns about their “front.” Goffman said that “front” includes “expressive equipment” that can be used subconsciously, or in this case, consciously by the person performing.12 This concern for their “front” was because they saw these possessions as extensions of who they were.13 For this analysis, clothing is part of

the “expressive equipment.”

By changing what Informant 2 wore, her family was actively trying to control their expression to other people in their social circle based upon their beliefs about what those clothes meant about their socioeconomic status. And this, as Goffman would refer to it as, is the “appearance,” which are the “stimuli which function … to tell us of the performer’s social statuses.”14 The same ideas apply to Informant 1 and her experience of dressing up when doing presentations. She was altering her “front” to change how others perceived her and how she perceived herself. In this instance, clothing was not only an outward expression, but an inward one, too. Her appearance informed her audience and herself of her status.

Folklore often can serve as boundaries in different communities, and in the case of clothes, they can be used to signify membership in a speciﬁc group. Informant 2 now uses sexuality to determine how she presents herself. While the experiences of Informant 2 involved her parents controlling what she wore to make sure she ﬁt into their social circle, she now uses clothes as an indicator of her LGBTQ+ identity, to show she is an “insider” to other members of her community. She does this by including LGBTQ+

friendly apparel or dressing in ways so that she is perceived as someone that is a part of that group. The tradition of folklore, signifying your role as an insider was key in full acceptance into a community. These insiders are likely to know certain jokes or stories that others who are “outsiders” may not understand based on having shared experiences.

Clothes and Contamination

A particularly interesting aspect of Belk’s analysis is in his discussion of contamination. Contamination is the attachment of positive and negative associations to objects, usually through physical contact.15 In the stories shared by Reddit users Key_Surprise_8652, ResponsibleShop-400, there are examples of contamination. For them, clothes served as ways to remember a loved one, either good memories, which is positive contamination, or the ones associated with their death, which is negative contamination.

An example of positive contamination is Informant 1’s relationship with secondhand goods. Shopping with her grandmother as a kid created a good association with this practice, and because of this, her thrifted clothes are more valuable

than the new clothes hanging in her closet. By continuing to thrift her clothes, she is hoping to relive those same feelings that she experienced as a child, which is a form of positive contamination.

Conclusions

Identity, social change, and societal status can be communicated through clothes, but more importantly tell us about the people that are wearing them and the life that they have lived. Folk beliefs are passed through generations and live within the shirts on our backs and the shoes on our feet. The presentation of self does intersect with the folklore of clothing, as well as our sense of self. Goffman’s theories of group identity and social control directly applied to the experiences of both individuals interviewed, speciﬁcally relating to their sexualities, status, sentiment, and superstition. Belk’s discussion of how possessions can function as extensions of who we are and the ways in which they can do that, like contamination, further contributes to the idea that the clothing that someone wears has meaning beyond aesthetics. Belk says that the items that we possess serve as reﬂections of who we are and how we have changed, and Informant 1 and Informant 2’s experiences support

that. Each informant chose their expressive equipment,” based on how they wished to be perceived or the control they wished to exert over a situation.16

Further research would be appropriate to increase the number of interviews and to expand outside of the LGBTQ+ community, or to see if there are consistencies among attitudes and behaviors across the community at a larger scale.

Notes

1. Goffman, Erving. “The Presentation of Self in Everyday Life.” Anchor Books, New York, 1959.

2. Belk, Russell W. “Possessions and the Extended Self.” Journal of Consumer Research, Oxford University Press, 1988.

3. Belfanti, Carlo Marco. “The Civilization of Fashion: At the Origins of a Western Social Institution.” Journal of Social History, 43(2), 261-283, 2009.

4. Icy Sedgwick. “The Folklore of Clothes: Defying Fairies, Finding Love, and Bringing Luck,” Icy Sedgwick, 2023, https://www.icysedgwick.com/folklore-of-clothes/.

5. Corey Nachman. “The 30 Strangest Superstitions in Sports History,” Business Insider, 2011, https://www.businessinsider.com/thestrangest-pre-game-rituals-2011-8.

6. Icy Sedgwick. “The Folklore of Clothes: Defying Fairies, Finding Love, and Bringing Luck,” Icy Sedgwick, 2023, https://www.icysedgwick.com/folklore-of-clothes/.

7. Belk, Russell W. “Possessions and the Extended Self.” Journal of Consumer Research, Oxford University Press, 1988.

8. Melissa De Witte. “Dress codes can reveal social aspirations, political ideals, says Standford scholar,” Stanford News, Stanford University Communications, 2021, https://news.stanford.edu/2021/02/10/dresscodes-reveal-politics-social-change/.

9. Melissa De Witte. “Dress codes can reveal social aspirations, political ideals, says Standford scholar,” Stanford News, Stanford University Communications, 2021, https://news. stanford.edu/2021/02/10/dress-codes-reveal-politics-social-change/.

10. Mhoon, Abena L. “Dressing for Freedom.” Black History Bulletin, 67(1/4), 26-29, 2004.

11. Goffman, Erving. “The Presentation of Self in Everyday Life.” Anchor Books, New York, 1959.

12. Ibid.

13. Belk, Russell W. “Possessions and the Extended Self.” Journal of Consumer Research, Oxford University Press, 1988.

14. Goffman, Erving. “The Presentation of Self in Everyday Life.” Anchor Books, New York, 1959.

15. Belk, Russell W. “Possessions and the Extended Self.” Journal of Consumer Research, Oxford University Press, 1988.

16. Goffman, Erving. “The Presentation of Self in Everyday Life.” Anchor Books, New York, 1959.

Works Cited

Belfanti, Carlo Marco. “The Civilization of Fashion: At the Origins of a Western Social Institution.” Journal of Social History, 43(2), 261-283, 2009.

Belk, R. W. “Possessions and the Extended Self.” Journal of consumer research, 15(2), 139-168, 1988.

De Witte, Melissa. “Dress Codes Can Reveal Social Aspirations, Political Ideals, Says Standford Scholar,” Stanford News, Stanford University Communications, 2021, https://news.stanford.edu/2021/02/10/dresscodes-reveal-politics-social-change/.

Goffman, Erving. “The Presentation of Self in Everyday Life.” Anchor Books, New York, 1959.

Mhoon, Abena L. “Dressing for Freedom.” Black History Bulletin, 67(1/4), 26-29, 2004.

Nachmen, Corey. “The 30 Strangest Superstitions In Sports History.” Business Insider, 2011, https://www.businessinsider.com/thestrangest-pre-game-rituals-2011-8.

Sedgwick, Icy. “The Folklore of Clothes: Defying Fairies, Finding Love, and Bringing Luck.” Icy Sedgwick, 2023, https://www.icysedgwick.com/folklore-of-clothes/.

AI Statement

AI was not used in the development of this submission, apart from the Editor feature on Microsoft Word for minor edits like spelling check and tone suggestions.

From Policy to Practice: Advocating Systemic Reforms for Climate Change Solutions

Jocelyn Escobar

Faculty Mentor: Josh Blakely, M.S.Ed. Cormier Honors College

Climate change is a critical public issue that extends beyond personal concerns, impacting communities, economies, and ecosystems worldwide. Its consequences include rising sea levels, more frequent extreme weather events, and disruptions to food and water supplies. These challenges require collaborative efforts and informed decision-making to address effectively. Advocating for systemic reforms in industries and policies is essential to address the root causes of climate change effectively. This includes not only transitioning to renewable energy sources but also rethinking consumption patterns, waste management, and corporate practices. This paper explores the systemic changes necessary to combat climate change, the role of large corporations in this transfor-

mation, and effective advocacy strategies to mobilize individuals, communities, and policymakers. By understanding these interconnected elements, we can work toward a more sustainable future that prioritizes environmental integrity and social equity. Engaging diverse stakeholders, from grassroots organizations to corporate leaders, is crucial to fostering a uniﬁed approach that addresses the complexities of climate change. In his 2017 book, You Are More Powerful Than You Think, community organizer Eric Liu outlines several practical strategies that climate change activists can use to effectively drive change.

Systemic reforms target the underlying structures and practices that contribute to climate change.

According to climate scientist Larry Collins, reform begins with identifying the root causes of the problem. While individual actions can lead to meaningful change, the primary responsibility lies with corporations that signiﬁcantly contribute to carbon emissions and environmental degradation. Effective systemic reform involves transitioning to renewable energy sources and implementing policies that incentivize sustainable practices. Liu’s Strategy 1, “Adjust the Arena,” plays a key role in addressing this issue. Liu suggests reframing climate change—from a distant issue to one that affects every individual’s health, security, and economy—to create urgency and collective action. By reframing climate change this way, we can shift the perception that these issues are abstract, instead showing how they are personal and immediate (Liu, 2017). This approach can garner greater public support for policies that tackle the climate crisis, as people will view climate action as essential for their well-being, not just for the environment.

Energy Production: The fossil fuel industry is a primary contributor to climate change and requires immediate reform. A shift toward renewable energy sources such as wind and solar is crucial. Policies should

support the development of technologies that harness these renewable resources effectively. Liu’s Strategy 3, “Attack Your Opponent’s Plan,” is key to advancing the renewable energy agenda. Communities and activists can build networks to demand renewable energy policies from local, state, and federal governments. Liu argues that by joining forces, individuals and groups can exert pressure on larger systemic structures, demanding change that corporations and governments cannot ignore (Liu, 2017). Organizing and amplifying collective action can make renewable energy a priority on the political agenda, pushing for comprehensive reforms at all levels of governance.

Corporate Responsibility: Large corporations play a pivotal role in addressing climate change. A recent survey of U.S. corporations revealed that while they have been slow to adopt sustainability practices, many now recognize their responsibilities (Hashmi et al., 2015). These corporations are increasingly investing in energy-efficient methods and renewable energy sources, albeit with a stronger focus on domestic operations compared to international ones. Liu’s Strategy 5, "Organize in Narratives," provides a valuable framework for corporations to tell

a positive story about their role in combating climate change. By embracing sustainability, companies can create a new narrative, positioning themselves not only as proﬁt-driven entities but also as stewards of the planet. As Liu suggests, the story a company tells itself about its contribution to societal good can be just as important as its bottom line. A compelling sustainability narrative can inspire both employees and consumers to act (Liu, 2017). When corporations shift their narrative to one of sustainability, they inﬂuence public perception and set a model for others in the industry.

Regulatory measures such as carbon pricing, cap-and-trade mechanisms, and carbon emission quotas are essential in driving investments in low-carbon technologies (Chen, Ma, & Bai, 2024). Research shows that benchmarking allocation tends to result in higher investments in low-carbon technology compared to grandfathering allocation. This suggests that effective regulatory frameworks can incentivize corporations to adopt greener practices. Emphasis on transparency further underscores this point. Regular reporting on emissions and sustainability practices enables consumers and investors to hold corporations accountable, reinforcing a cycle of

positive change. Transparency allows for external pressure that can push corporations to continue improving their environmental performance and align their business practices with sustainability goals.

Large corporations must transition from being part of the problem to becoming part of the solution. Their involvement in sustainability practices is vital for systemic reforms. As noted in the survey-based research, companies are engaging in various sustainability initiatives, including investing in renewable energy sources and supporting environmental organizations (Hashmi et al., 2015). However, there are discrepancies between domestic and international efforts, indicating that corporations need to prioritize sustainability equally across all operations. This shift not only supports climate goals but also improves corporate proﬁtability and public image. The examination of corporate sustainability practices reveals that corporations investing in energy-efficient technologies not only reduce their carbon footprint but also enhance their competitiveness in the market. Generating electricity from renewable sources such as solar and wind has gained traction among large corporations. By prioritizing these energy sources, they can signiﬁcantly

reduce greenhouse gas emissions. Responsible disposal of chemical waste and adoption of circular economic principles are crucial for mitigating environmental harm. Effective corporate waste management practices can reduce pollution and contribute to a healthier ecosystem. For corporations to truly help ﬁght climate change, they need to be open about their actions and responsible for their impact on the environment. This means sharing information about their emissions and sustainability practices. When companies report on their environmental efforts regularly, it builds trust and encourages them to do better. Using frameworks like the Global Reporting Initiative (GRI) can help companies disclose their environmental impact. Transparency, a central concept in Liu’s framework, allows consumers and investors to hold corporations accountable, reinforcing a cycle of positive change (Liu, 2017).

Advocating for systemic reforms requires a multi-faceted approach, including public awareness, collaboration among stakeholders, and strategic use of regulatory frameworks. Raising public awareness is a crucial step in addressing climate change. Collins emphasizes that discussing climate change and its implications can signiﬁcantly enhance

public understanding and concern. Utilizing relatable frames—linking climate change to economic stability and public health—can foster a sense of urgency and motivate collective action (Collins, 2024).

Liu’s Strategy 1, “Reframe the Narrative,” plays a critical role here by helping advocates frame climate change as a fundamental issue of survival and justice. This reframing can encourage individuals to see their responsibility as practical, as it will directly affect their lives and livelihoods (Liu, 2017). By emphasizing the personal, immediate stakes of climate change, advocates can create a more inclusive and compelling narrative that engages a broader audience.

Collaboration between advocacy groups and corporations is essential for driving meaningful reforms. “Knowledge co-production,” a concept where stakeholders come together to address complex social issues, can be highly effective here (Collins, 2024). By leveraging each stakeholder’s expertise, comprehensive strategies can be developed to promote sustainability and environmental justice. Advocacy efforts must also target policymakers to create supportive regulatory environments. Engaging in dialogue with legislators can lead to the development of effective climate

policies. Supporting initiatives such as renewable energy incentives or establishing stricter emissions regulations can facilitate the transition to a sustainable economy.

Consumer advocacy is vital in pushing companies to adopt sustainable practices. As people become more aware of climate issues, they often choose to buy eco-friendly products. This demand motivates companies to develop greener alternatives. Liu’s Strategy 3, "Build Your Power," is essential here because it encourages individuals and groups to organize collective action, increasing the power of consumer demand. Campaigns promoting sustainable sourcing and zero-waste packaging, for example, can lead companies to change how they operate. Education also plays a powerful role in advocating for climate action. By teaching students about climate change, we can create a generation that cares about sustainability. Educational programs can also highlight how climate change disproportionately affects marginalized communities, fostering empathy and support for equity-based reforms. Public engagement is vital in the ﬁght against climate change. By raising awareness, sharing information, and encouraging community involvement, individuals can create

a groundswell of support for sustainable practices. When communities demand accountability, businesses innovate and change (Liu, 2017). Collaborative efforts between grassroots organizations, corporations, and policymakers can drive systemic reforms that address the root causes of climate change effectively.

Despite the clear path toward systemic reform, several challenges remain. One signiﬁcant hurdle is the ideological divide surrounding climate change. Research indicates that individuals with conservative ideologies may perceive climate-related reforms as threats to their economic and cultural values (Stanley et al., 2024). This asymmetry in threat perception, often rooted in political, cultural, and sometimes misinformation-based divides, leads to lower support for climate policies among conservatives, complicating advocacy efforts. To overcome these barriers, it is essential to frame climate change discussions in ways that resonate with diverse audiences. Advocates should emphasize the economic beneﬁts of climate action, such as job creation in the renewable energy sector and cost savings from energy efficiency. Building coalitions that include voices from various political and social backgrounds can enhance

the credibility of climate advocacy efforts. Liu’s approach to narrative change aligns with this, emphasizing that advocates must ﬁnd ways to communicate issues in a way that appeals to a broader spectrum of beliefs. For instance, framing climate action as an opportunity for economic growth and resilience can help bridge ideological divides (Liu, 2017).

Effectively advocating for systemic reforms in industries and policies to address climate change requires a concerted effort from all sectors of society, particularly from large corporations. By acknowledging their role and responsibility in this transition, corporations can play a pivotal part in fostering a sustainable future. Raising public awareness, promoting collaboration among stakeholders, and engaging policymakers are essential for achieving meaningful progress. Climate change is not just an environmental issue; it intersects with social and economic justice, disproportionately impacting the most vulnerable communities. As we address this urgent challenge, reforms that prioritize sustainability, equity, and corporate accountability will be critical to ensuring a healthier planet for future generations. By enhancing transparency, encouraging consumer advocacy, supporting

grassroots movements, and emphasizing education, we can develop effective climate action strategies. The collective action of individuals, businesses, policymakers, and advocacy groups is crucial to driving the systemic reforms needed for a sustainable future.

Works Cited

Larry Collins (Professor of Environmental Science), interviewed by Jocelyn J. Escobar, October 23, 2024, transcript and recording.

Chen, W., Ma, Y., & Bai, C. (2024). The Impact of Carbon Emission Quota Allocation Regulations on the Investment of Low-Carbon Technology in Electric Power Industry Under Peak-Valley Price Policy. IEEE Transactions on Engineering Management, 71. https://doi.org/10.1109/TEM.2021.3121002

Hashmi, M. A., Damanhouri, A., & Rana, D. (2015). Evaluation of Sustainability Practices in the United States and Large Corporations. Journal of Business Ethics, 127(3), 673–681. https://doi.org/10.1007/s10551-014-2056-4

Mills, D., Schwartz, J., Lee, M., Saroﬁm, M., Jones, R., Lawson, M., Duckworth, M., & Deck, L. (2015). Climate change impacts on extreme temperature mortality in select metropolitan areas in the United States. Climatic Change : An Interdisciplinary, International Journal Devoted to the Description, Causes and Implications of Climatic Change, 131(1), 83–95. https://doi.org/10.1007/s10584-0141154-8

Liu, E. (2023). You are more powerful than you think: A citizen’s guide to making change happen. PublicAffairs.

Stanley, S. K., Jylhä, K. M., Leviston, Z., & Walker, I. (2024). Is conservative opposition to climate change threat-based? Articulating an integrated threat model of climate change attitudes. British Journal of Social Psychology, 63, 879–893. https://doi.org/10.1111/ bjso.12710

AI Statement

In the development of the this paper, I utilized OpenAI’s ChatGPT as a tool to assist with drafting the title. I also used Grammarly to suggest phrasing and structure. The ﬁnal content was reviewed and approved by me. No additional AI tools were used in this process.

Complementary Medicines and Practices for Type 2 Diabetes Self-Management

Olivia Hildreth

Faculty Mentor: Amanda Blaisdell, Ph.D.

Department of Health, Recreation, and Kinesiology

Diabetes has been thought to be adequately managed with a healthy diet and exercise. However, that is not the case for some patients; these individuals need some other type of intervention. Complementary medicines or holistic strategies may be promising for managing diabetes. If proper diet and exercise are not helping a patient with diabetes enough, they can use complementary therapies to help their glycated hemoglobin test results (A1C) go down. To explore the hypothesis, this study examines the literature on how supplements like Ashwagandha, yoga, and counseling may help patients manage their diabetes more effectively. The population of interest is middle-aged people who have tried the recommended diet and practiced moderate exercise but are seeing no

improvements in their A1C. Those diagnosed with type II diabetes may beneﬁt from a good diet, exercise, yoga, ashwagandha supplements, and diabetes management counseling. Current research supports daily yoga (Singh, 2020) and taking supplements in diabetes management (Lopresti et al., 2019), as well as attending diabetes counseling (Hashim, 2022).

Lifestyles with healthy eating and exercise may make it easier to manage diabetes (Adeva-Andany et al., 2019). Although good lifestyle habits can help, other habits can worsen it. Those who drink and smoke can worsen the risk or cause their diabetes to worsen (Feng et al., 2023). Additionally, cultural practices may act like peer pressure and make it hard for patients to

manage their diabetes effectively (Jang, 2023). Studies still need to assess whether complementary health strategies such as taking ashwagandha, practicing yoga, or attending counseling could help manage A1C better than diet and exercise alone. A combination of therapies or the addition of another beneﬁcial therapy that has not yet been practiced could revolutionize diabetes care and patient self-management.

Complementary therapies may also improve patients' lives. For example, yoga is considered an agonist in glycemic control (Singh & Khandelwal, 2020b). If yoga can improve glycemic control, then a person who practices yoga for a prolonged period may be better able to successfully manage their A1C numbers. Complementary therapies can also reduce stress associated with financial burdens and can help patients diagnosed with type II diabetes in the long run and reduce anxieties that may contribute to insufficient adherence to medical advice for diabetes management (Blanchette et al., 2021). Complementary medicines have been found to cost significantly less than other therapies. Saving money on medicines and therapies, can lessen financial strain and relieve stress on the patient overall (Socal

et al., 2022). Yoga can also be practiced at home. For example, Nike Training Club offers yoga and stretching classes right in a person's home (Richards, 2023), and the website DoYogaWithMe offers free yoga class for any person on any level of learning (DoYogaWithMe, 2025).

Lowering overall stress can help a person with type II diabetes manage their condition and can aid in lowering high blood pressure, a common comorbidity for those with type II diabetes (Hashim, 2022). The supplement ashwagandha has been shown to help with stress levels, improve stress resilience, and reduce anxiety (Nyak et al., 2015). It has been found to have stress-relieving effects on the hypothalamuspituitary-adrenal axis, the part of the brain that controls stress, (Lopresti et al., 2019). Ashwagandha may also improve sleep, giving the body a chance to work and heal itself (Mikulska et al., 2023). Ashwagandha is a lowcost supplement. For example, a 60-day count of ashwagandha from Walmart costs about $10.00 (Walmart 2025). It is also offered at pharmacies like CVS, Target, and Amazon. (Perspective on Traditional Herbal Medicine— Ashwagandha, 2022).

Diabetes management counseling can help patients manage diabetes accurately by helping to reduce anxieties associated with identifying lifestyle changes that are both feasible and quickly adopted into everyday life. Lifestyle counseling to aid in diabetes management allows individuals with low health literacy to feel more in control of their health as they work with a professional who can identify feasible solutions for complex health conditions (Hashim, 2022). There are also free counseling options that may be beneﬁcial for patients. Websites such as Dietitian Live offer nutrition therapy to help patients develop a management plan for their diabetes along with addressing other issues that could be making the condition worse. Dietitian Live addresses stress, sleep, and exercise, and the sessions are fully remote (DietitianLive, 2025). When patients hear “therapy,” they may assume it will be expensive and will not look into it. If a person also has a pre-existing severe mental illness that has gone untreated, that may also make them less willing to participate in therapy (Berry et al., 2020).

For patients who have tried the suggested diets and exercise but do not see improvements, in addition to these traditional therapies, other

interventions may be needed. Patients may benefit from introducing alternative or complementary ways to improve their diabetes management with fewer traditionally prescribed pharmaceuticals. While complementary health strategies have been carefully selected, they may affect some people differently and interact with other pharmaceuticals and substances, harming the person. While this chance is present, it does not mean it will happen. Whenever a patient experiments with new therapies, there is a chance of harm due to unexpected outcomes or interactions. More studies need to be conducted to determine the benefits of a combination of alternative or complementary strategies, which may be used in addition to traditionally prescribed pharmaceuticals. Safe studies that explore the benefits of various complementary therapies for diabetes are necessary so that patients can find alternatives to medicines and improve their quality of life through lifestyle management. The suggested therapies benefit everyone, regardless of a diagnosis of type II diabetes or not. It stands to reason that patients who explore these alternative and complementary strategies will improve their quality of life and wellness.

References

Adeva-Andany, M. M., Rañal-Muíño, E., VilaAltesor, M., Fernández-Fernández, C., Funcasta-Calderón, R., & Castro-Quintela, E. (2019). Dietary habits contribute to deﬁne the risk of type 2 diabetes in humans. Clinical Nutrition ESPEN, 34, 8–17. https://doi.org/ 10.1016/j.clnesp.2019.08.002

Blanchette, J. E., Toly, V. B., & Wood, J. R. (2021). Financial stress in emerging adults with type 1 diabetes in the United States. Pediatric Diabetes 22(5), 807-815. https://doi.org/10.1111/pedi.13216

Berry, K., Sheardown, J., Pabbineedi, U., Haddock, G., Cross, C., & Brown, L. J. E. (2020). Barriers and facilitators to accessing psychological therapies for severe mental health difﬁculties in later life. Behavioural and Cognitive Psychotherapy, 48(2), 216–228. https://doi.org/10.1017/S1352465819000596

Colella, M., Charitos, I. A., Ballini, A., Caﬁero, C., Topi, S., Palmirotta, R., & Santacroce, L. (2023). Microbiota revolution: How gut microbes regulate our lives. World Journal of Gastroenterology, 29(28), 4368–4383. https://doi.org/10.3748/wjg.v29.i28.4368

Diabetes — Dietitian Live. (2024, August 15). Dietitian Live. https://dietitianlive.com/welcome/diabetes/?utm_source=google&utm_ medium=cpc&utm_campaign=diabetes_broa d_tcpa&gad_source=1&gbraid=0AAAAAqiPZBLWX2jr0poa1K0JgO_pwILD1&gclid=Cjw KCAiA8Lu9BhA8EiwAag16bwdd3zlOaS_HI8t yerQNMSznFo55fcHSBLtmScsXbbdGNt7fxo YkJBoClnMQAvD_BwE

Free Online Yoga Videos — Classes and Poses | DoYogaWithMe.com. (2025). Doyogawithme.com. https://www.doyogawithme.com/

Feng, C., Feng, L., Shan, Z., Han, H., Cao, Y., Sheng, A., Guash, M., & Wang, L. (2023). Abstract P344: Trends and Disparities in Lifestyle Quality Among US Adults With Diabetes. Circulation, 147(Suppl_1). https://doi.org/10.1161/circ.147.suppl_1.p344

Hashim, M. J. (2022). The art of diabetes care: guidelines for a holistic approach to human and social factors. Journal of Yeungnam Medical Science, 40(2). https://doi.org/ 10.12701/jyms.2022.00577

Jang, S.-M. (2023). Diabetes Self-Management in Vulnerable Populations. The Journal of Korean Diabetes, 24(2), 102–106. https://doi.org/10.4093/jkd.2023.24.2.102

Lopresti,A.L., Smith, S.J., Malvi, H., Kodgule, R. (2019).An Investigation into the stress-relieving and pharmacological actions of an ashwagandha (Withania somnifera) extract. A randomized,double-blind,placebo-controlled study. https://pmc.ncbi.nlm.nih.gov/ articles/PMC6750292/

Mikulska, P., Malinowska, M., Ignacyk, M., Szustowski, P., Nowak, J., Pesta, K., Szeląg, M., Szklanny, D., Judasz, E., Kaczmarek, G., Ejiohuo, O. P., Paczkowska-Walendowska, M., Gościniak, A., & Cielecka-Piontek, J. (2023). Ashwagandha (Withania somnifera)—Current research on the health-promoting activities: A narrative review. Pharmaceutics, 15(4), 1057. https://doi.org/10.3390/pharmaceutics15041057

Nyak, S., Kayak., S., Panda, B. K., & Das, S. (2015). A clinical study on management of stress in type-2 diabetes mellitus (madhumeha) with ashwaghanda (withania sominfera). Ayuhdhara 2(6), 413-417. https://doi.org/10.1007/s13668-023-00481-0

Dev, A., & Kadam, D. S. (2022). Perspective on Traditional Herbal Medicine – Ashwagandha. Journal of Advances in Bio- Pharmaceutics and Pharmacovigilance, 4(1), 9–22. http://matjournals.co.in/index.php/JABP/article/view/501

Richards, A. (2023, March 30). Nike Training Club on Netflix launches Dec. 30: Everything you need to know. Netflix Tudum. https://www.netflix.com/tudum/articles/niketraining-club

Singh, V., & Khandelwal, B. (2020b). Effect of yoga and exercise on glycemic control and psychosocial parameters in type 2 diabetes mellitus: A randomized controlled study. International Journal of Yoga, 13(2), 144. https://doi.org/10.4103/ijoy.ijoy_45_19

Singla, D. R., Schleider, J. L., & Patel, V. (2023). Democratizing access to psychological therapies: Innovations and the role of psychologists. Journal of Consulting and Clinical Psychology, 91(11), 623–625. https://doi.org/10.1037/ccp0000850

Socal, M. P., Cordeiro, T., Anderson, G. F., & Bai, G. (2022). Estimating savings opportunities from therapeutic substitutions of highcost generic medications. JAMA Network Open, 5(11), e2239868. https://doi.org/ 10.1001/jamanetworkopen.2022.39868

AI Statement

In developing the citations of this Literature Review: Complementary Medicines and Practices for Type 2 Diabetes Self-Management, AI was used to complete citations. The AI websites used were mybib and Citation-Machine. Mybib and Citation-Machine were provided the URL’s for the sources to complete the appropriate citations. No additional AI tools were used in this process.

Feeding and Swallowing Disorders in Children with Autism: What Caregivers Need to Know

Olivia Hopkins

Faculty Mentor: Shannon Salley, Ph.D.

Department

of Social Work and Communication Sciences and Disorders

Abstract

This study investigates the complex topic of feeding and swallowing disorders in children with autism, highlighting the signiﬁcant challenges they pose, particularly related to sensory sensitivities and oral motor difficulties and the persistent lack of understanding around these disorders. It examines diagnostic criteria, risks, familial impacts, cultural nuances, and evidence-based intervention strategies, with a focus on practical guidance for caregivers to equip them with resources for navigating these challenges (Schulz & Eden, 2016). Despite the prevalence of these disorders, many remain unaware of the struggles, underscoring the urgent need for targeted investigations and supportive meas-

ures. Speciﬁcally, this paper aims to provide Speech Language Pathologists with the tools to empower caregivers to better support families of autistic children facing feeding and swallowing difficulties (Gent et al., 2024).

Introduction

Feeding and swallowing disorders are signiﬁcant, yet often overlooked, challenges faced by children with autism spectrum disorder. (Adams, 2022). Although these disorders are prevalent among autistic children, research remains limited, leaving caregivers with inadequate resources to effectively address them (Tathgur & Kang, 2021).

This paper argues that a deeper understanding of the diagnostic criteria, risks, and intervention strategies

is crucial for improving the lives of these children and their families. Specifically, this study aims to answer the research question: How can caregivers be better equipped to assist autistic children with feeding and swallowing disorders? To address this, we will examine existing diagnostic criteria and propose potential modifications, enabling caregivers to better recognize and manage these difficulties. These challenges, characterized by sensory sensitivities, oral motor impairments, and communication deficits, can lead to selective eating, nutritional deficiencies, and respiratory complications, significantly impacting the health and well-being of affected children (Adams, 2022). Moreover, the stress and strain of managing these disorders can profoundly affect family dynamics, contributing to conflicts, financial burdens, and caregiver burnout (Kayaalp et al., 2020). Cultural and societal factors, including beliefs, norms, and access to resources, further influence the perception and management of feeding and swallowing disorders in autistic children (Adams, 2022). By exploring these factors and providing practical guidance for caregiving, this research seeks to empower caregivers with the knowledge and resources necessary to effectively support their autistic children.

Literature Review

Feeding and swallowing disorders present a significant, multifaceted challenge for autistic children, impacting their health and well-being (Adams, 2022). Research consistently demonstrates the prevalence of these difficulties, with studies reporting rates between 46% and 89%, underscoring their clinical significance (Sharp et al., 2013). Sensory sensitivities are a primary factor, often resulting in food aversions and selective eating patterns (Chistol et al., 2017). Additionally, oral motor impairments contribute to difficulties with chewing, swallowing, and managing food boluses (chewed-up food), increasing the risk of respiratory complications. Communication deficits and behavioral challenges further complicate mealtimes, disrupting feeding routines and exacerbating caregivers' stress. The impact of feeding and swallowing disorders extends beyond the affected children to their families, with caregivers experiencing stress and disruptions in family dynamics (Lefton-Greif et al., 2014). There are also financial burdens associated with specialized diets and therapy, which add to the challenges faced by families, exacerbating existing stressors. Behavioral interventions, such as applied behavior analysis (ABA) and

systematic desensitization show promise in expanding food repertoires and improving mealtime behaviors (Sarcia, 2020). Sensorybased approaches, including sensory integration therapy and oral motor therapy, aim to address underlying sensory and motor dysfunction contributing to feeding difficulties (Addison et al., 2012). It is important to integrate collaboration with professionals such as healthcare professionals, educators, and community organizations to provide holistic care and support to autistic children and their families.

Diagnostic Criteria

Clear and standardized diagnostic criteria are essential for identifying feeding and swallowing disorders in autistic children. While the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) outlines criteria for autism spectrum disorder, it does not address feeding and swallowing difficulties as core features of ASD. As a result, clinicians often rely on observational assessments and parent/ caregiver reports to identify these hardships (Baraskewich et al., 2021). Recent research suggests the need to incorporate feeding and swallowing concerns into the diagnostic framework for ASD. This recognition originates from the growing under-

standing of the prevalence and clinical significance of these disorders in autistic individuals (Adams, 2022). Proposed modifications to existing diagnostic criteria may include specific indicators such as feeding behaviors, sensory sensitivities, oral motor impairments, and associated medical conditions. For example, diagnostic criteria could include observations of food refusal, selective eating patterns, gagging or choking during meals, prolonged meal times, or avoidance behaviors related to specific textures or tastes (Esposito et al., 2023). Early intervention is crucial for addressing these challenges effectively and minimizing the risk of associated complications such as malnutrition, aspiration pneumonia, and psychosocial difficulties.

Recognizing feeding and swallowing disorders as integral components of ASD diagnosis can enhance access to specialized services and support for affected children and their families. Multidisciplinary teams comprising speechlanguage pathologists, occupational therapists, dietitians, and medical professionals can collaborate to develop tailored intervention plans that address the unique needs of each child (Okoye et al., 2023).

What Feeding

and Swallowing Disorders Look Like in Autistic Children

Feeding and swallowing disorders in autistic children manifest in diverse ways, reflecting the complexity of sensory, motor, and behavioral factors (Adams, 2022). These disorders can significantly impact a child's ability to consume food safely and effectively, potentially leading to nutritional deficiencies, respiratory complications, and psychosocial challenges (Sharp et al., 2013).

A prominent feature of these disorders is sensory sensitivity. Many autistic individuals exhibit heightened sensitivity to certain textures, tastes, smells, or visual stimuli, resulting in aversions and preferences for specific foods (Chistol et al., 2017). For example, a child may refuse foods with specific textures, such as crunchy or slimy, or react strongly to particular tastes, such as sour or bitter. These sensory sensitivities can lead to highly selective eating patterns, where the child accepts only a limited range of foods, often resulting in nutritional imbalances and deficiencies (Cermak et al., 2010).

difficulties with oral motor coordination, which can affect their ability to chew, swallow, and manage food boluses effectively (Lefton-Greif et al., 2014). These difficulties may present as gagging, choking, or coughing during meals, as well as prolonged meal times and fatigue associated with eating.

Children with oral motor impairments may also exhibit inefficient chewing or swallowing patterns, increasing the risk of aspiration and respiratory complications (Kosutova & Mikolka, 2021).

Communication deﬁcits and behavioral challenges further complicate the feeding and swallowing process for autistic children. Difficulty communicating hunger or discomfort, limited expressive language skills, and challenges with social interaction can make it challenging for the child to express their needs or preferences during mealtimes (Volkert & Vaz, 2010). Behavioral patterns such as insistence on sameness and sensory-seeking behaviors can disrupt mealtime routines and exacerbate feeding difficulties (Sarcia, 2020).

In addition to sensory sensitivities, autistic children may experience

The presentation of feeding and swallowing disorders in autistic children varies widely depending on individual differences in sensory sensitivities, oral motor abilities,

communication skills, and behavioral patterns (Adams, 2022). Some children may exhibit mild difficulties with speciﬁc food textures or tastes, while others may have severe aversions and struggles with oral motor coordination. Additionally, co-occurring medical conditions such as gastroesophageal reﬂux disease (GERD), constipation, or food allergies can further complicate feeding difficulties in autistic children (Al-Beltagi et al., 2023).

The Effects/ Risks of Feeding and Swallowing Disorders in Children

Feeding and swallowing disorders in children, particularly when left untreated or poorly managed, can have profound and wide-ranging effects on their physical health, nutritional status, and overall wellbeing. These disorders have signiﬁcant risks that extend beyond the immediate challenges of mealtime difficulties, impacting various aspects of the child's development and quality of life. One of the primary effects of feeding and swallowing disorders in children is nutritional deﬁciency. Children with these disorders often have limited diets due to sensory aversions, oral motor difficulties, or behavioral challenges, resulting in inadequate intake of essential nutrients.

This can lead to malnutrition, nutrient deﬁciencies, and failure to thrive, impairing growth and development during critical stages of childhood (Van den Engel-Hoek et al., 2015). Feeding and swallowing disorders increase the risk of aspiration, a potentially life-threatening complication in which food or liquid enters the airway instead of the digestive tract. Aspiration can lead to aspiration pneumonia, a serious respiratory infection that can cause lung damage, respiratory distress, and even death if left untreated.

Children with compromised swallowing function, such as those with dysphagia or oral motor impairments, are particularly vulnerable to aspiration and its associated complications (Kosutova and Mikolka, 2021). In addition to the immediate physical risks, feeding and swallowing disorders can have longterm consequences for the child's health and well-being. Chronic malnutrition and inadequate nutrient intake can impair cognitive development, weaken the immune system, and increase the risk of chronic health conditions such as obesity, diabetes, and cardiovascular disease later in life (Groce et al., 2014). Something else to understand is the stress and anxiety associated with feeding difficulties can impact the child's emotional and psychological well-being, leading to social with-

drawal, behavioral problems, and diminished quality of life. Caregivers often experience heightened stress, anxiety, and feelings of guilt or inadequacy when faced with the challenges of managing their child's feeding difficulties (Garro et al., 2005). These disorders place signiﬁcant demands on healthcare resources, including diagnostic assessments, therapeutic interventions, and ongoing monitoring and support.

Impact on Family Dynamic

Feeding and swallowing disorders in children with autism spectrum disorder exert signiﬁcant stressors on family dynamics, affecting relationships, routines, and overall wellbeing (Lefton-Greif et al., 2014). The challenges associated with managing these disorders permeate various aspects of family life, leading to emotional strain, ﬁnancial burdens, and disruptions in daily functioning (Kayaalp et al., 2020). One of the primary impacts of feeding and swallowing disorders on family dynamics is the heightened stress and anxiety experienced by caregivers (Garro et al., 2005). Parents often feel overwhelmed and powerless when confronted with their child's feeding difficulties, leading to feelings of frustration, guilt, and inadequacy. The constant

worry about their child's nutritional intake, safety during mealtimes, and long-term health outcomes can take a toll on caregivers' mental and emotional health, contributing to heightened levels of stress and burnout (Tathgur & Kang, 2021). Feeding and swallowing disorders disrupt family routines and mealtime dynamics, creating tension and conﬂict within the household (Ausderau et al., 2019). Mealtime battles, food refusal, and behavioral challenges turn mealtimes into stressful and chaotic events, straining relationships between family members and diminishing the enjoyment of shared meals. Siblings may feel neglected or resentful of the attention directed towards the affected child, further exacerbating family tensions.

The emotional impact of feeding and swallowing disorders extends beyond the immediate family to extended relatives and social networks. Caregivers experience feelings of isolation and social withdrawal as they struggle to navigate their child's feeding difficulties and cope with the associated stressors (Tathgur & Kang, 2021). Stigmatization and misconceptions surrounding feeding disorders in autism compound these feelings, leading to increased feelings of shame and isolation among affected families.

Despite these challenges, families affected by feeding and swallowing disorders in children with autism demonstrate resilience and resourcefulness in navigating these difficulties (Adams, 2022). Supportive networks of family, friends, and healthcare professionals play a crucial role in providing emotional support, practical assistance, and guidance to caregivers, helping them cope with the challenges they face (Bosch & Mansell, 2015).

Intervention Strategies

Addressing feeding and swallowing disorders in children with autism spectrum disorder requires a multidisciplinary approach that considers the complex interplay of sensory, motor, communication, and behavioral factors. A variety of intervention strategies tailored to the individual needs and preferences of each child can help improve feeding skills, promote nutritional intake, and enhance overall well-being. Behavioral interventions, such as applied behavior analysis and systematic desensitization, focus on modifying behaviors related to feeding difficulties and increasing acceptance of a wider range of foods (Adams, 2022). Systematic desensitization involves gradual exposure to feared or aversive stimuli in a controlled and supportive

environment, helping children overcome sensory sensitivities and expand their food repertoires. Sensory-based approaches target underlying sensory processing difficulties that contribute to feeding challenges in children with ASD. Sensory integration therapy, which involves structured sensory activities aimed at regulating sensory responses, can help children become more tolerant of various food textures and tastes (Tanner and Andreone, 2015). Oral motor therapy focuses on improving oral motor coordination and strength through exercises targeting the lips, tongue, and jaw, facilitating more efficient chewing and swallowing (Wilson et al., 2021). Collaboration with healthcare professionals, including speech-language pathologists, occupational therapists, dietitians, and physicians, is essential for developing comprehensive intervention plans that address the diverse needs of children with feeding and swallowing disorders in ASD. Speech-language pathologists can assess oral motor function, swallowing abilities, and communication skills, guiding the development of individualized feeding goals and strategies (Adams, 2022). Providing education, training, and support to caregivers empowers them to implement strategies and techniques at home to reinforce positive feed-

ing behaviors and advocate for their child's needs within the community (Arikpo et al., 2018).

Conclusion

In conclusion, addressing feeding and swallowing disorders in children with autism spectrum disorder requires a comprehensive and multidisciplinary approach that considers the unique needs and challenges of each child. Caregivers play a crucial role in supporting children with autism spectrum disorder who experience feeding and swallowing difficulties. By implementing practical strategies, providing emotional support, and fostering a positive mealtime environment, caregivers can help facilitate successful feeding experiences and promote the overall well-being of their children (Adams, 2022). Establishing a routine mealtime can help children with ASD feel comfortable. Consistency and predictability can reduce anxiety and resistance surrounding food. It is essential to prioritize early intervention and ongoing support to address feeding and swallowing difficulties effectively and minimize the risk of associated complications. Early identiﬁcation and intervention can signiﬁcantly improve outcomes and enhance the quality of life for children with ASD and their families (Ausderau et al.,

2019). Collaboration between caregivers, healthcare professionals, educators, and community organizations is key to providing holistic and coordinated care that addresses the diverse needs of affected individuals and promotes positive outcomes (Bosch and Mansell, 2015). By raising awareness, promoting education, and advocating for the needs of individuals with ASD and their families, we can work towards creating a more inclusive society where all children have the opportunity to thrive and reach their full potential.

References

Adams, S. N. (2022). Feeding and swallowing issues in autism spectrum disorders. Neuropsychiatric Disease and Treatment, (18), 2311–2321. https://doi.org/10.2147/ndt.s332523

Addison, L. R., Piazza, C. C., Patel, M. R., Bachmeyer, M. H., Rivas, K. M., Milnes, S. M., and Oddo, J. (2012). A comparison of sensory integrative and behavioral therapies as treatment for pediatric feeding disorders. Journal of Applied Behavior Analysis, 45(3), 455–471. https://doi.org/10.1901/ jaba.2012.45-455

Al-Beltagi, M., Saeed, N. K., Bediwy, A. S., Elbeltagi, R., and Alhawamdeh, R. (2023). Role of gastrointestinal health in managing children with autism spectrum disorder. World Journal of Clinical Pediatrics, 12(4), 171–196. https://doi.org/10.5409/wjcp.v12.i4.171

Arikpo, D., Edet, E. S., Chibuzor, M. T., Odey, F., and Caldwell, D. M. (2018). Educational interventions for improving primary caregiver complementary feeding practices for children aged 24 months and under. Cochrane Database of Systematic Reviews, 5(5). https://doi.org/10.1002/14651858.cd011768. pub2

Ausderau, K. K., St. John, B., Kwaterski, K. N., Nieuwenhuis, B., and Bradley, E. (2019). Parents’ strategies to support mealtime participation of their children with autism Spectrum Disorder. American Journal of Occupational Therapy, 73(1), 7301205070p1. https://doi.org/10.5014/ajot.2019.024612

Baraskewich, J., von Ranson, K. M., McCrimmon, A., & McMorris, C. A. (2021). Feeding and eating problems in children and adolescents with autism: A scoping review. The international journal of research and practice, 25(6), 1505–1519. https://doi.org/10.1177/ 1362361321995631

Bosch, B., and Mansell, H. (2015). Interprofessional collaboration in health care. Canadian Pharmacists Journal, 148(4), 176–179. https://doi.org/10.1177/1715163515588106

Chistol, L. T., Bandini, L. G., Must, A., Phillips, S., Cermak, S. A., and Curtin, C. (2017). Sensory sensitivity and food selectivity in children with autism spectrum disorder. Journal of Autism and Developmental Disorders, 48(2), 583–591. https://doi.org/10.1007/ s10803-017-3340-9

Esposito, M., Mirizzi, P., Fadda, R., Pirollo, C., Ricciardi, O., Mazza, M., and Valenti, M. (2023). Food selectivity in children with autism: Guidelines for assessment and clinical interventions. International Journal of Environmental Research and Public Health, 20(6),

5092. https://doi.org/10.3390/ ijerph20065092

Garro, A., Thurman, S. K., Kerwin, M. E., and Ducette, J. P. (2005). Parent/caregiver stress during pediatric hospitalization for chronic feeding problems. Journal of Pediatric Nursing, 20(4), 268–275. https://doi.org/10.1016/ j.pedn.2005.02.015

Gent, V., Marshall, J., Weir, K. A., and Trembath, D. (2024). Investigating the impact of autistic children’s feeding difficulties on caregivers. Child: Care, Health and Development, 50(1), e13218. https://doi.org/10.1111/cch.13218

Groce, N., Challenger, E., Berman-Bieler, R., Farkas, A., Yilmaz, N., Schultink, W., Clark, D., Kaplan, C., and Kerac, M. (2014). Malnutrition and disability: Unexplored opportunities for collaboration. Paediatrics and International Child Health, 34(4), 308–314. https://doi.org/ 10.1179/2046905514y.0000000156

Kayaalp, A., Page, K. J., and Rospenda, K. M. (2020). Caregiver burden, work-family conﬂict, family-work conﬂict, and mental health of caregivers: A mediational longitudinal study. Work and Stress, 35(3), 1–24. https://doi.org/10.1080/02678373.2020. 1832609

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Lefton-Greif, M. A., Okelo, S. O., Wright, J. M., Collaco, J. M., McGrath-Morrow, S. A., and Eakin, M. N. (2014). Impact of children’s feeding/swallowing problems: Validation of a new caregiver instrument. Dysphagia, 29(6), 671–677. https://doi.org/10.1007/s00455-0149560-7

Okoye, C., Obialo-Ibeawuchi, C. M., Obajeun, O. A., Sarwar, S., Tawﬁk, C., Waleed, M. S., Wasim, A. U., Mohamoud, I., Afolayan, A. Y., and Mbaezue, R. N. (2023). Early diagnosis of autism spectrum disorder: A review and analysis of the risks and beneﬁts. Cureus, 15(8). https://doi.org/10.7759/cureus.43226

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AI Statement

I used Google’s Gemini and ChatGPT for grammar mistakes and proofreading. I told the AI to ﬁnd any spelling errors and to make sure my punctuation was correct. I used it for the layout I have provided, and it helped me organize and brainstorm my thoughts.

The Economic Impacts of Sea Level Rise on Economically Valuable Coastal Properties, Land, and Infrastructure

Benjamin Gettier

Faculty Mentor: Larry B. Collins, Ph.D. Department of Biological and Environmental Sciences

Abstract

The global rising sea level poses an increasing threat to economically valuable coastal properties, land, and infrastructure worldwide. This paper reviews some of the economic impacts of sea level rise, including increased ﬂooding, land loss, and damage to coastal infrastructure, which pose risks to local economies, global trade networks, coastal wetlands, real estate markets, and port facilities. It underscores the need for acomprehensive risk assessment to propose new strategies. This survey highlights the compounded challenges of sea level rise, the social and economic consequences of infrastructure and habitat loss, and the urgent need for sustainable solutions. The ﬁndings emphasize the necessity of

addressing these risks to protect coastal communities and maintain economic stability.

Acknowledgements

I would like to thank the Incite editorial team for their thoughtful comments that improved the quality of this manuscript. I would also like to acknowledge that this paper would not be possible without my faculty advisor, Dr. Collins, and his continued support throughout the writing process.

Introduction

Several policy documents have highlighted the consequences of a warming planet (IPCC, 2023; Crimmins et al., 2023). The threats that rising seas pose to our coastal

communities are highlighted in these reports as one primary impact that climate change is exacerbating. Rising sea levels threaten economically valuable coastal regions through land loss, increased ﬂooding, and damage to critical infrastructure. Recent literature (Xie et al., 2021; Hanson & Nicholls, 2020) also suggests that a sustained sea level rise (SLR) will pose signiﬁcant risks, especially to residential properties, transportation networks, and critical facilities.

These risks will impact communities in coastal areas because coastal areas support very diverse economies, including tourism, ﬁsheries, and trade, while hosting important infrastructure such as ports, transportation networks, and residential developments. Coastal wetlands, estuaries, and even mangrove forests provide essential ecosystem services like shoreline protection, water ﬁltration, and biodiversity conservation, but their proximity to shoreline makes them susceptible to the impacts of SLR. These repercussions are not just threatening the natural systems which protect our way of life but directly impacting economic systems as well. We must quantify the possible future damage caused by changing climate and assess the relationship between the different variables at

play. Assessing risks to coastal assets is one of the most difficult challenges scientists face today as these regions face direct, indirect, and compounding effects of changing climate, which can be challenging to quantify.

Given these challenges to our economy and communities, this study addresses the urgent need to evaluate the global economic consequences of SLR through a synthesis of current research on its effects on coastal property, infrastructure, and land value. Despite extensive literature on the physical science of SLR, there remains a gap in understanding its compounded economic impacts, particularly across diverse geographic locations with unique cultures and vulnerabilities. The wide geographic scope reﬂects this gap, as well as the universal nature of SLR.

Methods

Search Strategy

An electronic search was conducted through EBSCO and Longwood University’s Greenwood Library database in October of 2024 to locate published articles in English which discussed SLR and economic effects on coastal populations,

specifically economically valuable land, properties, and infrastructure. The search string utilized for both databases was: "Sea level rise" AND ("economic impact" OR "economic loss"). Step 1 of the literature search was the initial search, refining the search terms based on result count and titles of results. Step 2 involved refining inclusion/exclusion criteria to reflect the types of sources most applicable to the research question. This included reading through abstracts to further validate the relevance to the research. Step 3 was a final evaluation of papers being included. This involved thoroughly reading each paper, as well as reviewing the citations to conduct an ancestral search of the literature. This process is displayed in Figure 1 below.

Inclusion criteria

• Articles evaluating the economic impacts of SLR on coastal populations within a 5-year publication period (2019-2024)

• Articles focusing on direct and indirect economic loss and impacts on economically valuable properties or land

Exclusion criteria:

• Books, web articles, and other general audience media

• Non-peer-reviewed articles

• Textbooks and other educational materials

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Results

The search identiﬁed 113 articles collected from EBSCO and the Longwood University database. From these articles, 104 articles were excluded, while 12 articles were selected due to their alignment with the inclusion criteria.

The literature review examined studies that focused on economic impacts of SLR on valuable coastal properties and land worldwide. Figure 1 below provides an overview of each of the studies incorporated in this review. Major themes found in the literature are outlined below.

Coastal Land Inundation

Coastal land inundation, the ﬂooding or submergence of coastal areas due to water intrusion, has become a critical issue due to the rising of global sea levels. This phenomenon poses signiﬁcant risk to land availability and economic stability in coastal regions. As a direct

consequence of SLR, inundation threatens to submerge valuable land and diminish ecosystem services critical to both natural and economic systems. This recurring theme highlights the widespread recognition among researchers of the need to assess and address the risks posed by inundation, not only for immediate local impacts but

also for long-term global economic stability. By examining this theme collectively, the literature shows the interconnected challenges and vulnerabilities shared across coastal regions.

For example, Joo and Kim (2021) examined the impact of rising sea levels on coastal land inundation and how this affects land value assessments, focusing on Haeundaegu, Busan. The researchers utilized GIS for spatial analysis to simulate two scenarios, a worst-case scenario (RCP 8.5) with an 83 cm rise by 2120 and a more moderate increase of 23 cm. They found that 3.8%–5.5% of Haeundae-gu's land, especially high-value areas, may face inundation. This highlights the vulnerability of urban coastal regions where economic and residential assets are concentrated. Joo and Kim's research also emphasized the need to incorporate SLR projections into land value assessments. Currently, land valuations often overlook coastal flooding risks, potentially leading to economic instability for property owners and insurers. By incorporating flood and SLR data, such assessments can reflect actual coastal risks, improving transparency and equity in land-related financial transactions. The authors advocated for government intervention to integrate this data

into real estate appraisal models to mitigate future economic risk.

In 2020, Li et al. focused on how flooding events can significantly reduce property values in vulnerable areas, affecting economic stability. Coastal regions facing frequent recurring flooding, amplified by climate change, experience higher risks due to rising sea levels and storm surges. For example, regions like Dorchester County and Baltimore have shown projected increases in flood damage and affected properties, which lead to substantial economic impacts. Baltimore, specifically, could face property losses increasing up to six times from current levels under extreme climate scenarios by 2100, with a rise in damage costs from approximately $29 million in 2003 to as much as $173 million. Similarly, flood damage estimates in rural areas like Dorchester County indicate escalations from $100 million to over $200 million by 2100. These increased risks strain property markets and reduce asset values, highlighting the urgent need for climate adaptation and mitigation strategies

Another study by Setiadi et al. in 2023 examined the impact of SLR and coastal erosion on the west coast of Jepara, Indonesia,

particularly in the Kedung and Tahunan Districts. It highlights that accelerated SLR and storm surges exacerbate abrasion, damaging land, settlements, and infrastructure. By 2100, economic losses from SLR-related damage are estimated to reach 3.06 trillion IDR (205 million USD), having the greatest impact on aquaculture, rice ﬁelds, and residential areas. Their research emphasized that infrastructure-based adaptation, like coastal road construction, is insufficient alone and suggests integrating blue-green infrastructure, river embankments, and protective systems to mitigate future impacts effectively.

In 2021, Xie et al. focused on studying the impacts of SLR through the economic loss of regional properties. Unlike previous research that studied the rate at which the sea level will rise in this area, Xie et al. predicted and estimated the economic cost as coastal properties are damaged or lost. After analyzing all properties located in the ﬂood-prone areas of the Tampa Bay Region, they concluded that this information would be incredibly relevant to other similarly situated coastal regions. To ﬁnd their data and conduct their analyses, they utilized satellite altimeter data to generate projections for future SLR. To process their data into usable

form, they developed three scenarios to represent possible outcomes for the damage caused by SLR (2021).

Xie et al. found that 7,577 properties valued in total at around $12.256 billion will ﬂood under their "highend warming scenario" by the end of the century (2021). While Xie et al. provided an informational study to present the negative impacts of SLR, they were limited in that only the current housing cost was analyzed. At the same time, the damage caused by SLR is long-term. Their data does not consider the costs associated with properties, such as residents' belongings and other values that are not directly associated with the property's value. The researchers also note the variability in climate prediction, especially far into the future (2021).

Port Infrastructure

Port infrastructure is often prioritized in the reviewed literature due to its critical role in global trade and its vulnerability to the impacts of SLR. Ports are pivotal hubs for economic activity, yet they are often located in low-lying coastal areas, making them susceptible to ﬂooding, erosion, and other climaterelated challenges. This theme underscores the collective recognition

among researchers of the urgent need to adapt and invest in port infrastructure to sustain global commerce and mitigate the economic risks posed by rising sea levels. As evidenced by multiple studies (Hanson & Nicholls, 2020; Rivosecchi & Singh, 2023), these recommendations include investing in existing global port facilities, investment in developing new port facilities, and speciﬁcally implementing a collective approach with environmental engineering solutions and retroﬁtting existing man-made solutions. Through a combined examination of this issue, the literature provides insights into the widespread and long-term implications for coastal economies and international trade networks.

For example, the study conducted by Hanson & Nicholls in 2020 highlights the need for investment in global port facilities. The increasing demands on our global trading networks and the impacts of climate change, speciﬁcally SLR, will require signiﬁcant investment in port infrastructure. By 2050, it is estimated that this investment could range between $223 billion and $768 billion. This investment will be directed towards constructing new port areas, due to the current insufficiency of existing facilities. The drivers of this need for

investment are a compound of the increasing trade growth and SLR. Maritime trade is projected to increase between 200-400% by 2050 compared to 2010 (Hanson & Nicholls, 2020). This will require port areas to double or potentially quadruple in their capacity. While SLR necessitates adaptation of existing facilities, these costs are relatively low due to the need for building new facilities to meet capacity requirements.

Kingston, Jamaica, also faces heightened flood risks due to SLR, posing significant threats to critical infrastructure such as the Kingston Container Terminal (KCT). The city is vulnerable due to its low-lying topography, proximity to the coast, and the increasing impacts of climate change. The study conducted by Rivosecchi & Singh in 2023 identifies medium to high coastal exposure around the KCT, particularly in Hunts Bay. Projections indicated that SLR could elevate flood risks significantly by the end of the century, with exposure around the KCT drastically increasing under higher level SLR scenarios. Portions of the terminal lie less than 1 meter above sea level, making them susceptible to flooding even in the low end SLR scenarios. The KCT, being a hub for Jamaica’s imports and exports as well as a critical port in Central and

South America, highlights the need for implementing adaptation measures to mitigate these risks. For Kingston, the researchers emphasize the importance of balancing hard-engineering solutions with nature-based approaches. While reinforcing infrastructure like seawalls may offer immediate protection, integrating environmental engineering solutions like habitat restoration and retroﬁtting existing man-made solutions can enhance our longterm resilience. Despite efforts, and the strategic importance of the KCT, no formal plans to adapt to climate change have been implemented.

Coastal Wetlands as Natural Buffers

Coastal wetlands are critical in mitigating the impacts of SLR and storm surges. Coastal wetlands provide natural protection by attenuating wave energy, reducing flood depths, and stabilizing shorelines, making them invaluable for safeguarding both human activity and biodiversity. This theme reflects the collective emphasis among researchers on conserving and restoring wetlands to enhance coastal resilience. By exploring this theme collectively, the literature highlights wetlands shared ecological and economic benefits across diverse coastal regions.

It turns out that wetlands can provide a natural buffer that protects coastal properties from SLR. For example, the study conducted by Rezaie et al. in 2020 found that these natural habitats can reduce both flood depth and associated property damage by up to 14% during low-intensity storms. This protection is achieved by the wetlands’ ability to attenuate storm surge, mitigate wave energy, and stabilize shorelines. Wetlands reduce flood levels and protect residential properties from extensive damage. During a 50-year modeled storm scenario, the presence of wetlands prevented property damage up to $13 million under current conditions and up to $32 million in projected 2050 SLR scenarios. These findings underscore the monetary value of conserving coastal wetlands. Preserving and restoring these wetlands is vital for enhancing coastal resilience against future storm surges and SLR. Wetlands function as natural barriers and offer cost effective alternatives to engineered solutions. This provides indirect benefits as well, such as maintaining biodiversity.

Economic Relocation and Inland Shifts

Economic relocation and inland shifts are a major response to the

increasing risks of SLR and coastal flooding. As vulnerable coastal areas face this increasing risk, businesses and residents are driven to migrate inland, resulting in shifts in population density and economic activities. This theme highlights the collective understanding among researchers of the far-reaching implications of these relocations, including changes to regional economies, urban development, and long-term land use planning. For example, in 2020, Li et al. conducted research into the economic effects of anticipated flooding events. Economic models in their study suggest that rising flood risks lead businesses and residents to migrate inland, redirecting investments and activities away from vulnerable coastal regions. The expectation of future flooding contributes to shifts in settlement patterns as well as business operations. The effects particularly concentrate in lowlying areas susceptible to inundation. As populations and investments move inland, flood-prone areas experience a decline in economic productivity. This relocation of economic activities leads to a measurable reduction in GDP for these regions, with long-term implications for local economies. These findings highlight the need for proactive adaptation.

Real Estate Impacts

SLR and flooding pose significant economic consequences to property values in coastal regions. Real estate markets are directly influenced by the increasing risks of inundation and flood damage, which can lead to property devaluation, changes in insurance costs, and altered investment patterns. This theme reflects a shared recognition among researchers of the compounding effects that climaterelated risks have on housing markets, regional economies, and financial stability. By exploring this issue collectively, the literature highlights the urgent need for adaptive strategies in real estate practices.

In 2020, Pommeranz & Steininger conducted research into how flood risk affects housing prices through spatial spillover effects in floodprone areas, with their case study focused specifically on Dresden, Germany. They used a spatial Durbin error model to quantify direct and indirect effects of flood risk on property prices. Their results indicated that while direct price reductions in flood zones were limited, indirect spillover effects from neighboring properties lead to significant price discounts, especially when located in frequent flood areas.

Price discounts were recorded to be on average 6.5% for houses and 4.8% for condominiums. Their study highlighted that ﬂood risk tends to spread within regions, affecting not only the designated ﬂood zone and affected land, but that which is adjacent as well. The authors emphasize the importance of using models that can account for spillover effects when evaluating property value risk. They concluded that consistent use of these models would increase the accuracy of real estate evaluation practices.

Discussion

This study has reviewed recent research on the economic impacts of SLR on coastal properties, infrastructure, and land. The ﬁndings underscore that SLR is not just a physical challenge but a compounded socio-economic threat, with diverse implications for local economies, global trade, and environmental systems. As sea levels are projected to continue rising, future research must focus on integrated approaches to address these challenges. Emphasizing sustainable adaptation strategies, such as wetlands restoration, resilient infrastructure, and collaborative policymaking, is essential to safeguard coastal communities and economic stability worldwide.

Compounding of Effects

This paper highlights the interconnected challenges posed by SLR, emphasizing the urgent need for further research to understand its multifaceted impacts on coastal communities globally. The research on coastal land inundation illustrates the compounding nature of the effects of SLR. Rising sea levels exacerbate flooding, erosion, and storm surge impacts, amplifying risks to property, infrastructure, and ecosystems. For instance, the studies by Joo and Kim (2021) and Xie et al. (2021) highlight how inundation damages properties and destabilizes financial systems dependent on accurate land valuation and property markets. Furthermore, the simultaneous need for new port infrastructure (Hanson & Nicholls, 2020) and adaptation measures for wetlands and ecosystems (Rezaie et al., 2020) highlights the cascading nature of these effects. This compounding creates a feedback loop where initial impacts, such as loss of wetlands or damaged infrastructure, increase vulnerabilities and escalate the cost of mitigation and adaptation. Efforts should focus on vulnerable regions, such as low-lying urban areas and economically significant coastal infrastructure, while exploring sustainable solutions like

wetland restoration, resilient urban planning, and innovative adaptation strategies. Given the number of studies included in this review, the need for continuous research within this domain is needed.

Stakeholders

The implications of coastal inundation extend across diverse stakeholders, including governments, property owners, insurers, developers, and local communities. Government bodies play a pivotal role in setting regulatory frameworks, as emphasized by Joo and Kim’s (2021) call for integrating sea level rise data into land valuation policies. Insurers face heightened risks due to increasing claims from ﬂood-prone areas, while property developers must adapt their practices to consider long-term climate scenarios. Local communities, particularly those in low-income and rural areas like Dorchester County (Li et al., 2020), bear disproportionate economic and social burdens. The research highlights the need for cooperative strategies involving these stakeholders to address vulnerabilities and invest in sustainable solutions.

Implications

The implications of coastal inundation are far-reaching, affecting local

economies, global trade, and environmental systems. The vulnerability of critical infrastructure like ports (Hanson & Nicholls, 2020; Rivosecchi & Singh, 2023) suggests potential disruptions to supply chains, which could ripple through international trade networks. Additionally, the loss of natural buffers such as wetlands (Rezaie et al., 2020) could lead to increased reliance on costly engineered solutions, further straining public resources and the global supply chain. The economic impacts on property values, as highlighted by Xie et al. (2021) and Pommeranz & Steininger (2020), also emphasize the need for systemic adjustments in real estate practices to account for climate risks, ensuring ﬁnancial stability and resilience.

Limitations of Literature Review

This review has certain limitations that warrant consideration. First, the studies' geographic focus is uneven, emphasizing urban and economically signiﬁcant regions such as Haeundae-gu, Baltimore, and Kingston. This limitation is due to a lack of current literature focusing on this topic, and may overlook the unique challenges smaller, rural, or less-developed coastal areas face. Second, many studies rely on inherently uncertain projections,

particularly those extending to the end of the century. Finally, as noted by Xie et al. (2021), variability in climate predictions and limited consideration of non-property-related costs, such as personal belongings and community impacts, also restrict the scope of analysis.

Future research should prioritize integrated approaches that examine the relationship between coastal inundation's physical, economic, and social dimensions. Models should also be developed that comprehensively model the long-term economic impacts, including migration patterns, regional GDP shifts, and an evaluation of the loss of properties and possessions.

Desmet, K., Kopp, R.E., Kulp, S.A., Nagy, D.K., Oppenheimer, M., Rossi-Hansberg, E., & Strauss, B.H. (2021). Evaluating the Economic Cost of Coastal Flooding. American Economic Journal: Macroeconomics, 13(2), 444486. https://doi.org/10.1257/mac.20180366

Hanson, S.E. & Nicholls, R.J. (2020). Demand for Ports to 2050: Climate Policy, Growing Trade and the Impacts of Sea-Level Rise. Earth’s Future, 8. https://doi.org/ 10.1029/2020EF001543

IPCC. (2023). Summary for Policymakers. In: Climate Change 2023: Synthesis Report. Sixth Assessment Report of the Intergovernmental Panel on Climate Change. 1-34. doi: 10.59327/IPCC/AR6-9789291691647.001

Joo, S., & Kim J. (2021). The Effect of Sea Level Rise on Adjacent Land and the Resulting Land Value Assessment Method. Journal of Costal Research, S1(114), 479-483. https://doi.org/10.2112/JCR-SI114-097.1

References

Bui, N. & Sharp, B. (2024). House Prices and Flood Risk Exposure: An Integration of Hedonic Property Model and Spatial Econometric Analysis. The Journal of Real Estate Finance and Economics, 69, 100-131. https://doi.org/10.1007/s11146-022-09930-z

Crimmins, A.R., C.W. Avery, D.R. Easterling, K.E. Kunkel, B.C. Stewart, and T.K. Maycock, Eds. (2023). Fifth National Climate Assessment. U.S. Global Change Research Program. https://doi.org/10.7930/NCA5.2023

Li, M., Zhang, F., Barnes, S., & Wang, X. (2020). Assessing storm surge impacts on coastal inundation due to climate change: case studies of Baltimore and Dorchester County in Maryland. Natural Hazards, 103, 2561-2588. https://doi.org/10.1007/s11069020-04096-4

Neelamani, S., Al-Houti, D., Al-Ragum, A., Al-Salem, K., & Al-Saleh, A.H. (2022). Assessment of coastal inundation cost due to future sea level rise: A case study for Kuwait. Marine Georesources & Geotechnology, 40(5), 523537. https://doi.org/10.1080/1064119X. 2021.1909195

Pommeranz, C. & Steininger, B.I. (2020). Spatial Spillovers in the Pricing of Flood Risk: Insights from the Housing Market. Journal of Housing Research, 29(S1), S54-S85. https://doi.org/10.1080/10527001. 2020.1839336

Rezaie, A.M., Loerzel, J., & Ferreira, C.M. (2020). Valuing natural habitats for enhancing coastal resilience: Wetlands reduce property damage from storm surge and sea level rise. PLoS ONE, 15(1). https://doi.org/10.1371/ journal.pone.0226275

Rivosecchi, A. & Singh, M. (2023). Small Island City Flood Risk Assessment: The Case of Kingston, Jamaica. Water, 15(3936). https://doi.org/10.3390/w15223936

Setiadi, R., Wibowo, S.S., Putri, E.R., Handoyo, R.R., Puteri, C.I.K., & Dewi, A.A.A. (2023). The Efficacy of Coastal Road Development to Protect West Coast of Jepara from Abrasion and Future Sea Level Rise. IOP Conference Series: Earth and Environmental Science, 1264. http://dx.doi.org/10.1088/17551315/1264/1/012017

Vu, V.D., Pham, H.T., & Bui, T.T.T. (2020). A study on the effects of sea level rise on mangrove ecosystem in Giao Thuy district, Nam Dinh province. Vietnam Journal of Science, Technology and Engineering, 62(3), 90-96. https://doi.org/10.31276/VJSTE.62(3).90-96

Xie, W., Tang, B., & Meng, Q. (2022). The impact of sea-level rise on urban properties in Tampa due to climate change. Water, 14(1). https://doi.org/10.3390/w14010013

AI Statement

No AI tools were used in the process of writing this manuscript.

Recognition or Refusal? Marginalized Identity Development in Passing and The Color Purple

Lee Kassay

Faculty Mentor: David Magill, Ph.D.

Department of English and Modern Languages

Have you ever thought about how one forms their sense of identity? What makes us develop into conscious individuals? German philosopher G.W.F. Hegel thought that he knew the answer. In his 1807 book, Phenomenology of Spirit, Hegel outlined what is now referred to as the “master-slave dialectic,” where he theorized that self-consciousness forms from mutual interaction with another. The other acts as an external force one can compare themselves to, such as becoming aware of one’s external appearance upon observing the appearance of another. Thus, when it is personhood one recognizes in the other realizing that others have complex thoughts and feelings rather than simply being an object – that then allows one to recognize the personhood in themselves. Hegel empha-

sized that this process of recognition must be mutual in order to facilitate some rendering of selfconsciousness. It is a “double movement of the two self-consciousnesses” that enables people to recognize their traits in another, as viewing the other as an object rather than a fellow human being does not allow either party to come to understand one another – one because they are objectifying the other, and the other because they are being objectiﬁed (Hegel 549).

However, Hegel also thought that this recognition could be met with negativity. Seeing oneself within another leads to questioning of one’s own identity – after all, if they are not the only ones exhibiting these behaviors, then who is to say that they themselves are an

individual? This questioning results in a “life-and-death struggle” between the two parties, each seeking to remove the external representation of one’s selfhood and thus prove they are the independent person – the predominant self-consciousness (Hegel 551). To win this struggle and metaphorically “kill” the other person is to reduce them below one’s own status, establishing the winner as “master” over that relationship. Winning reassures the “master” of their independent personhood, thus ending the questioning of identity that the other person caused. The loser, on the other hand — the “slave” — is left to contemplate, seeking what they are if not an independent person and thus continuing their own identity development. While the “master” stops developing their identity, the “slave” becomes increasingly aware of their own selfhood through “work” for the dominant consciousness.

Though there are other, more literal interpretations of Hegel’s “masterslave dialectic,” I interpret the Hegelian dialectic as a metaphorical process, encompassing self-conscious development as forwarded by interpersonal relationships. Utilizing this approach offers an interesting perspective on the formation of identity, particularly in the case

of marginalized identity; often shunted by society, marginalized groups generally become conscious of how they differ from normative expectations through comparison. Thus, I propose looking at two works that deal with this very subject: Nella Larsen’s 1929 novella Passing and Alice Walker’s 1983 novel The Color Purple. Both texts center around Black queer women in dissatisfying marriages that struggle with their overlapping marginalized identities upon becoming enraptured with another woman. However, despite their similar framework, the fate of both protagonists vastly differs, presenting contrasting narratives on how identity development diverges based on one’s willingness to recognize mutuality through another.

Nella Larsen’s Passing is set in 1920s New York during the height of the Harlem Renaissance, but also of Jim Crow America. Two mixed women, once childhood friends, reunite on the rooftop of a whitesonly hotel. Both women were raised in the Black community but are capable of “passing” as white, i.e., to be perceived as fully white rather than their marginalized identity. However, each has chosen to navigate their biracial heritage in different ways: Irene Redﬁeld, in accordance to community

expectations, lives as Black, while Clare Kendry has transgressed those expectations to live as white. Despite this, Irene enters a whitesonly hotel with no thought towards the consequences of discovery, taking advantage of the privilege her racial ambiguity affords her. That changes when she notices an “attractive-looking woman” across the room, becoming captivated by her appearance of “dark, almost black, eyes and that wide mouth like a scarlet ﬂower against the ivory of her skin” (Larsen 9). However, when this woman — who is, in fact, an unrecognized Clare — stares back at her, Irene begins to question herself: “Gradually there rose in Irene a small inner disturbance, odious and hatefully familiar … Did that woman, could that woman, somehow know that here before her very eyes on the roof of the Drayton sat a Negro?” (10). Before Clare returns her stare, Irene does not even spare her race a second thought, but, aligning with Hegel’s theory, being recognized spurs Irene to recognize herself. This recognition is dually coded as one of romantic attraction. Irene cannot help but look to Clare’s “strange, languorous eyes” and focus on her beauty, reciprocating her stare because “All her efforts to ignore her, it, were futile” (10).

A similar phenomenon occurs for Clare. After their reunion in the hotel, Clare sends a letter to Irene after years of no contact, where she states, “[I] cannot help longing to be with you again, as I have never long for anything before” and “You can’t know how in this pale life of mine I am all the time seeing the bright pictures of that other that I once thought I was glad to be free of” (Larsen 7). Like Irene, Clare’s encounter with her childhood friend has spawned a simultaneous racial and romantic recognition. On the one hand, Clare’s words to Irene read like a love letter, fraught with what Deborah McDowell describes as “sexual overtones” (McDowell 374). Saying that one is “longing” for another is indeed outside of the norms of most friendships, especially to someone they have not seen in years. On the other, Clare hints to her reconsideration of how living as white — “this pale life” — does not completely fulﬁll her, demonstrating a developing racial consciousness.

Thus spawns Irene and Clare’s “lifeand-death” struggle. Both are torn between two choices: to either acknowledge their identity through the other, or to reject those notions completely. Acknowledgement means admittance that the boxes they have put themselves in do not

fully encapsulate them — for Irene as Black, for Clare as white, and for both as heterosexual. After all, as Josh Toth points out, Clare’s very act of passing indicates how the strictness of 1920s America’s binary racial categories are “insufficient, impractical, illusory” – to say nothing of attitudes towards homosexuality (Toth 56). Rejection takes away that internal conﬂict, returning both to the safety that aligning to societal norms affords them, even if that safety comes at the cost of satisfaction. For Clare, acknowledgement is winning, as inferred from her insistence on reentering Irene’s life, interacting with the Black community, and showing clear attraction towards Irene. What holds her back is the cost of leaving, both in the cushiness of white life and the potential retribution of her racist husband.

However, Irene remains more conﬂicted, with her status as the focal character affording the reader more insight into her struggle. Irene clearly desires Clare, but she also wishes to completely cut Clare out of her life, to be “through with Clare Kendry” (Larsen 32). This manifests in Irene enjoying Clare’s presence when she is around but lamenting her involvement with Clare when alone. In response to the desire that Clare’s presence invokes, Irene tells

herself that “she had only to turn away her eyes, to refuse her recognition” (34, emphasis added). Irene’s refusal to acknowledge these feelings when alone is indicative of her refusal of the “masterslave dialectic” as a whole. She does not want to enter a dialectic with Clare because acknowledging Clare’s feelings would necessitate acknowledging her own feelings, though she cannot help but participate when Clare engages with her.

Eventually, while Clare begins to come to terms with her identity, Irene’s conﬂict ends in rejection; after much internal strife, Irene insists on maintaining ideals of safety and security. To facilitate the “death” of Clare, Irene convinces herself that Clare is betraying her by cheating with Irene’s husband, internally slandering her character. However, the brunt of this does not fall on Irene’s husband, as “She still intended to hold fast to the outer shell of her marriage, to keep her life ﬁxed, certain” (77). By holding onto that certainty and refusing internal change, Irene thus establishes herself as the “master” in their relationship and Clare as the “slave,” a status reinforced by Clare’s gradual self-recognition. However, their dialectic aligns more with how Frantz Fanon characterizes a distorted “master-slave

dialectic,” as where “in the past each had a ﬁxed position. Now the inferior thinks he has acquired worth … and the superior is determined to conserve the old hierarchy” (Fanon 211). Rather than continuing this process of identity development, Irene completely rids herself of Clare through the metaphorical “death” of slander and literal “death” Clare soon encounters. Meanwhile, facilitating Clare’s death prevents Clare from the natural conclusion of her own identity development: accepting her Blackness and queerness through leaving her marriage and continuing a relationship with Irene. Thus, both Irene and Clare are prevented from self-actualization through Irene’s actions.

Hegel never impressed that the “master-slave dialectic” is inherently negative, though this is the result for Irene and Clare. In fact, he insisted that it was the only way to achieve self-recognition, as “The individual who has not risked his life may well be recognized as a person, but he has not attained the truth of this recognition as an independent selfconsciousness” (Hegel 551). An apt demonstration of a more positive dialectic lies in Alice Walker’s The Color Purple. Set in early 20th century rural Georgia, the novel centers around Celie, a Black girl that grows

up in an isolated and abusive environment. People around Celie treat her like an object, looking to her as a source of physical labor, sexual gratiﬁcation, and an outlet for physical aggression. Additionally, the men that have power over her life –ﬁrst her stepfather, and then her husband – consistently put her down, calling her “ugly” and “used.”

In turn, Celie internalizes this objectiﬁcation, both devaluing her own personhood and disregarding the personhood of those around her. Walker consistently represents this through Celie’s comparison of herself and others to wood. When being abused by her husband, she describes her coping as “I make myself wood. I say to myself, Celie, you a tree. That’s how come I know trees fear man” (Walker 22). Other people are even less alive than her in her eyes; her stepson as an example is “another piece of wood. Not a living tree, but a table, a chifforobe” (29). Because, as Hegel states, selfconsciousness “exists only in being acknowledged,” Celie is unable to fully formulate her identity because no other acknowledges her personhood, nor can she reﬂect that personhood back onto others (Hegel 549).

However, Celie’s life changes with the introduction of Shug, Celie’s

husband’s ex-lover. Despite their precarious relation to each other, Celie first learns of Shug before her marriage upon being gifted a photograph of her. Though the photograph is a literal object, it quickly becomes her closest confidant, and Celie begins to idealize Shug as the human connection she has been longing for. Shug also serves as the first person Celie feels attracted to, with Celie describing her as “The most beautiful woman I ever saw” (Walker 6). Though she may not be conscious of it yet, Celie’s desire is the first step in forwarding her selfconsciousness; as Frantz Fanon puts it, “As soon as I desire I am asking to be considered. I am not merely here-and-now, sealed into thingness. I am for somewhere else and for something else” (Fanon 218).

This imagined dialectic is brought into reality when Celie meets the real Shug. Celie clearly has expectations of Shug to be the person that will truly recognize her and treat her like a person, spawned from the imagined personality she has reﬂected onto Shug’s photograph. When Shug ﬁrst walks up to her, Celie thinks to herself that “I need to see her eyes. I feel like once I feel her eyes my feets can let go of the spot where they stuck” (45). When the real Shug does meet her eyes, though, it is with the same

demeaning attitude of others before her, laughing and saying, “You sure is ugly” (45).

Despite this seeming lack of recognition on Shug’s part, I argue that this moment maintains itself as a point of recognition between the two. Celie sees Shug as an actual living person for the first time, as opposed to the object she idealized. In the same sense, Shug sees Celie for the first time beyond the objectifying lens through which Celie’s husband has undoubtedly portrayed Celie. This begins their life-and-death” struggle, where both grapple between objectifying the other and recognizing who the other actually is, all while Shug struggles literally with a deadly sickness. For Celie, this objectification manifests in sexual desire, describing how “First time I got the full sight of Shug Avery long black body with it black plum nipples, look like her mouth, I thought I had turned into a man” (48). Keeping in mind that the only men Celie has known have been ones who objectified her, Celie paralleling her admiration for Shug’s physical form to that of a man points to her struggle to not mirror how men around her express desire. Celie thus must grapple to acknowledge Shug’s true personality rather than the ideal Celie has of her. For Shug,

her physical health is directly correlated to her alignment with Celie’s husband’s ideals, as Celie describes how “Shug halfway tween sick and well. Halfway tween good and evil, too” (55-56). Thus, to acknowledge Celie’s aliveness is to facilitate Shug’s own life to continue.

However, their dialectic diverges from Hegel when, through developing a romantic connection with one another, both recognize the personhood in each other. Unlike Irene and Clare, Celie and Shug’s relationship presents itself this way not because Shug is denying her identity, but rather because Shug is further along in her identity development. Thus, she acts as a guide to Celie, being the “independent consciousness whose essential nature is to be for itself” while Celie is “the dependent consciousness whose essential nature is simply to live or to be for another” (Hegel 552). Shug has experienced more of the world, demonstrating her mastery through a mentorship of Celie’s selfhood, but also a centering of her world around herself rather than Celie. Meanwhile, Celie has to continue working on her identity development, forwarding her selfhood through “work” within their relationship. Their dialectic is most uneven when Celie is still relatively uncertain of her identity, regularly pining

after Shug while she is away; meanwhile, Shug constantly leaves Celie to seek other romantic relationships. However, this gradually evens out as Shug helps Celie forward her sense of self, such as reframing her conceptualization of the world from one dominated by men to one where women can seek independence. An example of this is when Celie and Shug talk about the nature of God, where Shug introduces the removal of God conceptually from the white, patriarchal vision that society has instilled in them: “My ﬁrst step from the old white man was trees. Then air. Then birds. Then other people.” (Walker 19495). Noting Shug’s emphasis on trees, the very object that Celie viewed both herself and others as, Shug removes it from the objectifying standard Celie has for it and thus begins Celie’s process of reconceptualizing the world as one beyond male domination.

Ultimately, analyzing Passing and The Color Purple in tandem through a Hegelian lens reveals the extent in which, despite similar basic frameworks, the master-slave dialectic can vary drastically in outcome.

Irene questions her worldview upon Clare’s reintroduction into her life, but her inability to go beyond the prevailing structure of her life ultimately inhibits her from achieving

self-actualization about her racial and sexual identities. This in turn inhibits Clare from her own self-actualization due to how identity development relies on mutual recognition to function, with the death of both women’s selfhood being represented through Clare’s literal death. In contrast, Celie and Shug resolve their dialectic more mutually, with Shug not reinforcing her standards of the world onto Celie to maintain power over the relationship; this allows Celie to grow beyond her position as “slave” and gradually balances their dialectic to one of ultimate reciprocity. Their dialectics are dually deﬁned by desire, with both Irene and Celie’s willingness to participate in their mutual recognition hinging on their desire for their female love interests. Comparing these two works allows one to see how the Hegelian dialectic can either naturally conclude positively through mutual acknowledgement, thus resulting in ﬂourishing relationships, or be distorted and end in isolation.

Hegel, Georg Wilhelm Friedrich. “Phenomenology of Spirit: The Master-Slave Dialectic.” The Norton Anthology of Theory & Criticism, W.W. Norton & Company Ltd., 2018, pp. 549555.

Kaplan, Carla, editor. Passing: A Norton Critical Edition. W.W. Norton & Company, 2007.

Larsen, Nella. Passing. 1929. Kaplan, pp. 1-82.

McDowell, Deborah. “[Black Female Sexuality in Passing].” Kaplan, pp. 363-379.

Toth, Josh. “Deauthenticating Community: The Passing Intrusion of Clare Kendry in Nella Larsen’s Passing.” MELUS, vol. 33, no. 1, 2008, pp. 55-73. JSTOR, https://login.proxy. longwood.edu/login?url=https://www.jstor.or g/stable/30029741. Accessed 21 Nov. 2024.

Walker, Alice. The Color Purple. 1982. Penguin Books, 2019.

AI Statement

The following was written without the use of AI tools in any capacity, including but not limited to ChatGPT, Grammarly, Claude, and DALL-E. This work is the author’s own with the assistance of faculty mentors in the writing and revision process.

Works Cited

Fanon, Frantz. Black Skin White Masks. Grove Press Inc., 1987.

Janus Kinase Inhibition in Autoimmunity: Upadacitinib and Ulcerative Colitis

Jade Riddle

Faculty Mentor: Amorette Barber, Ph.D.

Department of Biological and Integrated Environmental Sciencess

Ulcerative colitis (UC) is a chronic inflammatory bowel disease, having an estimated global incidence of 5 million cases, that is characterized by continuous inflammation of the rectum and colon (Kobayashi et al. 2020; Le Berre et al. 2023). This inflammation typically only occurs in the mucosal layer, leading to superficial damage of the bowel wall (Kobayashi et al. 2020). As a result, the typical symptoms of UC are blood and/or mucus in the stool, increased frequency of bowel movements, and tenesmus, also known as urgency (Kabayashi et al. 2020). Sometimes patients may present with bloody diarrhea accompanied by anemia, increased heart rate, and fever (Kabayashi et al. 2020). Although the exact cause of UC is not known, patients tend to have a defect in the epithelial barrier of their intestines and altered expression of

the tight junction proteins, leading to increased permeability (Kabayashi et al. 2020). The ﬁrst line of treatment is often oral or rectal 5-ASA and steroids (Kabayashi et al. 2020). Around 20-25% of patients will also require surgical intervention through either a colectomy or proctocolectomy (Kabayashi et al. 2020).

UC pathogenesis is thought to be driven, in part, by an imbalance in the ratio of CD4+ T cell subsets, particularly Th1/Th2 and Th17/Treg ratios (Imam et al. 2018). T cells are cells of the adaptive immune system. They are activated in the secondary lymphoid organs and must have an antigen presented to them on an MHC molecule on the surface of an antigen-presenting cell, most often a dendritic cell. Dendritic cells uptake the bacterial antigens at the site of infection then modify their

cytoskeletons to enter a draining lymphatic vessel. They then enter the lymph node and settle into the T-cell area. T cells have highly speciﬁc receptors on their cell surface called T cell receptors (TCR).

The variable region of these receptors is determined through a process called VDJ recombination which promotes diversity in the TCRs across the T cell population of the body, allowing for a wide variety of pathogenic antigens to be recognized. In order to be activated, T cells must receive two signals. The ﬁrst is the interaction between the TCR and the MHC molecule, and the second is that a protein on the T cell surface called CD28 has to bind to a protein on the antigen presenting cell surface known as B7. This is known as co-stimulation. If the T cell receives signal 1 but not signal 2, it will become anergic to prevent autoimmunity. If it receives signal 2 but not signal 1, nothing will happen.

Once the T cell receives both signals, it begins to express IL-2 which is a major growth factor for T cells and drives their proliferation. After T cell activation, CTLA-4 is expressed which has a higher affinity for B7 than CD28, inhibiting activation. Additionally, after activation, T cells no longer require co-stimulation. CD4+ T cells then differentiate

into different subtypes with distinct effector functions based on the cytokines that are present in the environment. Th1 cells are skewed by the presence of IL-12 and IFNy, and they primarily help to enhance cellular immune responses by activating macrophages and CD8+ T cells. They secrete IFNy, IL-2, IL-3, and TNF-a, or mostly pro-inflammatory cytokines. IFNy in particular helps to increase the expression of MHC on the surface of dendritic cells, increase the activity of natural killer cells, increase differentiation of B cells, and increase antibody production (specifically IgG). Th2 cells, on the other hand, are skewed by the presence of IL-4, and they primarily help to enhance humoral immune responses. They secrete mostly anti-inflammatory cytokines (IL-4, IL-5, IL-3, IL-6, IL-13, IL-10, and TGFβ). IL-4, IL-5, and IL-6 activate B cells, and the specific cytokine will skew the isotype of the resultant antibodies. Certain cytokines produced by each type of T cell will also inhibit the differentiation of T cells into the other type. For example, IFNy inhibits Th2 differentiation, and IL-10 inhibits Th1 differentiation.

There are two more types of CD4+ T cells. These are Tregs and Th17. Tregs are skewed by the presence of TGF-β and IL-2, and they

suppress cellular immune responses, speciﬁcally that of CD8+ T cells. They do this through the production of IL-10 and TGF-β. Th17 cells are skewed by the presence of TGF-β and IL-6, and they are implicated in autoimmunity but also help to clear extracellular bacteria on the skin and in the intestines as well as fungi. They produce IL-17, IL-22, IL21, IL-1, and TNF-a. Like with Th1 and Th2, the presence of Treg cells and the cytokines that they produce inhibits the differentiation of Th17 cells, and the presence of Th17 cells and the cytokines that they produce inhibits the differentiation of Treg cells.

In individuals with UC, it is thought that intestinal inﬂammation is associated with higher levels of T cell activation and maturation (Kaluzna et al. 2022). It has been found that patients with UC have lower levels of naive T cells in their blood compared to a healthy control, and that patients with concurrent HIV infections have higher levels of remission, pointing to the involvement of CD4+ T cells in disease progression (Kaluzna et al. 2022; Imam et al. 2018). Speciﬁcally, studies have shown that patients with UC have higher levels of Th2 cells and that IL-13, a cytokine secreted by Th2 cells, plays a big role in UC pathogenesis (Kaluzna et al. 2022). IL-13 has an effect on the integrity of the

intestinal barrier, leading to increased apoptosis of epithelial cells and reduced epithelial regeneration (Kaluzna et al. 2022). Patients with UC also have been shown to have increased levels of Th17 cells; however, Th17 cells can have both protective and detrimental effects concerning intestinal inﬂammation (Kaluzna et al. 2022; Imam et al. 2018). IL-17 stimulates the synthesis of pro-inﬂammatory cytokines such as IL-1 and TNF-a, but alongside IL23, it helps to maintain the tight junctions between intestinal epithelial cells (Kaluzna et al. 2022). However, in the face of excessive activation, they may become more pathogenic (Kaluzna et al. 2022). Surprisingly, patients with UC have also been shown to have elevated levels of Tregs, but their functions are reduced with them being more likely to undergo apoptosis and not being able to prevent the differentiation of other T cell subsets (Kaluzna et al. 2022).

With all of the involved cytokines and signal transduction pathways, there are multiple potential targets for immunotherapy for UC. One promising treatment is upadacitinib (UPA), a Janus kinase (JAK) inhibitor (Ernest-Suarez & Panaccione 2023). UPA, also known as Rinvoq, is a small molecule oral medication taken once daily (Ernest-Suarez &

Panaccione 2023; Mohamed et al. 2024). It speciﬁcally acts as a competitive inhibitor of the ATP binding pocket of the JAK-1 protein (ErnestSuarez & Panaccione 2023). It was approved by the FDA in 2019 for the treatment of rheumatoid arthritis and has subsequently been approved for use in UC, Crohn’s disease, psoriatic arthritis, and ankylosing spondylitis (Mohamed et al. 2024). Rinvoq is considered an “advanced therapy” for UC and is typically only prescribed to those who have not found success with or are intolerant to anti-TNF therapies (Kobayashi et al. 2020; Ernest-Suarez & Panaccione 2023).

As previously discussed, in UC, symptoms are thought to be caused by an imbalance in Th1/Th2 and Th17/Treg ratios as well as the resulting secreted pro-inﬂammatory cytokines. JAK proteins are kinases associated with the receptors for various cytokines, playing a vital role in signal transduction and thus activating downstream effector proteins (Harrison 2012). JAK-1 speciﬁcally is associated with 3/4ths of the cytokines involved in the pathogenesis of UC including IL-4, IL-6, and IL-13 (Ernest-Suarez & Panaccione 2023). Therefore, UPA is effective in treating UC because it not only blocks the differentiation of Th2 and Th17 cells but also some

of the effects of pro-inﬂammatory cytokines because the signal transduction pathway is interrupted. Clinical trials found that around 50% of patients who received Rinvoq achieved clinical remission in 52 weeks, and 68% (of those taking 30mg) were able to maintain remission compared to only 22% of the placebo group (Ernest-Suarez & Panaccione 2023). Quality of life scores also changed by 58.9 points in those taking 30 mg Rinvoq versus just 17.9 points for the placebo group. UPA is considered safer than previous pan-JAK inhibitors (Ernest-Suarez & Panccione 2023). The most common adverse events reported are upper respiratory tract infections, nasopharyngitis, increased blood creatinine kinase levels, acne, and reactivation of herpes zoster (Ernest-Suarez & Panaccione 2023; Mohamed et al. 2024). UPA may also increase a patient’s susceptibility to bacterial diseases and cancer later in life due to the fact that it dampens the differentiation of Th17 cells.

UPA also has the potential to be used in the treatment of hidradenitis suppurativa (HS), a chronic autoinﬂammatory skin condition characterized by painful abscesses across the body in regions where apocrine sweat glands are located. As an auto-inﬂammatory disorder,

the inappropriate secretion of proinflammatory cytokines plays a role in the development of HS, specifically IL-1, TNF-a, IFNy, IL-17, IL-23 and IL-6. The IL-6 and IFNy receptors have JAK1 as an associated kinase. Therefore, UPA can block both of these cytokines’ signaling pathways and help to reduce the extent of the inflammation. However, UPA may not be the most effective JAK inhibitor to use in HS as the JAK3 protein is upregulated in patients with HS, not JAK1 (Del Duca et al. 2020). Despite this, JAK inhibition remains a promising therapeutic approach, as it can effectively block key inflammatory signaling pathways, having the potential to treat a wide variety of autoimmune and autoinflammatory conditions.

References

Del Duca E, Morelli P, Bennardo L, Di Raimondo C, & Nisticò SP. 2020. Cytokine Pathways and Investigational Target Therapies in Hidradenitis Suppurativa. Int J Mol Sci. 21(22):8436.

Ernest-Suarez K, & Panaccione R. 2023. Update on the role of upadacitinib in the treatment of adults with moderately to severely active ulcerative colitis. Therap Adv Gastroenterol, 16, 17562848231158235.

Harrison DA. 2012. The Jak/STAT pathway. Cold Spring Harb Perspect Biol. 4(3): a011205.

Imam T, Park S, Kaplan MH, & Olson MR. 2018. Effector T Helper Cell Subsets in Inﬂammatory Bowel Diseases. Front Immunol. 9(1212).

Kałużna A, Olczyk P, & Komosińska-Vassev K. 2022. The Role of Innate and Adaptive Immune Cells in the Pathogenesis and Development of the Inﬂammatory Response in Ulcerative Colitis. J Clin Med. 11(2): 400.

Kobayashi T, Siegmund B, Le Berre C, Chen Wei S, Ferrante M, et al. 2020. Ulcerative colitis. Nat Rev Dis Primers 6, 74.

Le Berre C, Honap S, and Peyrin-Biroulet L. 2023. Ulcerative colitis. Lancet Gastro. 402(10401):571-584.

Mohamed M-E, Bhatnagar S, Parmentier JM, Nakasato P, Wung P. 2024. Upadacitinib: Mechanism of action, clinical, and translational science. Clin Transl Sci. 17:e13688.

AI Statement

No AI tools were used in the planning, creation, or revision of this paper.

Investigating Effects of Electrode Attachment Position in Single Molecule Electronics

Ashley Seiders

Faculty Mentor: Benjamin Topham, Ph.D. Department of Chemistry and Physics

Abstract

Single molecule electronics is a developing ﬁeld in which electronic device components are made from individual molecules. The electrical current that passes through single molecule junctions depends on the design of the molecular junction. Photoswitches are molecules that observe “on” and “off” states with different conductance in each state. This study used computational chemistry to investigate the performance of a spiropyran molecular photoswitch and found that the performance of the switch depended signiﬁcantly on the position of electrode attachment.

Introduction

The ﬁeld of single molecule

electronics is an ever-growing area of research that focuses on studying electrical current transmitted through individual molecules.i Single molecule electronics can be devices such as switches, diodes, or transistors that can be smaller, less expensive, and more efficient than traditional devices. Several principles have already been established in the ﬁeld of single molecule electronics, including how conductance is affected by molecular length and conjugation.ii These principles and others may be related to the molecular orbitals of the molecule in the junction.iii

Photoswitches are unique in single molecule electronics, having the ability to switch between two different forms that each observe different conductance. These molecules

use different wavelengths of light to switch between “on” and “off” states.iv Structurally, photoswitches either make or break a bond present in the molecule to switch between states, which affects conjugation and molecular length, which in turn impacts conductance. When bonds are formed or broken, and the length of the molecule changes, the junction can experience electrode displacement, which can negatively impact the performance of the switch.v

Figure 1. Spiropyran/merocyanine photoswitch

The molecule spiropyran (S) has been investigated for its use in single molecule electronics as a switch due to its reversible isomerization to merocyanine (M) (Figure 1). The switching mechanism can be induced by light,iv acid-base chemistry,v force,vi or other factors. The transformation from spiropyran to merocyanine leads to a longer, more planar, more conjugated molecule (Figure 2). In terms of single molecule electronics, this isomerization typically leads to an increase in conductance for merocyanine rel-

ative to spiropyran. However, the molecule experiences electrode displacement when switching, which is not ideal for repeated switch operation.

Figure 2. Standard electrode attachment conformation for spiropyran with molecular length changes for merocyanine depicted below junction

Different electrode attachment positions on the molecule can mitigate this issue by allowing the molecule to still be excited and lengthen while eliminating electrode displacement. The aim of this study is to investigate how photoswitch conductance responds to varying electrode locations to reduce electrode displacement and understand the role of molecular orbitals in the photoswitching behavior of these molecules.

Electrode Conformational Effects

In order to avoid electrode displacement associated with the

change in molecular length, alternative conformations have been sought for the S/M switch. Altering the attachment location from a standard (horizontal) position to an orthogonal one reduces electrode displacement by removing the switching mechanism from the conducting pathway of the junction.viii There are additional options regarding the position of electrode attachment. Various attachment conformations were calculated, and it was conﬁrmed that moving the switch out of the conducting pathway does minimize electrode displacement, but the conductance can be location-dependent (Figure 3). In the two cases described here, an orthogonal pathway was created on differing rings of the switch and were observed to have varying conductance. Not only was there varying conductance between

conformations, the S1/M1 switch also had an opposite conductance pattern than expected, with the “off” state (S) observing more conductance than the “on” state (M), aligning with the low ON/OFF ratio of 0.55, compared to the higher ON/OFF ratios seen by the S0/M0 (4.26) and S2/M2 (4.38) switches. Both S0/M0 and S2/M2 had the expected “on” and “off” state conductance. Additionally, M2 had a higher conductance than M0, supporting the idea that an orthogonal conﬁguration has a positive effect on the conductance by reducing electrode displacement and shortening the distance between the electrodes.

Figure 3. (a) Varying electrode attachment conformations investigated (b) Current plot for all conformations from 0-2V

Electrode Attachment Location and Molecular Orbitals

Unexpected conductance results for S1/M1 led to further investigation into the factors that affect electronic transmission and conductance, including the molecular orbitals present in the molecule. The highest occupied molecular orbital (HOMO) of each molecule were of particular interest. Though the HOMOs were the focus of the study, it is noted that the HOMOLUMO gap did shrink with the switching behavior from S to M in all cases, as expected. The results showed that there were energy level shifts between “on” and “off” states, which was expected (Figure 4). However, visualization of the orbitals revealed important details regarding the electrode attachment location. Calculations indicate that the HOMO in each case (S0, S1, and

S2) is mostly restricted to the indoline moiety of the molecule. The related conductance through the “off” state of the molecule is affected by where the electrodes are attached in relation to the HOMO. In S1, the HOMO is present in the conductance pathway, however in S2, there is no orbital density in the pathway. This causes the conductance of S1 to be relatively larger, decreasing the ON/OFF ratio and indicating a less effective switching behavior. The S/M switch is effective because the “off” state of the molecule has two sides separated by the spiro CO bond near the center of the molecule. Switching to the “on” state, conjugation between the two sides is established when that bond is broken. With that desired switching mechanism, it is undesirable to have the HOMO present through the conductance pathway in both forms of the molecule, as seen with S1/M1.

Figure 4. Electron density and energy of HOMO for each molecule in the on and off states.

Conclusion

Photoswitches hold great potential to be implemented in single molecule devices. Changing the location for electrode attachment can be beneﬁcial by reducing displacement through the junction. However, it is also important to consider the molecular orbitals of the molecule, speciﬁcally the HOMO, to promote the desired switching mechanism and achieve promising conductance results. Future studies into additional electrode attachment locations in relation to molecular orbitals can hold valuable information on how to optimize switch performance.

Computational Details

Molecules of interest were built with carbon connection groups leading to a single sulfur bond to the gold electrodes (Figure 2). Geometry was optimized using molecular mechanics with the MM2 force ﬁeld using Chem3D software. Electron transmission was calculated using a wide band limit with the Landauer approximation and the LANL2DZ basis set with QChem software.v

Notes

i. Aviram, A.; et al. Chem. Phys. Lett. 1974, 29, 277-283.

ii. Tao, N.; et al. Nat. Nanotech. 2006, 1, 173–181.

iii. Daaoub, A.; et al. J. Phys. Chem. Lett. 2022, 13, 9156-9164.

iv. Kim, Y.; et al. ChemPhysChem 2020, 21, 2368.

v. Wojtyk, J. T. C.; et al. J. Phys. Chem. 2007, 111, 2511-2516.

vi. Davis, D. A.; et al. Nature 2009, 459, 68-72.

vii. Jago, D.; et al. Small 2024, 20, 2306334.

viii. Shao, Y.; et al. Mol. Phys. 2015, 113, 184.

References

Aviram, A., & Ratner, M. A. (1974). Molecular rectiﬁers. Chemical Physics Letters, 29(2), 277-283. https://doi.org/10.1016/00092614(74)85031-1

Daaoub, A., Ornago, L., Vogel, D., Bastante, P., Sangtarash, S., Parmeggiani, M., Kamer, J., Van Der Zant, H., Sadeghi, H., & More Authors (2022). Engineering transport orbitals in single-molecule junctions. Journal of Physical Chemistry Letters, 13, 9156-9164. https://doi.org/10.1021/acs.jpclett.2c01851

Davis, D., Hamilton, A., Yang, J., Cremar, L. D., Gough, D. V., Potisek, S. L., Ong, M. T., Braun, P. V., Martinez, T. J., White, S. R., & More Authors. (2009). Force-induced activation of covalent bonds in mechanoresponsive polymeric materials. Nature, 459, 68–72. https://doi.org/10.1038/nature07970

Jago, D., Liu, C., Daaoub, A. H. S., Gaschk, E., Walkey, M. C., Pulbrook, T., Qiao, X., Sobolev, A. N., Moggach, S. A., Costa-Milan, D., Higgins, S. J., Piggott, M. J., Sadeghi, H., Nichols, R. J., Sangtarash, S., Vezzoli, A., & Koutsantonis, G. A. (2024). An orthogonal conductance pathway in spiropyrans for well-deﬁned electrosteric switching single-molecule junctions. Small, 20(8), Article 2306334. https:// doi.org/10.1002/smll.202306334

Kim, Y., Hellmuth, T. J., Sysoiev, D., Pauly, F., Pietsch, T., Wolf, J., Erbe, A., Huhn, T., Groth, U., Steiner, U. E., & Scheer, E. (2012). Charge transport characteristics of diarylethene photoswitching single-molecule junctions. Nano Letters, 12(7), 3736-3742. https://doi.org/ 10.1021/nl3015523

Shao, Y., Gan, Z., Epifanovsky, E., Gilbert, A. T. B., Wormit, M., Kussmann, J., … Head-Gordon, M. (2014). Advances in molecular quantum chemistry contained in the Q-Chem 4 program package. Molecular Physics, 113(2), 184–215. https://doi.org/10.1080/00268976. 2014.952696

Tao, N. (2006). Electron transport in molecular junctions. Nature Nanotechnology, 1, 173–181. https://doi.org/10.1038/nnano.2006.130

Wojtyk, J. T., Wasey, A., Xiao, N. N., Kazmaier, P. M., Hoz, S., Yu, C., Lemieux, R. P., & Buncel, E. (2007). Elucidating the mechanisms of acidochromic spiropyran-merocyanine interconversion. The Journal of Physical Chemistry, 111(13), 2511–2516. https://doi.org/ 10.1021/jp068575r

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