Spectrum volume 8(1) by Saint Francis University

SPECTRUM Journal of Student Research at Saint Francis University

Volume 8 (1) Fall 2017

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SPECTRUM: Journal of Student Research at Saint Francis University Volume 8 Issue 1 Table of Contents The State of Mental Health for Residents in West Central Pennsylvania Shelbie L. Jamison; Jill M. Cavalet

A Burning House: An Experiment in the Cell Phone Novel Genre Tara L. Fritz; Kirk Weixel

Using Case Studies as Instructional Material to Influence Introductory Anatomy and Physiology Students’ Learning and Attitudes Danae L. Peters; Kelly L. Garanich

Call for papers

(Student authors’ names underlined.)

Faculty Editors: Balazs Hargittai Professor of Chemistry bhargittai@francis.edu

Grant Julin Associate Professor of Philosophy gjulin@francis.edu

Student Editorial Board: Allison Bivens ’12 Hayden Elliott Jonathan Miller ’08 Morgan Onink Rebecca Peer ’14 Hannah Retherford Margaret Thompson

Managing Designer: Grace McKernan

Cover: Photo by Stephanie Hargittai

Kayla Brennan Eric Horell ’13 Steven Mosey ‘14 Shaelyn Parry Miranda Reed William Shee ‘17 Staci Wolfe

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The State of Mental Health for Residents in West Central Pennsylvania Shelbie L. Jamison Physician Assistant Sciences Department School of Health Sciences slj110@francis.edu

Jill M. Cavalet Physician Assistant Sciences Department School of Health Sciences jcavalet@francis.edu

Mental health stigmas are a growing problem not only nationwide, but worldwide. The popular opinion around the notion of mental health plagues patients with stereotypes, preventing them from living a normal life. The classification of a stigma placed on a patient with a behavioral health disorder is â€œa process involving labelling, separation, stereotype awareness, stereotype endorsement, prejudice and discrimination in context in which social, economic or political power is exercised to the detriment to members of a social groupâ€? (Clement et al., 2015). Stigmas cause barriers to healthcare, social interaction, and financial instability. Three observations resulted from this study: 1) Healthcare providers perceived stigmas at a higher rate than their patients did. 2) Stigmas were more prevalent in inpatient settings than in outpatient settings, and for patients aged 50 years and older. 3) While the prevalence of mental health stigmas is not as high in West Central Pennsylvania as in other areas of the world, stigma is still present in the lives of the patients, families, and providers affected by a disorder. Many of those outside of the mental health world are unaware of various stigmas placed on the patients and providers in Behavioral Medicine. While these stigmas can be detrimental to the lives of some, others are unaware of the various types. Patients, providers, and the public need to be aware of these stigmas to help rid them from society. It is important to note that the terms mental health illness and mental health disorder will be used interchangeably. Mental health is the state of wellbeing of an individual, while a mental illness or disorder is a condition that affects a personâ€™s thinking, mood, and behavior. Guidelines listed in to the Diagnostic and Statistical Manual of Disorders, Fifth Edition are used to help diagnose and treat patients with mental illnesses. The original research performed will explore the demographics and opinions of patients and providers most affected by these stigmas. The literature review will offer these patients and providers insight about how to push through and combat these public opinions. Stigmas placed on mental health disorders have a major impact on the healthcare these patients receive, their willingness to seek help, the ways in which others view them and their families, and their ability to be hired and to retain a job. While there is growing

knowledge of mental health worldwide and many ways to help combat stigmas, many clinicians, family members, and even patients are unaware of the stigmas. Patients and clinicians in West Central Pennsylvania still fall victim to stigmas every day. This paper will serve to educate about stigmas and impact they have on those affected. Literature review Impact on Healthcare. Despite the worldwide increasing incidence of mental health diagnoses, seeking treatment has not shown a similar trend in the United States. Research by Townsend, Gearing, and Polyanskaya (2012), has shown that a total of 22-46% of people will experience a mental disorder in their lifetime, but only 36% of those people seek treatment for the disorder. This shockingly low number indicates there are many people in the world in need of treatment for a mental disorder that are not receiving it. Many of the patients who do seek care do so through informal measures. Individuals who do not have access to health insurance or who fear hospitalization, taking medicine, and losing their autonomy typically resort to internet support groups, often led by untrained facilitators (Townsend et al., 2012). Many informal types of

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treatment do not provide the patients with the care they need to get better. Patients feel they are doing their best to seek help and make improvements, but many of these informal measures are ineffectual, sometimes inhibiting potentially good outcomes. The World Health Organization has further recognized the strong impact mental health disorders have on healthcare. Mental health disorders now stand as the “…second largest cause of disease burden and disability worldwide” (Shim and Rust, 2013). With such an immoderate impact on the health of people worldwide, the fact that so many of these patients do not seek help is baffling. In fact, many formally diagnosed patients accept a referral to a specialist, but cancel the appointment afterwards (2013). Despite many of these patients wanting the help, they are fearful of how their lives may change after they reach out for help. Therefore, the fear of being labeled with a mental illness is stronger than the will of the patient to seek help for a potentially debilitating problem. Before a patient can seek formal help from a trained therapist or medical provider, the patient must overcome stigmas surrounding care. Bathje and Pryor (2011) assert that the individuals must first have sympathy toward themselves, so that they believe that they are deserving of the help they need. Many stigmas surrounding mental health patients have lead them to believe that they are to blame and are unworthy of the treatment. These selfdeprecating beliefs lead to more self-stigma and a worsened health. Untreated illness is worse for patients who are dealing with psychosis, bipolar disorder, major depressive disorder, and anxiety disorder (Clement et al., 2015). Many of these disorders are potentially life threatening when undiagnosed and untreated. According to Clement et al., out of fear, shame, and other perceived consequences, mental health patients will often hide the fact that they have a problem, mask their symptoms, and opt to handle the problem privately and individually (2015). The prevalence and medical inhibitions of stigmatizing patients should have disappeared almost two decades ago in the United States. Golberstein, Eisenberg, and Gollust discuss a report released by the Surgeon General of

4 the United States in 1999 that stated, “For our nation to reduce the burden of mental illness, to improve access to care… stigma must no longer be tolerated,” (2008). Yet, even after warnings from the Surgeon General, stigmas abound. They create barriers of stigma to adequate and appropriate healthcare, despite more than twenty years of research revealing that patients suffering from mental disorders have nothing to feel ashamed about. Confidentiality is critical to overcoming access to treatment for patients, especially mental health patients. Clement et al. (2015) discovered the feeling of being stigmatized ranked as the fourth highest overall barrier towards healthcare, and this barrier is much higher for individuals in the military. The fear that their confidentiality will be violated is the number one deterrent to a patient seeking treatment; this would likely result in an increase in stigma for that patient (2015). Settings in which patients suffering from a mental health issue receive care are often perceived as jeopardizing confidentiality. Providers should be aware that patients prefer “…primary care settings rather than in specialty mental health settings, especially older adults and minority populations” (Shim and Rust, 2013). This is because much of the mental health stigma stems from the perception of stereotypical mental health inpatient settings. Those receiving outpatient therapy fear less stigma when the treatment occurs in a setting much like that of a primary care provider. In addition, these settings are more relaxed for the patient and aid in the relief of anticipation of being stigmatized. If a patient is seen walking into an outpatient treatment center, the public is more likely to interpret the setting as any other office visit. Impact from Society. Stigmas placed on patients can also play an important role in how patients view themselves and interact with others. In a study by Bathje and Pryor, researchers concluded that the stigmas fall into the following categories: psychiatric symptoms, social-skill deficits, physical appearance, and labels (2011). Society uses these categories to form stigmatizing opinions about those who suffer from mental health disorders. The study revealed actual stigmas patients face on a daily

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basis. The stigmas, accompanied with a sense of fear and lack of sympathy, include the perception that people with a mental health disorder are, “… inherently dangerous, unkempt or disheveled, and responsible for their illness” (2011). These stereotypes and stigmas felt from others can cause someone with a mental health disorder to feel ashamed and alienated, ultimately worsening the status of their disorder due to excessive emotional stress. Studies have revealed these thoughts lead to a self-stigma that patients have towards themselves, and that such a relationship between public opinion and self-stigma are significantly related (2011). Self-stigma is the belief that societal stigmas apply to the individual, and that they essentially are what society says they are. These patients often wholeheartedly believe that these labels apply to them, and they begin incorporating them into their identity. One should note the interesting differences in gender and age groups among individuals who seek help and those who do not. Women with mental health disorders are more likely to navigate social stigma in a positive manner and less likely to form self-stigma when compared to men (Bathje and Pryor, 2011). Men are more likely to feel stigmatized; therefore, they are more likely to succumb to self-stigma. Unfortunately, the data do not support lessening of stigmatizing people, but rather a worsening of public opinion. Parcesepe and Cabassa assert, “The odds of describing a person with mental illness as violent in 1996 were 2.3 times the odds of describing a person with mental illness as violent in 1950” (2013). Even more detrimental are the effects of stigma on children, both those with and without a mental illness. Children view their peers who have mental health disorders as more violent and shameful compared to peers with a physical, identifiable disorder or disease, such as a broken bone or a form of cancer (2013). This datum reveals that stigmas rampant in public discourse are passed on to children, who continue to pass them onto the next generations. In a conversation about children with mental health disorders, adults were more likely to blame parenting, poor effort, substance abuse and

5 stress than they were to blame genetics, God’s will, and brain functioning (2013). Thus, the cause of mental illness in children is more likely to be seen as the fault of another than a natural cause. Adults are more likely to stigmatize and less likely to believe the legitimacy of mental health disorders in children versus adults. Children are often perceived as pure and gentle beings. Therefore, to associate an innocent child with a mental health disorder that is considered to be shameful and harmful is nearly impossible for many people. While the public does have a positive opinion about patients with mental health disorders seeking help and is supportive of professional care, most remain doubtful about the effectiveness of this care (Parcesepe and Cabassa, 2013). Further, the societal viewpoint of treatment is more favorable to certain types of treatment over others. Public viewpoint is that non-biological treatments such as therapy, talking to friends, and self-help groups are more effective than biological medicinal routes (2013). While each method of treatment is determined by many factors and on a patient-to-patient basis, this is not an idea supported by the public. Biological routes or medicinal forms of treatment are viewed as more stigmatizing than non-biological routes, like therapy groups and family counseling. The public has shown great concern for the use of medications to treat mental illness, especially the effectiveness versus harmfulness of each medication, believing that they could possibly have developmental effects and stunt the personality of children (2013). However, the prescription of medication is seen more favorably when used as an option for adults. The public opinion against the use of medication, especially with children, is so powerful, that researchers discovered these attitudes against medications are overwhelmingly frequent even in cases in which people affected by mental illness attempted suicide (2013). Public opinion is that there are still better treatments for the disorder, even when the use of medicine is highly indicated. The public opinion against medicinal interventions for mental healthcare is quite shocking, but even more important to understand is why this is the case in order to aid in the education of the public and

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ideally, the correction of public attitudes towards the uses of medicinal treatment for patients suffering from mental health issues. Financial Impact. The stigma behind labelling patients with a mental health disorder can have disadvantageous and even damaging financial consequences on a patient. Most of these patients want to work and have a career. However, some are unable to work, either due to the seriousness of their condition or to conflicts arising from stigma and lack of employers being educated about mental health issues. Staiger, Waldmann, Rüsch, and Krumm discovered that having a mental health illness is “…both a result of and a risk factor for unemployment” (2017). Some of those with mental health disorders are perpetually unemployed, adding to the maintenance of social stigma against them. The longer these patients are unemployed, the worse their mental illness becomes (Staiger et al., 2017). These patients are in such a destructive cycle, an escape seems nearly impossible. Studies have shown that employers would prefer that their applicants be open about their mental health disorder on their application (Brohan et al., 2014). Legally, these patients are not required to disclose that information on an application. These applicants must choose between whether they should keep that potentially sensitive information to themselves or disclose of the information to an employer. The same study has also found that these same employers have rated applicants with a mental health illness “… as less employable than either a candidate with a physical disability or a candidate with no disability” (Brohan et al., 2014). Herein lies a paradox: while these employers are indicating that they would like job applicants to share their mental health illness with them at the time of application, they are transparent about rejecting job applicants based on their disclosures. Naturally, out of fear of not being hired, patients keep their mental health illness to themselves. Stigma placed on these patients in the workplace not only comes from the employer, but also from their colleagues. A survey of the general American population has revealed that 58% of workers are unwilling to work with someone with a diagnosed

6 mental health illness (Brohan et al., 2014). Paradoxically, the same study has shown that the American population thinks of those with a mental health illness in a less-stigmatizing way when they are employed (2014). Clearly, the American public would like those with mental health disorders to work, but they would prefer not to work with them. In the case of even securing employment, patients have expressed that they believe that much of this stems from employers’ lack of education about mental health disorders. One patient suggested, “Fear was the reason for a lack of knowledge and that it is easier for people to think about mental health problems with a narrow range of knowledge rather than acknowledge the complexity and diversity involved” (2014). This explanation for stigma in the workplace is the same as stigmas placed on patients anywhere else. Without public education about mental health disorders, patients are mistreated because of its difficult nature. Thus, there are often insurmountable barriers to those with mental health disorders landing and keeping a job. Many patients have described the importance of finding an employer who accepts them and is educated on mental health illnesses (Brohan et al., 2014). When working with an accepting employer, patients feel less pressure to keep such a major part of their life hidden, especially in situations when time off work and professional help is necessary. Patients were encouraged by providers to find workplaces that were supportive and had a higher tolerance and understanding for their illness (Mestdagh and Hansen 2014). According to Mohammed-Collins and Harriss, the stigma about mental illness also has a large impact on the patient while at work, often resulting from a mismatch between the worker’s job and their abilities (2015). In many instances, patients partake in “…menial work, their duties [are] restricted, and they [are] refused time off to see mental health professionals” (2014). Working environments like this restrict the growth of these patients and make them more susceptible to stigma. The role of the clinician in this situation would be to empower the patient by supporting them, strengthening their functioning and abilities, and to support them on their job search

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(2014). Further, work sensitivity training can be helpful for both the employees and the employers to help work through any potential mental health stigma. There is also evidence that reveals the helpfulness of employees in other fields receiving training on mental health illnesses. In a study performed by Staiger et al., patients often list employment agency staff as an important resource and support system in their stressful search for a supportive employer and appropriate job (2017). Training these employment agency workers on mental health illnesses would be quite helpful to all parties involved. Even though many of these patients are stuck in this cycle plagued by stigma, with the right training and education, society can break this cycle. How to Combat Stigma. An important outcome of this research is to educate patients, families, providers, and the public on how to fight off stigmas on mental health disorders to improve the quality of care and life for patients. Children are an important age group to target because the stigma must end with them. Unfortunately, much of the prejudice towards others stems from the actions and words of parents. In 2009, England launched a nationwide program called Time to Change to target the stigmas and discrimination towards those with mental health disorders (Henderson, Evans-Lacko, Flach, Thornicroft, 2012). Integrating programs like Time to Change into the curriculum of schools nationwide and in the US will improve the attitudes that these children have towards their peers and others with mental health disorders. Like many other instances of discrimination and prejudice throughout history, change must begin with the education of others and advocacy for those affected by it. Clinicians need to be better trained to deal with mental health patients. Bathje and Pryor suggest that clinicians must avoid labels and use person-first language when addressing a patient help to decrease the incidence of stigma (2011). Person-first language means referring to a patient as: a person with depression versus a depressed person. The person always comes before the illness. Studies are also supporting that increasing the sympathy of the

7 general public towards patients with mental health disorders will also drastically decrease the perception of stigma. The knowledge of sympathy protects patients from self-stigma even though they know the stigma exists, and sympathy from the public towards these patients helps neutralize the feelings of discrimination that propagate into stigma (Mohammed-Collins and Harriss, 2015). Changes in these categories may offer some critical steps about how to combat mental health stigma. Other options to combat stigma stem from the treatment of patients suffering from a mental health disorder. As discussed before, the public doubts the efficacy of the treatment these patients are receiving. The clinician must be open with the patient in all aspects of care. The transparency is necessary with their treatment options, the effectiveness of each treatment, the knowledge of the treatment, and the patientâ€™s willingness to partake in each of the various forms (Parcesepe and Cabassa, 2013). If patients feel forced into one treatment over another, this will only result in a negative outcome for the patient. The patient-provider relationship is crucial when trying to provide treatment while avoiding stigma. Educating the patients on the research done to prove the efficacy of various treatments will also help decrease the incidence of stigma towards methods of treatment and to foster a patient-provider relationship based on trust. The clinician should also be aware of these stigmas and should be willing to use other forms of less stigmatizing treatment for the patient, such as providing care in more relaxed settings, through online support groups, and through non-traditional mental health services (Townsend et al., 2012). Other factors that play a role in treatment for the patients include access to healthcare and cost barriers. The clinician should be aware of many forms of treatment to help the patient improve, especially if they cannot afford the treatment of choice. A new trend in treatment of mental health disorders comes before the diagnosis occurs. An article by Shim and Rust supports the idea of primary prevention and the whole-person approach where emphasis is on improving the health of entire communities through healthy living to help reduce

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the need for mental health intervention (2013). These doctors are aiming their treatment at prevention instead of trying to fix a mental health issue once it does occur. While many treatment strategies are available today, clinicians must to remember that treatment is on a patient-to-patient basis. No one treatment is the best treatment for every patient. The clinician must provide the patient and the family with coping strategies to help everyone better understand, address, and prevent stigmas. Unfortunately, stigmas associated with mental health are highly under-researched and requires much more data to pinpoint causes and effects that they have on patients. Methodology Participants. The Institutional Review Board at Saint Francis University gave approval for the research. Participants in this research were selected from a convenience sample of people using or providing care in inpatient or outpatient behavioral health services at the following locations: Penn Highlands in DuBois, Pennsylvania; Nulton Diagnotics and Treatment Center in Richland, Pennsylvania; and University of Pittsburgh, Altoona, Pennsylvania. Participants were asked to fill out questionnaires. Both medical providers and patients were at least 18 years of age and in a stable mental state. Procedure. An original questionnaire was administered to assess the degree of stigma for both patients and providers. A total of 200 patient questionnaires and 15 provider questionnaires were distributed to each location with an anticipation of a 10 percent return rate. A provider sees an average of 10 patients per day. Excess patient questionnaires were sent to compensate for large patient numbers. Questionnaires were distributed at each location for one month, from December 4, 2017 until January 4, 2017. Both patient and provider questionnaires were administered at the inpatient or outpatient location. Outpatient participants received the questionnaire to complete at the time of check-in. Inpatient participants completed the questionnaire at or near the time of discharge. The questionnaires took the patients approximately five to 10 minutes to

8 complete. Separated at the time of completion, consent forms and questionnaires were then placed into separate folders. A copy of the patient questionnaire is in Appendix A. Behavioral health providers who participated filled out the questionnaire at their leisure during the month of collection. A copy of the provider questionnaire is in Appendix B. Analysis. Questions on both the patient and provider questionnaires were coded and reversecoded based on whether or not they accurately assessed stigma. The questions were inputted into the International Business Machines Statistical Package for the Social Sciences (IBM SPSS). Data trends, correlations, and connections between data were provided via the software. Results The questionnaires yielded a total of 76 patient responses and 33 provider responses. There were 19 samples of inpatient providers, 10 samples of outpatient providers, and 2 samples that classified themselves as both inpatient and outpatient providers. Two providers declined to include their setting and were not included in the data. Overall, the data show that the opinion of the providers is skewed slightly to the left. Appendix C reveals that the majority of the provider responses fall on the left side of the histogram. The lower the total point value of results, the less the provider felt that they and their patients were stigmatized. The graph shows that the majority of the providers surveyed do not feel that stigma is overtly evident. What is interesting to note in Appendix D, is that the median of stigma in the inpatient setting is 22.5 compared to a median of 10.0 in the outpatient setting. Those providers who responded from an inpatient setting felt that stigma was much more evident than those from an outpatient setting did. A representation of stigma level compared to setting was evenly distributed among the patient participants. The inpatient setting yielded an average stigma level of 35.5 while the outpatient setting results also yielded an average stigma level of the same value, 35.5. A chart of these data can be found in Appendix E. Data for age and perceived stigma level were cross-analyzed. The

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participants were broken up into three age groups: group 1 consisted of 16 patients 18-25 years old, group 2 was 39 patients 26-50 years old, and group 3 was 12 patients 50 years and older. The majority of the participants fell within group 2, and a copy of these data can be seen in Appendix F. Group 3, with the oldest participants had the most perceived stigma, while group 2, and with the middle-aged patients had the least perceived stigma. Group 1, the youngest participants had the most moderate amount of perceived stigma. Appendix G reflects the data of perceived stigma among age. Discussion The stigma level assessed from the providers was slightly less than expected, but stigma level based off provider setting was not. As the literature review predicted, the providers that work in the inpatient setting are victims of and witnesses to more instances of mental health stigma. One should note, however, there were a substantially higher number of subjects from the inpatient setting versus the outpatient setting, adding a slight bias to these results. Because only two providers responded that they work in both settings, the results were insignificant and eliminated from the totals. The overall status of mental health stigma on patients was very similar to the providers. The slightly more skewed data of the patients suggests that they do not believe that stigma is as prevalent as the providers do. This is important, however, because this data shows that providers are indeed aware that the stigma is present, even if stigma is not as detrimental to these West Central Pennsylvania patients as for others across the country and the world. Providers still recognize this presence and consider stigma when initiating care. What is most interesting is that the average perception of stigma for patients in both settings was the same. This is not what would have been expected from the literature review. The current data suggest that those subjects from the inpatient setting should have reported substantially higher perceptions of stigma than those in outpatient settings. A speculation from this researcher as to why this occurred comes from the idea of habituation. Many

9 of the inpatient subjects will have had repeated hospitalizations and experiences in the inpatient clinic. This suggests that they have become used to the system. Over time, the idea of stigma may have become negligible to them, as they have become habituated to it. Another proposition is that those subjects in outpatient care are aware of the public stigma on mental health, but not that the public views inpatient and outpatient disorders differently. They may feel lumped under an umbrella category of mental health stigmatized patients, and therefore, perceive more stigma than is actually conveyed by the public toward them. Age is also a factor for levels of stigma a patient perceives. The data suggests that the older a patient is the more perceived stigma they will have. This did not prove to be true in the research collected. As expected, the older age group, patients 50 years and older, perceived the most stigma. However, the youngest age group, patients aged 18-25 years old, did not perceive the least amount of stigma. In fact, the youngest patients landed in the middle. The middle age group, patients aged 26-50 years old, felt the least amount of stigma. The majority of patients in this study fell in this middle category, so there was a slight bias in this age group. There in an increased likelihood that the public opinion in West Central Pennsylvania does not match that of the rest of the United States and the world, making these patients perceive less stigma about their mental illness. Limitations. The identification of various limitations throughout this research is evident: 1. The Institutional Review Board only approved the performance of research with adult participants. The absence of questionnaires and opinions from such a large age group of children and adolescents greatly limits the results. As the data previously mentioned supports, this age group, also impacted by stigma, has the potential to rid stigma from the new generations to come. 2. The research does not include any information about gender, income, or race, factors that also play a role in the impact of stigma on a person. 3. While the participants were not hand-selected, they also were not completely random. The patient

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samples only came from three different locations, not providing a very diverse sampling of subjects. 4. The questionnaires contained a â€œnot-applicableâ€? option for them to select, providing an easy answer for the patients and providers to choose when they had not decided how they felt on either side of the spectrum. The inclusion of this option had a negative skew on the results. 5. The subjects included only patients and providers. The opinions of family members and the public were not assessed, causing the results to be more of a narrow approach than broad. 6. The main researcher did not perform the administration of questionnaires. This allowed for a margin of error for potentially missed patients or questionnaires that were forgotten about or not collected. 7. There was not an identical amount of data collected from providers and patients in both inpatient and outpatient settings. There were more data received from the inpatient setting from both patients and providers, causing a bias toward this setting in the results. 8. There were also not an identical amount of data collected from each age group of patients. There were more than double the amount of data received from the middle age group of patients aged 26-50 years old than both of the other two groups, causing a bias toward this age group in the results. Recommendations for Future Research. To repeat this study again, many changes are necessary. The data from this study proves that the absence of data from children and adolescents are crucial. Obtainment of ethical approval from the Institutional Review Board is necessary to perform the research with this specific age group. When evaluating patient and provider opinion on stigma, screening for other factors such as gender and ethnicity would yield more specific and targeted results. Data has shown that these factors are important for determining stigma level, so one would find this information quite useful for categorizing stigma levels. Another strategy that would allow for a more detailed sampling would be to perform a longitudinal study on these participants over the next 10 years. The data would allow

10 researchers to see if the opinions of these participants on mental health stigma have improved or worsened over time. The current societal belief is that mental health disorders are becoming less taboo in the modern world, but a longitudinal study would prove whether that holds true. A study performed across cultures and ethnic backgrounds would be useful in determining the cause of mental health stigma. It would allow researchers to broaden their knowledge on groups of people that are most at risk. In the meantime, groups like the National Alliance on Mental Illness are advocating for the rights of those with mental health disorders while working to abolish public stigma across the nation. Conclusion Mental health stigma is incredibly prevalent in the United States and worldwide and negatively affects the patients, their families, and providers. Even though this stigma is incredibly prevalent, many of those affected by stigma do not even realize this. Patients, providers, and the public should be aware of these stigmas placed on mental healthcare, and help rid them from society. These patients are negatively impacted by stigma in their healthcare, social lives, and financial means. The data show that for these patients in West Central Pennsylvania, stigma is perceived, but patients and providers are not reporting high levels of stigma. Despite efforts to rid society of mental health stigma, more research and strong action is necessary to inform the public about them and provide those affected by stigma with the tools they need to contest them. Mental healthcare conditions are currently positive for patients in West Central Pennsylvania; however, changes must be made to societyâ€™s opinion of mental health for the patients, their families, and the providers. Acknowledgement Research was supported by Penn Highlands, DuBois; Nulton Diagnotics and Treatment Center, Richland; and UPMC, Altoona.

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Appendix A. Patient Questionnaire.

Appendix B. Provider Questionnaire.

Mental Health Stigma Questionnaire By completing this questionnaire, I indicate my consent to participate in the study. I understand that confidentiality will be maintained.

Mental Health Stigma Questionnaire By completing this questionnaire, I indicate my consent to participate in the study.

Please choose which option applies to you: Inpatient Outpatient Age:

Please choose which option applies to you: Inpatient Provider ☐ Outpatient Provider ☐ Title/Degree:

Below are fourteen questions that relate to the topic of social stigma on mental health disorders. Please only checkmark the one option that best applies to how you feel about the statement.

Below are ten questions that relate to the topic of social stigma on mental health disorders. Please only checkmark the one option that best applies to how you feel about the statement.

1= Strongly Agree

5= 2= 3 = Not 4= Strongly Agree Applicable Disagree Disagree

3 = Not 5= 2= 4= Applicabl Strongly Agree Disagree e Disagree

Most people with a mental illness seek help from a doctor/other provider.

15)

Most people with a mental illness seek help from a healthcare provider.

☐

I am embarrassed of my mental illness.

16)

My patients are embarrassed of their mental illnesses.

☐

I feel safe talking with others about my mental illness.

17)

I consider possible stigmas before I decide on patient care.

☐

Someone has treated me badly because I have a mental illness.

18)

☐

I feel that I am weak for seeking help for a mental illness.

The general public thinks less of me as a provider because of the specialty I work in.

19)

☐

People think that I am crazy because I have a mental illness.

I think that having a mental illness is looked at differently than a physical illness.

☐

6) 7)

I didn't want to seek treatment because of what people might think.

20)

It is generally easier to have a mental illness as a child than as an adult.

☐

People will treat me differently if they know I am being treated for a mental illness.

21)

My patients don’t want to seek treatment because of what people might think.

☐

I was scared of the medical treatment I might receive because of my mental illness.

22)

My patients are treated differently if others know they are being treated for a mental illness.

☐

10)

Other people think I am dangerous because I have a mental illness.

23)

My patients are scared of the medical treatment they might receive because of a mental illness.

☐

11)

I think that having a mental illness is looked at differently than a physical illness.

24)

I would feel comfortable being treated for a mental illness.

☐

12)

I think children can develop mental illnesses.

13)

It is easier to have a mental illness as a child than as an adult.

14)

I am afraid my job/career will be affected by my mental illness.

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12 1

Appendix C

28.500

10.000

16.500

10.000

13.000

4.500

2.500

7.000

7.000 N

Median

10.00000 .687

Std. Error of Skewness Note: The graph above exhibits the relationship of provider setting; inpatient, outpatient, or both, with the level of stigma that they perceive.

19.500

26.000 N

Median

Appendix D. Case Summaries

22.75000 .

Std. Error of Skewness

Rank of Stigma Level

22.500

4.500

30.500

26.000

28.500

13.000

2.500

26.000

Median

16.50000

Std. Error of Skewness a.

.421

Limited to first 100 cases.

Note: The table above exhibits the relationship of provider setting; inpatient, outpatient, or both, with the level of stigma that they perceive.

Appendix E. Case Summariesa Rank of Stigma Level

10.000

7.000

22.500

1.000

30.500

22.500

16.500

32.000

16.500 N Median Std. Error of Skewness

19 22.50000 .524

43.000

48.500

35.500

1.000

12.000

55.500

10.000

20.000

52.000

68.500

35.500

29.000

61.500

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70.000

10.000

64.500

14.000

48.500

5.000

8.000

68.500

2.500

66.500

31.500

2.500

64.500

58.500

29.000

61.500

14.000

26.000

45.000

35.500

58.500

71.000

35.500

10.000

31.500

29.000

52.000

55.500

48.500

26.000

35.500

23.000

17.000

Total

14.000

Median

55.500

39.500

Std. Error of Skewness

52.000 N Median

Median

Std. Error of Skewness

35.50000 .393

17.000

55.500

23.000

45.000

20.000

61.500

23.000

41.500

66.500

4.000

6.500

45.000

20.000

48.500

33 35.50000 .409

Std. Error of Skewness

69 35.50000 .289

Limited to first 100 cases.

Note: The table above exhibits the relationship of patient setting; inpatient, outpatient, with the level of stigma that they perceive.

Appendix F.

Note: The graph above exhibits the distribution of the ages of the patient participants in this study.

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Appendix G. Case Summariesa Rank of Stigma Level 1

35.500

61.500

55.500

43.000

35.500

39.500

6.500

35.500

23.000

48.500

8.000

14.000

35.500

52.000

55.500 N Median Std. Error of Skewness

26.000

66.500

68.500

45.000

2.500

17.000

35.500

61.500

17.000

2.500

48.500

41.500

5.000

26.000

55.500

61.500

29.000

Total

N Median

Std. Error of Skewness

35.50000 1

.564

6.500

61.500

58.500

48.500

12.000

14.000

29.000

45.000

52.000

1.000

10.000

55.500

41.500

66.500

20.000

4.000

31.500

52.000

68.500

29.000

71.000

26.000

20.000

14.000

10.000

Median

23.000

Std. Error of Skewness

10.000

58.500

48.500

64.500

.378 20.000

17.000 N Median Std. Error of Skewness

39 31.50000

12 37.00000 .637 67 35.50000 .293

Limited to first 100 cases.

Note: The table above exhibits the relationship of patient age grouping with the level of stigma that they perceive.

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Works Cited Bathje, G. J., & Pryor, J. B. (2011). The relationships of public and self-stigma to seeking mental health services. Journal of Mental Health Counseling, 33(2), 161-176. Retrieved from http://francis.idm.oclc.org/login?url=http://search.proquest. com.francis.idm.oclc.org/docview/864591241?accountid=4 216 Brohan, E., Evans-Lacko, S., Henderson, C., Murray, J., Slade, M., & Thornicroft, G. (2014). Disclosure of a mental health problem in the employment context: Qualitative study of beliefs and experiences. Epidemiology and Psychiatric Sciences, 23(3), 289-300. doi:http://dx.doi.org.francis.idm.oclc.org/10.1017/S204579 6013000310 Clement, S., Schauman, O., Graham, T., Maggioni, F., EvansLacko, S., Bezborodovs, N., . . . Thornicroft, G. (2015). What is the impact of mental health-related stigma on helpseeking? A systematic review of quantitative and qualitative studies. Psychological Medicine, 45(1), 11-27. doi:http://dx.doi.org.francis.idm.oclc.org/10.1017/S003329 1714000129 Golberstein, E., B.A., Eisenberg, D., PhD., & Gollust, S. E., B.A. (2008). Perceived stigma and mental health care seeking. Psychiatric Services, 59(4), 392-9. Retrieved from http://francis.idm.oclc.org/login?url=http://search.proquest. com.francis.idm.oclc.org/docview/213085869?accountid=4 216 Henderson, Claire,M.R.C.Psych, PhD., Evans-Lacko, S., Flach, C., M.Sc, & Thornicroft, Graham,M.R.C.Psych, PhD. (2012). Responses to mental health stigma questions: The importance of social desirability and data collection method. Canadian Journal of Psychiatry, 57(3), 152-60. Retrieved from http://francis.idm.oclc.org/login?url=http://search.proquest. com.francis.idm.oclc.org/docview/1010785676?accountid= 4216 Mestdagh, A., & Hansen, B. (2014). Stigma in patients with schizophrenia receiving community mental health care: A review of qualitative studies. Social Psychiatry and Psychiatric Epidemiology, 49(1), 79-87. doi:http://dx.doi.org.francis.idm.oclc.org/10.1007/s00127013-0729-4 Mohammed-Collins, R., & Harriss, A. (2015). Ending the stigma of mental ill health. Occupational Health & Wellbeing, 67(11), 27-29. Retrieved from http://francis.idm.oclc.org/login?url=http://search.proquest.

15 com.francis.idm.oclc.org/docview/1738082416?accountid= 4216 Parcesepe, A. M., & Cabassa, L. J. (2013). Public stigma of mental illness in the united states: A systematic literature review. Administration and Policy in Mental Health and Mental Health Services Research, 40(5), 384-99. doi:http://dx.doi.org.francis.idm.oclc.org/10.1007/s10488012-0430-z Shim, Ruth,M.D., M.P.H., & Rust, George,M.D., M.P.H. (2013). Primary care, behavioral health, and public health: Partners in reducing mental health stigma. American Journal of Public Health, 103(5), 774-6. Retrieved from http://francis.idm.oclc.org/login?url=http://search.proquest. com.francis.idm.oclc.org/docview/1349240555?accountid= 4216 Staiger, T., Waldmann, T., Rusch, N., & Krumm, S. (2017). Barriers and facilitators of help-seeking among unemployed persons with mental health problems: A qualitative study. BMC Health Services Research, 17doi:http://dx.doi.org.francis.idm.oclc.org/10.1 186/s12913-017-1997-6 Townsend, L., PhD., Gearing, R. E., PhD., & Polyanskaya, O., M.S. (2012). Influence of health beliefs and stigma on choosing internet support groups over formal mental health services. Psychiatric Services, 63(4), 370-6. Retrieved from http://francis.idm.oclc.org/login?url=http://search.proquest. com.francis.idm.oclc.org/docview/1370728818?accountid= 4216.

Shelbie Jamison ('18) is a Physician Assistant major with a minor in Psychology. She has been an active participant in the SFU community, served as an Executive Board member of the Gamma Sigma Sigma national sorority and of the Student Activities Organization, and is a member of the Physician Assistant Society. She is currently a student supervisor of the JFK Center. She is a member of the Order of Omega, Gamma Sigma Alpha, and Phi Eta Sigma National Honor Societies. She was awarded Sorority Woman of the Year (2017) by the Student Government Organization. After graduation, Shelbie hopes to work in the Behavioral Medicine field at her hometown hospital.

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A Burning House: An Experiment in the Cell Phone Novel Genre Tara L. Fritz Literature & Languages Department School of Arts & Letters tlf100@francis.edu

The research conducted as part of this project focused on the elements and history of the cell phone novel, a genre of literature that reached the height of popularity in Japan in 2007. My project is in two parts: first, a short introduction to the cell phone novel and my experiences writing one, and then a full-length novel written primarily on my cell phone. The focus of the novel was not only to write and edit it entirely on a cell phone but also to incorporate a diverse ensemble cast of at least four main characters. While my project began with the research into the cell phone novel genre, the ultimate goal was to create a manuscript of my own. The first draft of A Burning House came in at exactly 92,148 words. Each of those 92,148 words was tapped out on the iPhone 5's tiny on-screen keyboard. Later revisions, also completed on my phone, brought the word count down to just over 75,000 words. I had never heard of a cell phone novel before a professor mentioned it to me. The name itself sounded like a challenge—a novel written on a cell phone. I had written plenty of things on my cell phone before that—the beginnings of short stories, snippets of dialogue, ideas for characters and plots. I was also a big fan of challenging myself to write bigger and to write better. And so I decided to write my thesis on my cell phone. By the time I started writing, the height of the cell phone novel had already passed. In Japan, where the genre was invented, the peak popularity of cell phone novels was in 2007. That year, exactly half of Japan's ten best-selling novels began as cell phone novels (Snow). On the websites that hosted the first drafts of these novels, there were thousands more being read, updated, and commented on (Goodyear). These novels were written and read primarily by

Kirk Weixel, Ph.D. Literature & Languages Department School of Arts & Letters kweixel@francis.edu

teenage girls, and many of the authors were firsttime writers (Clark). They covered topics that were too taboo to talk about frankly and instead had to be covered in the veil of fiction on the Internet—sex, romance, rape, pregnancy, and love triangles, though true love always managed to win out in the end (Goodyear). Many of the authors, writing under pseudonyms, claimed the stories were autobiographical (Farrar). Their novels took place in sleepy country towns, which contrasted with the packed Tokyo trains that their authors usually rode. On busy morning commutes, many cell phone novel authors would write (and read) on these trains. Updates were written and designed to take up no more than a phone screen—much easier in Japanese, whose set of characters make it a much more compact language, where in English letters it would amount to about 140 characters. Most sentences were written in fragments, and the stories were primarily dialogue-driven with a strong emphasis on drama and action. They were unedited, raw, and emotional, written sentence-by-sentence (Goodyear). One woman—whose cell phone novel made her a bestselling author—would send her story to her readers line-by-line (Rudin). Though the genre was incredibly popular in Japan in the early 2000s, its popularity there has declined. The genre has not really reached the same level of popularity in the United States, but one can't help but see that technology is changing the way we read and write literature (Houston). Cell phone novels are the first new genre of literature to come out of the digital age; they've been followed by other genres like Twitterature and nanofiction of which Hemingway and his six-word stories would have been proud (Goodyear, Rudin). In a world that's

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becoming all the more fast-paced, where people are becoming more and more attached to their cell phones, these new genres of literature are emerging in order to keep up with the evolution of technology. Even established authors are joining in. British author David Mitchell, who is most famous for his book Cloud Atlas, wrote a short story in 140character segments on his Twitter account. The story was called “The Right Sort,” and it took place over the course of 280 tweets. This story later grew into one of Mitchell’s full-length novels, Slade House (“‘The Right Sort’”). Writing on a phone that was a lot more complex than the ones that the Japanese were using in 2007 was more of a challenge than I had anticipated, despite being able to use a full on-screen keyboard instead of just a few buttons. Still, I wanted to mirror the method of writing a cell phone novel as closely as possible. I tried texting sentences to myself or even writing out Tweets, where the 140-character limit kept my sentences choppy and fragmented in the same style I was trying to imitate. Both methods took too long for me to consider using them over the two months I had planned out to write my first draft. I ended up using an app called iAWriter, which kept my files meticulously organized; at the end of my first draft, I compiled each chapter on an app called Scrivener, which syncs with the same program on my computer. During the writing of the first draft, I used my writing app's Focus Mode feature, which highlights only a few lines of text at once, dimming the others. I wrote one sentence at a time. The Focus Mode kept me from scrolling back to look at what I had previously written and forced me to think fast and think ahead. I didn't keep a count of characters per sentence, but I deliberately made each sentence shorter to keep them under 140 characters. The end result was that many of my sentences were choppy and fragmented. It wasn't until the editing stage that I began to notice the difference between my first draft and my usual writing style. Besides the short sentences, I found I had a tendency of repeating words, something which is a lot harder to avoid when it’s impossible to look back at previous sentences. I also found myself leaving out details and focusing instead on action and dialogue.

17 Typing line-by-line was excruciatingly slow. Typing on my phone screen with its minuscule keyboard, using only my thumbs, was even harder. I found myself rushing through scenes where, had I been writing on my computer, I would have paused to add details and atmosphere. Like other cell phone novel authors, I found my chapters to be dialogueheavy. When I finally put all my one-line sentences together, even my paragraphs were short. Autocorrect was my constant enemy. Simple words autocorrected almost without me noticing into words I hadn't meant to write, and stray letters ended up between sentences and words. Only occasionally was autocorrect helpful in deciphering the jumbledup results of my clumsy fingers. Despite these setbacks, I still produced the longest manuscript I had ever written. Though longer, it was also the most convenient novel I’d written. One of the main reasons why the genre was developed was due to the need for something to do on a busy train, something portable but interesting enough to make the long, crowded journey bearable. I understand the appeal now. Here is a short list of all places where I have written and edited my novel—on an airplane, in restaurants and cafés, in the woods, in the moments before class started, on the beach, in my backyard, in a hair salon in France. Not only could I take my book anywhere with me, but it was always available if I needed to write down a quick note or if I found myself with a few moments of free time. And while I may have looked like I was glued to my phone, doing something pointless, I was actually creating my own world while I tapped away at my little keyboard. I may have given myself a bit of carpal tunnel and a few eye-strain headaches here and there, but I would say the challenge was worth it. Though I am not sure if it is my place to decide, I'd like to say that the end result of my experiment was perhaps more literary than the amateur stories popular in Japan— after two rounds of revisions, A Burning House certainly looks more like a traditional novel, and I believe it would be hard to tell that it was ever written on a cell phone in the first place. However, like the characters in Japanese cell phone novels, my characters search for the same sort of things—

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reconciliation, resolution, true love. Though my characters are not all teenagers, they are still just as capable of being angry, stubborn, and passionate. And though I am not a first-time writer posting Tweet-sized updates on a website, I still hope that I have captured the spirit of the cell phone novel. Maybe that doesn't mean we should all try writing the Next Great American Novel on our iPhones, but I would call this experiment a success all the same. A Burning House is a story about four very different people in the small town of Fairweather— a young woman returning to her grandmother’s estate after her failed wedding day, a man worried about the future of his business, a mother facing divorce and the loss of her child, and a teenager learning to control his anger. Each character is connected, in some way, to a strange and singular event: the fire that almost destroyed the Tempest House. The novel tells the individual story of each of these characters while also connecting them back to the house and to each other. A short excerpt is provided below. A Burning House Prologue The sun dipped at last below the distant hills, and in the low light a plume of smoke was just visible rising over the rooftops in the blue dusk. The streets were damp from the summer storm that had blown through early that evening; the air was still electrified, shivering, but the clouds had already dispersed like the storm had never come. Somewhere in Fairweather, a house was burning. A bolt of lightning had struck the tumbledown manor on the hill as a last parting gift from the thunderstorm. The cloud of smoke grew and rose, dark and acrid, against the evening sky. The house was over a hundred years old but had stood empty for two decades, the stone walls grown over with creeping ivy that always returned no matter how many times the groundskeeper tried to beat it back; the windows were covered with heavy curtains to keep away light and curious onlookers from the

furniture and dust inside. One spark in the north wing of the house had been enough to start a blaze. The neighborhood was sparsely populated—old winding roads connecting a few extravagantly large houses to form what folks called the Hill—but the fire didn't go unnoticed for long. A rain-damp boy with a bruise on his jaw saw the fire first as he was passing. He'd been walking slowly, head ducked low; he didn't belong in this neighborhood, but sometimes he liked to pretend that he did. He looked up when he smelled the smoke. Though he came from a rougher part of town, and was a little rough around the edges himself, for all his faults it was hard to ignore a disaster unfolding right in front of him. Already, flames were beginning to lick around the edges of the moss-spattered roof. Panic bloomed in his chest at the sight of it, but he was at a loss for what to do. There was only one other residence on that particular street, a cottage set back a ways from the manor house. In the driveway was a white van, and, taking it as a sign of life, the boy sprinted up to the front porch. He pounded on the door, but there were no footsteps, no shiver of the curtains that meant someone was home. He turned to leave, thinking maybe there would be someone on the next street over. Someone who would let him borrow their phone, since he didn't have one, to call the fire department. Then again, maybe somebody already had—called the police, or something. Maybe his job here was done. But as he turned toward the street again, he caught sight of a man walking up the driveway. A man he thought he recognized, but couldn't remember how. “What's going on?” The man was very tall and shouted like the boy’s father, and his voice sounded like it was carrying all the panic the boy was holding inside him. “Did you start this?” “Did I start the fire?” The boy bypassed fear and headed straight for anger. He might be reckless, sure, but he wasn't stupid. “You think if I started a fire I'd still be hanging around?” The man already seemed tired of him, more focused on the spreading flames as he pulled a cell

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phone from his pocket and motioned for the boy to leave. “I got it from here, kid. Best get out of here now, while you can.” The boy shivered as if the ominous statement was a gust of cold air. He knew now why he recognized the man, and only hoped he didn't recognize him either. He rubbed at the bruise on his jaw and pulled the hood of his jacket over his head again. The man wasn't looking at him now, too busy explaining the situation to emergency services on his phone; as quickly as he had served his purpose, the boy had been forgotten. He took off running down the street as the fire siren at the bottom of the hill began to wail, and he didn't look back. ---A full moon was rising into the quickly darkening sky by the time a fire truck pulled up to the manor house. The man who lived in the groundskeeper’s cottage and had made the call stood on the edge of his lawn and watched the blaze with a sort of resigned acceptance. Already, several neighbors had gathered, though almost no one dared to enter the shadowy bend of Ravenhead Road on any normal day. A burning house was an event worthy of a crowd. The fire hydrant at the end of the street had been placed there after the first fire and used only once since then, twenty-eight years ago. The first time, the house had been empty, too, and only half-built; the second time, it had not been empty at all. Someone had died in that fire. Now, the house stood like a shell of its former self, and the north wing burned quickly. “The parlor,” someone in the crowd announced, almost unheard as the firemen sprayed water into a fiery window. The others gathered on the lawn let out a near-simultaneous sigh of pity. “What a shame,” said someone else. “Saw the lightning bolt,” said the first, “from my kitchen window. I'll bet you could hear the thunder in the next county over.” The groundskeeper glared at the whispering and shuffling crowd, but he didn't ask them to leave.

Secretly, he enjoyed the sensation of not being alone. ---In a house on the next street over, a woman with a glass of wine in her hand stood in front of a large window. The wine was red, and her lips were stained with it. She took a sip as she watched the smoke rising over the pine trees, a jagged line of them like broken teeth in the backyard. “What you see?” A little girl with blonde hair in pigtails tottered barefoot across the rug. She wrapped her arms around her mother’s leg and tilted her face upward, smiling. The woman didn't look down at her. Instead, she reached down absentmindedly with her free hand to pat the girl’s head; her eyes were still locked on the smoke gathering like a cloud in the darkening sky. “Nothing, baby.” She took another sip of wine and tried to identify the feeling of dread in her stomach. She didn't know where the smoke was coming from—what house, or whether it was even a house that was burning—but something about the sight of it deeply unsettled her. Like a book out of place. Like a glass inexplicably shattered in the bottom of a sink. What you see, what you see? Something about the storm had thrown her offkilter. The loudest crack of thunder had woken her from where she was sprawled on the couch. Woken her like being thrown in a pool of ice water. Disorienting. The wine was starting to calm her down, but the specter of that inexplicable fear still lingered. “Don't bother Mommy, dear,” said the nanny as she rushed in to sweep the little girl away. The girl relinquished hold of her mother’s leg without much prodding. The night was fading in too quickly now. The lights of the fire trucks were just visible beyond the wall of trees, shimmering between the branches. The woman drained the last of the wine in her glass, but she didn't turn from the window, even when she couldn't see the smoke anymore.

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20 ----

In the morning, a woman in a hotel room received a phone call. It wasn't the first call she had received since arriving there, a fact she was pointedly trying to ignore. She had tossed her cell phone across the room hours ago, hoping against hope that it would lay silent and let her rest. When it went off again in the dim light of morning, startling her out of a light sleep, she decided to turn the phone off for good. Reluctantly, she slid from her pile of blankets in the unmade bed, brushing a bit of hair—newly cut with her own unskilled fingers—from the curve of her cheek. She bent down for the phone where it lay on the stained carpet. For once, the number was one she didn't recognize. She decided to answer it. She listened as an insurance agent explained to her that the property had caught fire, and blinked in confusion as her sleep-addled mind struggled to catch up. It was a second before she remembered— the inheritance. The house. Insurance would take care of most of it, the agent told her. The main structure of the house had escaped most of the fire and water damage, but the parlor was almost completely lost. Lightning. An act of fate. Whatever it was, it had given her an escape. “I'll be there,” she said, already packing, tossing scattered clothing one-handed into her single duffel bag. “I'll come supervise the reconstruction of the house.” The agent tried to tell her there was no need. That the groundskeeper could take care of it, and that living in the house might be dangerous after such a disaster. “It's my property,” she reminded him. She already had time off from work. She already had a copy of the key, which her father had kept for her

until she was old enough to put it in a safety deposit box in the bank. “I'll come to Fairweather.” There was nothing the agent could say to convince her otherwise. She hung up and, slinging her bag over her shoulder, left the room with her heart a little less heavy. Works Cited Clark, Ruth Cox. “Cell Phone Novels: 140 Characters at a Time.” LD Online. WETA, 2009. Web. 14 Mar. 2016. Farrar, Lara. “Cell Phone Stories Writing New Chapter in Print Publishing.” CNN. CNN, 26 Feb. 2009. Web. 14 Mar. 2016. Goodyear, Dana. “I ♥ Novels.” New Yorker. Condé Nast, 22 Dec. 2008. Web. 14 Mar. 2016. Houston, Taylor. “App-tacular: Writing on Phones, Smart Phones, and Tablets.” LitReactor. LitReactor, 4 Apr. 2012. Web. 14 Mar. 2016. “‘The Right Sort,’ David Mitchell’s Twitter Short Story.” The Guardian. Guardian News, 14 Jul. 2014. Web. 14 Mar. 2016. Rudin, Michael. “From Hemingway to Twitterature: The Short and Shorter of It.” The Journal of Electronic Publishing 14.2 (2011): n. pag. Web. 14 Mar. 2016. Snow, Danny O. “Would You Read a ‘Cell Phone Novel’?” Huffpost Books. Huffington Post, 15 May 2014. Web. 14 Mar. 2016.

Tara Fritz ('17, B.A., English) is a recent graduate of Saint Francis University. She was an English major with minors in French, Women's Studies, and Social Responsibility. She was President of the Literary Club and Blue Stockings Society, worked as a tutor at the Writing Center, and was actively involved in her sorority, Theta Phi Alpha. She was a member of Sigma Tau Delta, the English honors society. She is currently at George Mason University for her Master's degree in Creative Writing.

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Using Case Studies as Instructional Material to Influence Introductory Anatomy and Physiology Studentsâ€™ Learning and Attitudes Danae L. Peters Physical Therapy Department School of Health Sciences dlp109@francis.edu

Kelly L. Garanich Biology Department School of Sciences kgaranich@francis.edu

The study compared studentsâ€™ learning outcomes and attitudes using case studies to using traditional lectures in teaching sections of an introductory anatomy and physiology class at Saint Francis University. The exam scores from the chapter sections taught by case study were compared to the scores from the sections taught through lecture material. The only significant difference between scores occurred on the first exam, which had higher scores on the lecture material. Student attitudes toward the use of case studies were measured with a survey at the end of the semester. The survey showed that 50% of students felt the case studies helped them understand the material better and 69% thought their ability to think critically improved with the case studies. Most students expressed a positive or neutral opinion toward learning with case studies; however, many students felt rushed during the individual time during which they answered two to three questions concerning the case. Most students also felt rushed during the small-group time when they discussed the questions and shared the information they learned. Consequently, students felt they did not have enough time to investigate and discuss the case in order to gain a complete understanding; therefore, the students would likely have benefited from completing the case study individually as homework so class time could be utilized for small-group and class discussion. Introduction In a basic science class, such as anatomy and physiology, students tend to memorize material only to recall it for the exam. Shortly after the exam, the information is forgotten because the students do not give the information meaning, understanding, and depth. When students are exposed to anatomy through traditional lectures only, Bergman et al. (2013) found that students tend to associate anatomy with memorizing numerous structures and processes without understanding how the anatomical structures and physiological functions relate to medical conditions. As a result, the traditional lectures do not prepare students for long-term success because the knowledge is not given context, which makes the information more difficult to recall later (Khan et al., 2015). Since simple memorization does not result in authentic, or long-term, learning, students need to be motivated to learn with the focus of understanding context and laying the foundation for clinical interpretation, diagnosis, and treatment.

Authentic learning results from exposing students to real-world experiences and future work situations. Active learning techniques, such as case-based learning (CBL), promote authentic learning by making the content meaningful and important by relating it to real patient situations (Hamdy, 2016). In addition, students in a CBL curriculum spent much less time memorizing structures and processes without understanding the concepts (Wadhwa, 2005). Since these students engaged greater in meaningful learning, they were able to recall and apply the information better even after the class ended (Wadhwa, 2005). The directed case method used in this study facilitates learning by first describing a medical condition, followed by specific questions to direct investigation and discussion of the case. The specific questions help students construct the anatomical foundation for the case and direct them to the information the instructor considers essential for their learning. Once students have sufficiently

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investigated the case on their own, they discuss the case with their peers, which helps students better understand the case and its concepts (Yiou & Goodenough, 2006). Studies have shown that during discussion, students help one another learn, as those students who know the answer explain their correct reasoning to their peers who do not understand the concepts (Smith et al., 2009). In addition, if nobody in the group knows the correct answer, groups can develop the correct understanding through discussion and debate even without an explanation by the instructor (Smith et al., 2009). During the discussion, the professor acts as a facilitator instead of a teacher by asking relevant questions, guiding the discussion, and highlighting the learning objectives (Hamdy, 2016). As a result, the students engage in self-learning and peer instruction, which is more effective than when the professor provides detailed explanations, which often do not improve conceptual understanding (Smith et al. 2009). A strong knowledge and understanding of basic anatomical and physiological concepts is essential because it provides the foundation for students to understand dysfunctions of the human body that relate to medical conditions. Case-based learning (CBL) has been compared to traditional lectures in various aspects, and most investigations have concluded that CBL can significantly improve students’ overall exam scores and increase a deep approach to learning while decreasing the surface approach (Bockers, Mayer, & Bockers, 2013; Nair, Shah, Seth, Pandit, & Shah, 2013). The surface approach to learning involves “rote memorization and reproducing facts” while the deep approach involves “internalization of content [and] making learning meaningful” (Kulak & Newton, 2015, p. 13). Kulak and Newton (2015) compared instruction with CBL to instruction with a mix of other active learning methods and found that CBL significantly improved exam scores. They also found the level of the surface approach to learning increased over the semester with the mix of other active learning methods; however, CBL instruction did not show an increase in the surface approach to learning (2015). With regard to the surface or deep approach to learning, Dupuis and Persky (2007)

22 found that “traditional lecture is focused on content delivery and is not set up for higher levels of learning” (para. 2). In addition, the lack of active participation by the students did not allow for the development of critical thinking (Osinubi & AilojeIbru, 2014). In a Turkish dentistry school, deeper levels of learning were compared between casebased and lecture-based instruction using the structure of observed learning outcomes (SOLO) taxonomy, which is similar to Bloom’s taxonomy (İlgüy, İlgüy, Fişekçioğlu, & Oktay, 2014). Compared to the lecture group, the students in the CBL group scored significantly higher on the two highest levels of learning in the SOLO taxonomy, relational and extended abstract, which involved explaining causes, analyzing and evaluating the case, and predicting the prognosis (İlgüy et al., 2014). By fostering the deep approach to learning and exposing students to real medical conditions in the context of a specific anatomy topic, CBL develops the learner’s ability to recall anatomical information in the long-term, apply this knowledge to analyze and evaluate symptoms, and effectively diagnose and treat patients. By engaging students in critical thinking and applying anatomical knowledge to real medical situations, students are more likely to remain engaged in the learning process and take a deeper approach to learning. The higher-order cognitive skills required for the deep approach to learning only develop with practice. Therefore, active learning techniques allow students to practice these skills, which facilitates the shift to a deeper level of learning. Then, these students are prepared for greater success in their future careers when their developed higher-order cognitive skills are needed to solve novel problems and make sense of complex patient cases. Kulak and Newton (2015) reported that CBL helped students achieve “Bloom’s higherorder cognitive skills such as application, analysis, synthesis, and evaluation more than lecturing alone” (p. 14). In addition, Baeten, Dochy, and Stuyven concluded that students in a gradually implemented CBL curriculum had a decreased surface approach to learning and appreciated the variation in teaching methods when lectures were combined with case

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studies compared to students in a completely CBL curriculum (2012). Many researchers have found that CBL is an effective way to improve learning as an addition to traditional lectures to help students apply the theory of anatomy to the practice of medicine and increase interest in the content (Osinubi & Ailoje-Ibru, 2014; Cho & Csete 2004). This study incorporated a section of case-based learning into 9 out of 12 non-review anatomy and physiology chapters. The class was taught primarily by lecture except for the section covered by the case study. The goal of the case studies was to encourage self-learning and critical thinking as the concepts were applied to realistic patient situations. The case studies were designed to direct students to the most important concepts in their independent learning. The case studies required students to learn and understand the anatomical and physiological concepts before applying them to the case, which facilitated self-learning and critical thinking. Methods The study was quasi-experimental, in which all 28 students in section B of the Anatomy and Physiology I class at Saint Francis University were instructed using traditional lectures and directed case studies. One directed case study was written for 9 out of 12 chapters, and the information covered by the case was removed from the lecture material. The section relating to the case was noted in the case study, so students could read the textbook and learn independently in preparation for the case study. The case studies focused on one specific condition described in a short paragraph detailing symptoms and patient history. Some case studies also provided limited information on the treatment of the condition. Most case studies did not name the condition, so students had to diagnose the condition and explain how the dysfunction in the body caused the condition. Students were given the case study a minimum of two days before the class discussion of the case, so they could read over the information and do their own research outside of class. In class, students chose groups of four to work in through the entire semester. Groups divided the questions following the case study among themselves and

23 answered two to three questions independently, depending on the case. Students then shared their findings and discussed the case as well as the anatomical and physiological concepts related to the condition in their group. The professor facilitated the small-group activity by encouraging discussion, asking additional questions, and addressing any questions or concerns students had. The independent and small-group work was limited to 20-25 minutes and the rest of the class period, 25-30 minutes, was used to discuss the case as a class and resolve any misconceptions. At the end of the class discussion, students were given a PowerPoint for the information covered by the case study. The effect of the case studies on performance and studentsâ€™ attitudes was measured by exam performance and an attitude survey. Students were tested on their knowledge of the case study material on unit tests, which covered three to four chapters. Questions were multiple-choice, true-or-false, and short-answer for both the case study and lecture material. The mean exam scores from the case study material were compared to the scores from the lecture material with a paired two-sample t-test (p < 0.05) to determine if the case study significantly affected learning. The attitude survey was administered at the end of the semester and contained 10 Likert-scale questions and 2 openended questions concerning motivation, attitudes toward the case studies and instructor, and understanding of the material and case study. Results A paired two-sample t-test compared the mean test scores on the material covered in the lecture to the material covered in the case study. On the first exam, with case studies from chapters 6 and 7, there was a significant difference between the test scores on the material covered by the lecture (M = 88%, SD = 11.2%) and the material covered by the case studies (M = 68%, SD = 15.8%); t = 10.5, p = 3.9 x 10-11. The second exam covered chapters 8, 9, and 11, and showed no significant difference between the test scores of the material covered in the lecture (M = 73%, SD = 11.0%) and the material covered by the case studies (M = 76%, SD = 20.6%); t = 0.89,

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p = 0.38. The final exam, which was cumulative but focused on chapters 12, 13, 14, and 15, also showed no significant difference between the scores on the material covered by the lecture (M = 68%, SD = 14.5%) and the material covered by the case studies (M = 67%, SD = 18.4%); t = 0.75, p = 0.46. Chapters Exam

Mean Lecture Mean Case Case Lecture Standard Study Study Percentage Deviation Percentage Standard Deviation

nearly all students felt that the course instructor helped them understand the case study individually, and in the small-group and class discussions.

Positive, Neutral, or Negative Student Responses on Survey Percentage of Response

P TwoTail

100

5a, 6, 7

88%

11.2%

68%

15.8%

3.9 x 10-11

8, 9, 11

73%

11.0%

76%

20.6%

0.38

12, 13, 14, 15

68%

14.5%

67%

18.4%

0.46

Table 1. Student exam performance Notes: a Chapter 5 did not have case study associated with it. b Exam 2 had 28 participants and exams 3 and 4 had 27 participants *p < 0.05

As shown in figure 1, out of the 28 students in the class at the beginning of the semester, 26 students completed and returned the survey. One student withdrew from the class after exam 2 and one student did not come to class when the survey was completed. Most students had a positive or neutral response on question 1, which concerned the effect of the case studies on motivation to learn anatomy. On question 2, which compared the difficulty of learning the material through lectures and case studies, the same number of students selected “about the same” or “harder” and “much harder.” Most students had a positive initial reaction to the case studies (Q3) and most kept a positive opinion of the case studies (Q4), but a number of neutral initial reactions turned negative by the end of the semester. Fifty-eight percent of students described the difficulty of case studies as average on question 5, and many students found that the class discussions helped them better understand the case study and anatomy material (Q6). A significant number of students (69%) found that their ability to critically think and reflect on patient information on the case study improved “slightly” or “significantly” (Q7). According to responses on question 8-10,

Question

SPECTRUM

Q3 Q5 Q7 Q9 Negative

Neutral

Positive

Figure 1. Student responses on end-of-semester survey

Discussion For the first few case studies, the small-group discussion was inadequate since most groups passed around papers and copied answers, and each student did not get the experience of explaining his or her findings to the rest of the group, which was part of the case study design. Resistance to discussion and lack of time contributed to the lack of discussion, as one student said, “We never really discussed in our groups—each person would answer 1-2 [questions] and time was up before we went over it together.” The instructor encouraged students to review the case study and read the material prior to class to develop a basic understanding of the material before applying it to the case. Unfortunately, it was not possible to require students to complete the case studies as homework or assign participation points during the discussion of the case study since the points were not incorporated into the class or included in the syllabus at the beginning of the semester. In order to improve willingness to share and discuss, the small-group discussion was facilitated by encouraging students to rearrange their seats in a circle. In preparation for completing the case study, students were expected to read the sections covered by the case study in their textbook, learn the material

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independently, and complete very limited research online for five conditions that were not addressed in the book. However, many students did not read the relevant material prior to the class allotted for the case study. As a result, they spent most of the individual time searching for answers and building a narrow understanding of the anatomy instead of using the time to understand and apply the anatomical or physiological dysfunctions to the condition. Some students said there should have been a lecture about the material to prepare them for the case study. However, the case studies were designed to encourage and improve self-learning and critical thinking, which would have been reduced if students were taught the relevant concepts in a lecture prior to being given the case study. Therefore, it would have been beneficial to assign the case studies as homework, since students would have used the time outside of class to find the answers and build a foundation for fully understanding the case. On the other hand, when designing the study, the researchers felt that assigning more work for students outside of class due to the study was not fair and would produce negative feelings toward the case studies before students could appreciate the benefits. However, most students had a negative attitude toward the case studies because they did not have enough time to work on and discuss the case study. The most frequent comment on the open-ended questions was that students would prefer to complete the case study as homework and then use class time to discuss the anatomical basis of the case as smallgroups and as a class. Completing the case studies as homework would also likely improve discussion, as one student suggested, “Assign the reading and worksheet beforehand so when we came to class, we could discuss it, and not just copy answers.” Even though many students felt rushed to complete the case study and discuss the material, a number of students still had a very positive experience learning with the case studies. For example, one student commented, “I like learning through case studies because it makes things seem more realistic,” and another replied, “having more questions about case studies on tests would be a good way to prepare us,

25 especially health science majors, when we get a case on the job.” Due to the limited amount of time in the anatomy class overall—many instructors removed or shortened the last chapter—the time allotted for the case studies was also limited, so some students felt rushed to complete the case study and discuss the concepts in the small-group. However, students said that the case studies helped to make the information relevant and interesting, so it was easier to learn and recall. Most of the negative opinions expressed about the use of case studies as a teaching method concerned the amount of time available to complete them; however, a few students felt that they should be used only to review the material or should not be used at all. Eight students expressed the opinion that case studies should be used only to reinforce material instead of to teach. Only two students expressed a very negative opinion of using case studies to instruct instead of lectures, as one student wrote, “Do not use case studies. It wasted a lot of time…Anatomy is more of a lecture-based course.” The responses from the open-ended questions were helpful for identifying the flaws in the research design and ways in which the case studies were not beneficial for students. The exam scores comparing the material taught by traditional lectures to the case studies only showed significantly higher scores on the lecture material for the first exam; the second and third exams exhibited no significant difference between lecture and case study material. The first exam may have exhibited higher scores on the lecture material compared to the case study material because all of the short-answer questions on the exam related to the case study material, and students did not know how much the exam would focus on case study material. On the short-answer questions on the first exam, students tended to miss points by partially answering the question or leaving out key information since these ideas had to be recalled instead of recognized as in a multiple-choice question. Therefore, it was easier for students to miss points on the case study questions on exam 2 since most of the points from the case study were short-answer questions, but all of the lecture questions were multiple-choice or

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true-or-false. In addition, students may have assumed the case study material was less important since it was not addressed in lectures, which is typically how a professor indicates the importance of the material. Consequently, when studying for the exam, students may not have focused on the case study material, which would have made it more difficult to recall the concepts to answer the shortanswer questions. Over the course of the semester, the overall exam scores dropped, which is a normal trend as the information gets harder. Therefore, the decline in exam scores during the semester was not a significant concern when determining the effects of the case studies on learning and exam performance. In addition, the scores on the second exam were unusually high, according to the instructor, which caused the decline in overall test scores to be more significant. On the case study portion of the exams, the scores were not significantly lower than the lecture averages, except on the second exam when lecture scores were unusually high, so the case study portion of the exams did not cause the decline in exam scores. Unfortunately, it was not valid to compare the exam scores from the study to the historical averages due to changes in the exams and the student population. However, the instructor felt that exam scores were average or above average on all of the exams except for the final, which was cumulative for the first time. Therefore, the decline in exam scores over the course of the semester was a normal trend and was not likely to have been caused by the use of case studies to teach sections of the material. In addition, due to the short class period allotted for exams (50 minutes) and the limited amount of material that was taught with case studies from each chapter, the exams only had between 5 and 9 points per chapter focused on the case study material. Since there were more points from the lecture material compared to the case study material, the limited data from the case method made it difficult to conduct fair significance testing on whether there was a difference between teaching methods. However, the case studies did not cause test scores to drop significantly, except on the first exam, which had

26 some confounding variables that could explain the decline. Therefore, since half of the students felt that their understanding of anatomy and physiology improved and 69% felt that their critical thinking skills improved, the case studies were a positive addition to the curriculum. Conclusion The use of case studies to teach anatomy and physiology in an introductory course can improve students’ learning and critical thinking ability. The results of the study showed that there was no difference between test scores on material taught by lecture and case studies. However, the study did not compare the surface-level approach to learning to the deep approach due to the inability to measure these approaches before the implementation of the case studies or in a group that was not instructed with case studies. It would have been helpful to examine the effect of case studies on these approaches to explore further the effect of case studies on learning when combined with lecture instruction. It would have been valuable to compare students’ recall of the material taught with the case studies and the material taught with lectures three months after completion of the class to determine the effect on students’ long-term memory. Due to the limitations of the study, it was not possible to test the students after the class was completed. The time constraints on the study also limited the amount of data collected on exam scores and the number of case studies used. As a result of the small size of the study and the limited data comparing students’ learning of the case study material to the lecture material, it is not possible to determine ultimately whether the case studies improved students’ learning and understanding or if there was no difference with lecture instruction. Students could gain more from the small-group and class discussions and deepen their understanding with improvements in the implementation of the case studies. For example, students could complete case study questions as homework, and class discussion could improve with the rearrangement of seating into a circle and assigning participation points for the class discussions.

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Works Cited Baeten, M., Dochy, F., & Struyven, K. (2013). Enhancing student's approaches to learning: The added value of gradually implementing case-based learning. European Journal of Psychology of Education, 315-336. doi:10.1007/s10212-012-0116-7 Bergman, E. M., De Bruin, A., Herrier, A., Verheijen, I. W.H., & Scherpbier, A. (2013). Students’ perceptions of anatomy across the undergraduate problem-based learning medical curriculum: A phenomenographical study. BMC Medical Education, 13, 152. doi: 10.1186/1472-6920-13152 Bockers, A., Mayer, C., & Bockers, T. M. (2013). Does learning in clinical context in anatomical sciences improve examination results, learning motivation, or learning orientation? Anatomical Sciences Education, 7(1), 3-11. doi:10.1002/ase.1375 Cho, P., & Csete, J. M. (2004). A case for case studies: One teacher's reflective approach in clinical teaching. In O. Kwo, T. Moore, & J. Jones (Eds.), Developing learning environments: Creativity and collaboration in higher education (pp. 57-76). Hong Kong University Press. Retrieved from www.jstor.org.francis.idm.oclc.org/stable/j.ctt2jc6v0.9 Dupuis, R. E., & Persky, A. M. (2008). Use of case-based learning in a clinical pharmacokinetics course. American Journal of Pharmaceutical Education, 72(2), 1-29. doi:10.5688/aj720229 Hamdy, H. (2016). Authentic learning in health professions education. In K. A. Bin Abdulrahman, S. Mennin, R. Harden, & C. Kennedy (Eds.), Routledge international handbook of medical education (pp. 128-143). New York: Routledge. İlgüy, M., İlgüy, D., Fişekçioğlu, E., & Oktay, I. (2014). Comparison of case-based and lecture-based learning in dental education using the SOLO taxonomy. Journal of Dental Education, 78, 1521-1527. Retrieved from http://www.jdentaled.org/content/78/11/1521.full Khan, M. A., Qamar, K., Khalid, S., Javed, H., Malik, M., Gondal, A., . . . Imtiaz, F. (2015). Comparison of case based learning with conventional teaching-students' perspective. Pakistan Armed Forces Medical Journal, 65(3), 415-419. Retrieved from http://pafmj.org/pdfs/June2015/Article_26.pdf

27 Kulak, V., & Newton, G. (2015). An investigation of the pedagogical impact of using case-based learning in an undergraduate biochemistry course. International Journal of Higher Education, 4(4), 13-24. doi:10.5430/ijhe.v4n4p13 Nair, S. P., Shah, T., Seth, S., Pandit, N., & Shah, G. V. (2013). Case-based learning: A method for better understanding of biochemistry in medical students. Journal of Clinical and Diagnostic Research, 7, 1576-1578. doi:10.7860/JCDR/2013/5795.3212 Osinubi, A. A., & Ailoje-Ibru, K. O. (2014). A paradigm shift in medical, dental, nursing, physiotherapy and pharmacy education: From traditional method of teaching to casebased method of learning--A review. Annual Research & Review in Biology, 4(13), 2053-2072. doi:10.9734/ARRB/2014/9053 Smith, M. K., Wood, W. B., Adams, W. K., Weiman, C., Knight, J. k., Guild, N., & Su, T. T. (2009). Why peer discussion improves student performance on in-class concept questions. Science, 122-124. doi:10.1126/science.1165919 Wadhwa, S. (2005). Teaching learning and studying. New Delhi: Sarup & Sons. Yiou, R., & Goodenough, D. (2006). Applying problem-based learning to the teaching of anatomy: The example of Harvard Medical School. Surgical and Radiologic Anatomy, 28(2), 189-194. doi:10.1007/s00276-005-0062-z

Danae Peters ('18) is a Physical Therapy major with a minor in Movement Science and Spanish for Health Sciences. As a member of the Red Flash cross country and track and field teams, she stays very active. She actively participates in community service in the Loretto area and traveled to Costa Rica with HUGS United to serve people in La Carpio. Her proudest moment at SFU was helping the cross country team win the Northeast Conference Championship in 2016. After graduating from the SFU Doctor of Physical Therapy program, she hopes to work with orthopedic conditions or the geriatric population.

Call for papers Submission Guidelines The purpose of SPECTRUM is not merely to disseminate new results, but also to inform and enlighten. Our readership is a general and multidisciplinary audience who may not be an expert in your field of study. Consequently, please explain all pertinent concepts essential to understanding your article as well as any concepts that might not be common knowledge. Please submit your file in Microsoft Word format as an attachment to the following email address: bhargittai@francis.edu. The text should be single spaced, using 12-point Times New Roman font. Please use italics, rather than underlining, for emphasis. Organization of Manuscripts SPECTRUM is an interdisciplinary journal accepting submissions from the natural sciences, the humanities, as well as the professional schools (health sciences and business), therefore, the structure and style of each manuscript will differ from discipline to discipline. Regardless, all submissions must provide a cover sheet, a thorough introduction of the problem your research addresses, the conclusion(s), result(s) or findings of your research, as well as some form of bibliographic citation. Below are the general guidelines for these requirements, some of which may not apply to your area of research. Cover Sheet Title Names and departments of undergraduate researcher(s) and faculty advisor(s) Abstract (200 â€“ 300 words) Introduction Include general background of the relevant field and the larger problem your research addresses as well as its relevance within the field. In addition, explain what prompted your investigation, a summary of previous findings related to your research problem and what contributions your project brings (or was expected to bring) to the issue. Methods and Materials (If applicable) Summarize important methods and materials used in your research. Results/Conclusions Give detailed report of the results and or conclusions reached through your research. Discussion Results should be evaluated in the context of general research problem, the implications of which should be explained with conclusions, predictions or suggestions (if applicable) for further study. Tables (if applicable) Create tables in Microsoft Word format and insert into general text accompanied by a table legend. Each table needs a number based on its appearance in the paper, where it is referenced. Figures (if applicable) Please submit figures at the end of the article, one image per page; we will fit these in as we organize the manuscript. Each figure needs a number (the figures shall be numbered consecutively in the order of their appearance in the paper) and a title. SPECTRUM will be printed black and white, but there will be an online version where figures submitted in color will appear in color. References You may use any referencing style you choose so long as it is a standard format or your discipline (IEE, APA, ACS, PubMed) and that you use it consistently and to the appropriate bibliographical standards.

Saint Francis University

Published on Sep 16, 2017

Spectrum volume 8(1)

Volume 8(1) Fall 2017

Spectrum volume 8(1)

Published on Sep 16, 2017

Volume 8(1) Fall 2017

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