Research in Gerontological Nursing

Empirical Research 

African American Older Adults' Perceived Use of Technology for Hypertension Self-Management

Carolyn Harmon Still, PhD, MSM, AGPCNP-BC, CCRP; Lenette M. Jones, PhD, RN, ACNS-BC; Karen O. Moss, PhD, RN, CNL; Mary Variath, RN, MSN; Kathy D. Wright, PhD, RN, GCNS-BC, PMHCNS-BC

Abstract

With the unprecedented growth of technology for disease prevention and management, little is known about the experience and adoption of such technology in African American older adults with hypertension. A 90-minute focus group session was used to explore African American older adults' (N = 21) experiences with using technology (mobile devices and applications) for hypertension self-management. Twenty participants reported owning smartphones and used this technology to communicate; seek, acquire, and share information; engage in entertainment; and organize and manage time. Participants expressed concerns about not being informed or trained sufficiently to integrate technology for hypertension self-management. There is a need to develop novel hypertension self-management interventions that integrate technology and training programs for this marginalized population that may help improve blood pressure control and address important clinical and public health priorities of uncontrolled hypertension.

[Res Gerontol Nurs. 2018; 11(5):249–256.]

Abstract

With the unprecedented growth of technology for disease prevention and management, little is known about the experience and adoption of such technology in African American older adults with hypertension. A 90-minute focus group session was used to explore African American older adults' (N = 21) experiences with using technology (mobile devices and applications) for hypertension self-management. Twenty participants reported owning smartphones and used this technology to communicate; seek, acquire, and share information; engage in entertainment; and organize and manage time. Participants expressed concerns about not being informed or trained sufficiently to integrate technology for hypertension self-management. There is a need to develop novel hypertension self-management interventions that integrate technology and training programs for this marginalized population that may help improve blood pressure control and address important clinical and public health priorities of uncontrolled hypertension.

[Res Gerontol Nurs. 2018; 11(5):249–256.]

The successful adoption of technology by older adults is becoming increasingly important for self-management of chronic diseases such as hypertension (Czaja et al., 2006). Hypertension is the most commonly diagnosed condition among individuals 60 and older in the United States (Benjamin et al., 2017; Nwankwo, Yoon, Burt, & Gu, 2013). African American older adults have a higher prevalence of hypertension and are more likely to experience a higher burden of hypertension-related complications such as cardiovascular disease (e.g., ischemic heart disease, heart failure, stroke), kidney disease, and dementia compared to other U.S. populations (Benjamin et al., 2017; Nwankwo et al., 2013). Reasons for lack of blood pressure control among African American individuals are multifactorial (James et al., 2014). However, suboptimal adherence with antihypertensive medications and lack of participation in lifestyle modifications (e.g., balanced diet, low salt intake, regular physical activity) contribute significantly to this health disparity (Benjamin et al., 2017; James et al., 2014). Poor adherence to antihypertensive medications leads to loss of treatment efficacy, increased health care costs (∼$46 billion per year), and worse cardiovascular health outcomes (Benjamin et al., 2017; Nwankwo et al., 2013).

Evidence supports that a reduction in blood pressure can decrease morbidity and mortality from hypertension-related complications (SHEP Cooperative Research Group, 1991; SPRINT Research Group et al., 2015). However, disparities persist in hypertension self-management practices, with the poorest self-management practices reported in African American individuals (Whelton et al., 2016). Hypertension self-management practices and behaviors, such as medication adherence, blood pressure self-monitoring, and lifestyle modifications involving diet, exercise, and tobacco cessation, are associated with significant improvements in achieving and sustaining blood pressure control and reducing cardiovascular risk (Benjamin et al., 2017; James et al., 2014). Interventions such as patient education (Johnson et al., 2011), patient motivation, support, reminders, pre-packaged prescribed medications (i.e., wrapped individually for daily doses [e.g., morning, noon, bedtime]) (Costa et al., 2015; Krousel-Wood, Hyre, Muntner, & Morisky, 2005), and simplification of dosing, combined with behavioral and educational interventions (Glaser, Richard, & Lussier, 2017), have demonstrated some improvements in hypertension management. In addition, such interventions have been tested as combined multi-level complex interventions, but have demonstrated little or no effect in blood pressure reduction, adherence to antihypertensive therapy, or sustained improvements in lifestyle modifications of diet, exercise, and smoking cessation (Costa et al., 2015; Krousel-Wood et al., 2005; Pavlik et al., 2015; Zomahoun et al., 2017). Research focused on hypertension self-management often lacks a significant number of African American older adult participants. Therefore, research is needed to fully understand the reasons for suboptimal adherence to hypertension self-management and antihypertensive therapy and to implement appropriate interventions targeted at African American older adults.

Hypertension self-management interventions available on technology-enabled devices and applications (apps) have shown substantial efficacy in lifestyle modifications and blood pressure control (Band et al., 2017; Bobrow et al., 2016; Gibbons, 2011; Smith, 2014). Behavioral interventions comprising web-based education (Wantland, Portillo, Holzemer, Slaughter, & McGhee, 2004), home blood pressure monitoring (Band et al., 2017), personalized mobile short message service (SMS) (Abdullah et al., 2016; Bobrow et al., 2016; Davidson et al., 2015), and nurse-support counseling (Bosworth et al., 2008) have all demonstrated efficacy as single intervention strategies to improve blood pressure control. However, such interventions are not sustained in the long term or are delineated for individual situations or include a significant number of African American older adults, leaving many unanswered questions about what is necessary to achieve and sustain blood pressure control in African American older adults.

In the current shift to the digital age, use of commercial technologies (e.g., mobile devices, apps) in health care for disease prevention and management is increasingly promising (Tomlinson et al., 2009). These technologies are integrated into all areas of life and are ideal to deliver interventions to African American patients with hypertension (Buis et al., 2017; Gee, Greenwood, Paterniti, Ward, & Miller, 2015; Pavlik et al., 2015). In general, technology use among older adults is increasing (Anderson & Perrin, 2017). Comparatively, individuals age 70 and older have decreased their use, possibly due to decreased sensorium (vision and dexterity) required to operate smartphones (Gell, Rosenberg, Demiris, LaCroix, & Patel, 2015) or lack of digital literacy or digital engagement (Schreurs, Quan-Haase, & Martin, 2017). Moreover, there is a perception that African American individuals, especially older adults, use less technology than White individuals (Choi & DiNitto, 2013), considering the limited nationally representative sample and data stratified by age and race (Gell et al., 2015; Nielsen, 2015; Smith, 2014). However, African American consumers, including African American older adults, have embraced technology, and their smartphone use is 81% compared to 74% of the total U.S. adult population (Nielsen, 2015; Smith, 2014). Data have also shown that on a monthly basis, African American individuals, in general, spend approximately 56 hours using apps or mobile internet browsers on their smartphones (Nielsen, 2015). Therefore, an opportunity exists to use certain technology, such as text messaging and apps, to facilitate hypertension self-management in African American older adults (Gibbons, 2011).

Limited knowledge exists about use of and attitudes toward technology among African American older adults, especially for health benefits, and hypertension management in particular. There is an opportunity to use mobile devices as a first-line intervention for daily hypertension self-management support and technology integration to improve blood pressure control (Fallahzadeh, Aminikhanghahi, Gibson, & Cook, 2016; Flodgren, Rachas, Farmer, Inzitari, & Shepperd, 2015; Gibbons, 2011; Tomlinson et al., 2009). With the unprecedented growth in technology use for disease management, the literature suggests that research should be explored from a theoretical perspective and include tailored patient-specific behavioral interventions that are technology-mediated and link to daily life (Abegaz, Shehab, Gebreyohannes, Bhagavathula, & Elnour, 2017; Solomon et al., 2015). According to the Mobile Health Technology Acceptance Model, technology design in the presence of high perception of ease of use and usefulness will influence an individual to accept and adopt a technology for health care (Mohamed, Tawfik, Al-Jumeily, & Norton, 2011). To reach and engage African American older adults to integrate technology for hypertension self-management, the current authors aimed to identify these individuals' perceptions and experiences with technology use.

The current article details results of a research study conducted using a sample from the “Co-Created Intervention With African American Older Adults” study to manage stress associated with self-management of hypertension (Wright, Still, Jones, & Moss, 2018). The objectives of the current study were to use a qualitative approach to (a) explore African American older adults' experiences with technology, mobile telephones, and app use; (b) examine their perceived benefits of using health apps for hypertension; and (3) formulate suggestions that would increase their intentions to use the technology for hypertension self-management.

Method

The current study explored African American older adults' experiences with using technology (mobile devices and apps) for hypertension self-management. After Institutional Review Board (IRB) approval, participants provided signed informed consent to participate in the study.

Study Design

The design and rationale and primary results of the parent study, “Co-Created Intervention With African American Older Adults,” have been fully described else-where (Moss, Still, Jones, Blackshire, & Wright, 2018). Briefly, in the parent study, two focus group sessions were conducted to describe stress and self-management behaviors in African American older adults with hypertension (N = 31). Topics included feedback on health behaviors to co-create a self-management intervention with participants to cope with the stress of managing a chronic condition such as hypertension. Focus group participants also discussed mindfulness meditation, sleep hygiene, and the use of mobile apps to manage stress. Participants were enrolled if they were (a) community-dwelling, (b) African American, (c) 60 or older, (d) diagnosed with hypertension, and (e) able to provide consent. An individual was excluded if he or she had a diagnosis of severe cognitive impairment (Moss et al., 2018; Wright et al., 2018).

In the parent study, 90-minute focus groups were conducted in March and April 2017 in a private meeting room at a local community center in the Midwest. The principal investigator and co-investigators have longstanding established partnerships and rapport with the community, which provided the basis for commencing the research. The focus group questions were semi-structured with key interview questions, including an interview question from an interview guide to frame the conversation (Moss et al., 2018). All focus groups were assured of anonymity, and with permission, the focus groups were audio recorded and transcribed verbatim using an IRB–approved vendor.

Data from the parent study focus groups were used to co-create an intervention, “Team Learning to Take Control” (TLC) series. This intervention comprised four weekly sessions: (1) TLC—Monitor Your Blood Pressure; (2) TLC—Communication; (3) TLC—Sleep and Pain; and (4) TLC—Healthy Eating and Learning Portions (HELP). Prior to taking part in the TLC series, participants were re-consented, as required by the IRB. Herein, the first session, TLC—Monitor Your Blood Pressure, is discussed. Focus group methodology was used to explore the range of African American older adults' group experience with technology during the TLC—Monitor Your Blood Pressure session and is discussed in further detail.

TLC—Monitor Your Blood Pressure

The TLC—Monitor Your Blood Pressure session was an interactive educational platform that focused on hyper-tension self-management. The session lasted 120 minutes and was led by a PhD–prepared nurse practitioner (NP) (C.H.S.) with previous qualitative research experience, who specialized in the management of hypertension. During the first half of the session, participants were presented information on causes, risk factors, symptoms, and health complications associated with uncontrolled hypertension. Next, key topics were discussed, including monitoring blood pressure and the treatment of hypertension with lifestyle modifications (e.g., diet, exercise) and adherence to prescribed antihypertensive drugs.

An important component of hypertension self-management is the learning engagement activity of home blood pressure monitoring. Prior to attending the TLC—Monitor Your Blood Pressure session, participants were instructed to bring in their home blood pressure monitors. All participants were properly trained on best practices for home blood pressure monitoring. This training included the correct selection and positioning of the blood pressure cuff, appropriate positioning of the patient, and recognition of factors that may skew the measurement (James et al., 2014). Participants had the opportunity to demonstrate taking their blood pressure with their home blood pressure monitor to receive immediate feedback from the nurse researcher about their technique. In addition, the home blood pressure monitors were calibrated by nurses and NPs. Lastly, participants were asked to track their blood pressure and food intake for 1 week and provide at the next TLC session (Moss et al., 2018).

After completing the interactive educational component of this TLC session, African American older adults' experiences with various types of technology (e.g., mobile telephones, apps, SMS text reminders) for long-term management of hypertension were explored. The second half of the TLC—Monitor Your Blood Pressure session was designed to include a focus group discussion. A semi-structured group session is an appropriate approach to gather explorative information in a defined area of interest (Krueger & Casey, 2009), in particular, from African American older adults with hypertension underrepresented in technology research (Gibbons, 2011). Open-ended prompts and questions were planned to elicit participants' responses regarding their preference of technology and the factors that cause barriers to the acceptance of a technology-enabled intervention. Specifically, initial explorative prompts/questions were general, for example, “Tell me about your experience with using technology” and “Can you tell me about barriers that may prevent you from using technology to help manage hypertension?” Responses were audio recorded and analyzed. In addition, field notes were recorded by a research assistant (M.V.) and included observations such as emotions or comfort and discomfort relevant to the discussion.

Data Analyses

Data were collected during one focus group session to explore African American older adults' experiences with technology. The research team comprised four PhD nurse scientists (C.H.S., L.M.J., K.O.M., K.D.W.) with established collaborative practice and research relationships. The focus group transcript was verified and manually coded (using paper, pen, and highlighters) by the lead author (C.H.S.). Open coding and analysis, guided by conventional content analysis (Hsieh & Shannon, 2005), was used. An acronym and brief definition were assigned to each code. Two co-investigators (C.H.S., L.M.J.) independently coded the transcripts in accordance with the defined acronyms. The three researchers (C.H.S., L.M.J., K.O.M.) then compared and reconciled the codes for consistency. Raw data from the transcript were imported into the qualitative management software, Dedoose Version 7.0.23. Data from similar codes were clustered into categories. Similar categories were then grouped into four themes. The Dedoose software allowed the researcher (K.O.M.) to understand what is meaningful in the qualitative data and capture key themes/concepts in a different platform, as well as a visual perspective of the data. Themes identified were discussed among the research team, and consensus was reached through an iterative process. Summaries were written of findings within each of the themes.

Results

Twenty-one participants attended the TLC—Monitor Your Blood Pressure session. Participant age ranged from 62 to 91 years (mean age = 72 years). The majority of study participants were women (n = 20), and all participants reported owning a mobile telephone or smartphone. In addition to having hypertension, participants reported having more than one chronic condition. Other chronic conditions reported were diabetes, arthritis, and high cholesterol. Although this TLC session focused on hypertension management, with a special interest in the use of technology for hypertension management, participants were keen to discuss other ways that they use technology for managing their health. The four themes that emerged from the data were: (a) User Experience and Engagement With Technology, (b) Communication, (c) Integrating Technology for Managing Health, and (d) Nonacceptance of Technology.

User Experience and Engagement With Technology

A primary goal of the current study was to understand African American older adults' experiences with technology. Participants reported that their use of technology was limited to their mobile telephones or smartphones. Within this theme, a variety of comments and views were expressed in terms of how mobile devices were used. Most themes indicated consensus of the group that mobile telephones or smartphones serve four major functions: (a) communication with family and friends, including texting; (b) information seeking and acquisition and sharing data; (c) entertainment (e.g., photos, playing games); and (d) organization (e.g., calendar, time management). For example, when asked to describe whether they use their mobile telephones or smartphones for anything else, participants all said “yes,” and others went on further to explain, “I do everything [with my telephone],” and “Yeah, I look up directions [on mobile telephone].” Two participants' technology engagement involved using mobile telephones as a personal assistant/reminder to keep track of grocery lists and appointments.

Communication

Technology is pervasive and extremely important, as it has changed the way of communication. The conceptualization of communicating with technology is the loosely defined collection of devices or gadgets (e.g., iPad®, smartphones, computers) used to interact and/or share information with others. Participants often reported that their exposure to technology comprised using mobile telephones to communicate with their family and close social support networks. The most frequent expression of using technology to communicate was use of a social media platform. One participant said, “I play games...Okay, I'll be honest I Google® [holding up a mobile telephone] and I face chat.” Statements about other ways in which mobile telephones help with communication extended to using the internet, e-mail, and text messaging to communicate with family and friends. Another participant said, “I just talk [on the telephone].” Adoption of modern technology to communicate, connect, and socially interact was visible among these participants.

Integrating Technology for Managing Health

Increasingly used in health care, mHealth technology was embraced to support general health and self-management. This theme emphasized the connection between integrating various technology to self-manage health. Four participants reported being highly interactive, using their smartphones for health and self-management of their chronic disease. For example, one participant said she uses her smartphone to help manage her diabetes:

Well, it [mobile technology] helps me with my numbers [hemoglobin A1c] with my diabetes, because I used to take four pills a day—and now I just take one pill a day. I used to weigh 252 pounds, so it helped me a lot.

In particular, participants also described how they engaged with technology to improve their health by tracking their self-care activities. For example, a participant recounted how she used an app to track and monitor her diet and physical activity for hypertension self-management:

Well, it [using mobile telephone apps] was okay for me because I like monitoring my paces that I take…also, what I eat, then it would calculate it in there. So, it was good for me…. My doctor let me use it to see how I liked it. I liked it, but I wouldn't do it all the time.

This theme also highlighted participants' engagement in care activities on their mobile devices and the use of health information and technology. An example is the use of an electronic health record (EHR) portal for individual health data and services using a mobile telephone, as one participant noted: “I use MyChart [an online health management tool]. That's how I communicate with my doctor. And that's on your phone, too.”

Participants embraced integrating technology to manage their health as they described using mHealth to support health behaviors essential to their health. Specifically, participants mentioned they receive and share information with their health care provider about their health.

In contrast, one participant used a mobile app to help manage taking medications for a chronic condition, but found it somewhat difficult due to the technical and logistic challenges involved, stating: “I had my daughter put the app [health management app] on my phone, and the thing [mobile telephone] was beeping and I didn't know why, and [I] couldn't turn it [notice to take medication] off…. I'm not tech-savvy.” Of note, this participant offered insight that relevant education and training are needed to fully adopt and use technology to manage one's health.

Nonacceptance of Technology

Some participants preferred not to use technology to manage their health, or not to use mobile technology in general. One participant said, “The phone is for me to talk on, and that's that. Technology is fine, but it just ain't for me.” Another participant expressed similar views, stating, “What drives me crazy with the internet is when you want to do something, [you need] the password…and I have to think of a password for every time. I don't need it. I mean, it's not comfortable for me.”

In general, participants preferred non-technology methods for managing their health. One participant said, “I like writing lists. I don't do the thing [write lists] on-line…. I'm comfortable in my own world. I don't feel left out,” whereas another participant said, “Just give me the little med [medication] cups [pill boxes] and I'll just take my little 7-day (pointing to the medications).” Another participant stated preferring “the old-fashioned way, pencil and a piece of paper.” African American older adults with hypertension in this sample reported having only limited use or adoption of technology in terms of hypertension.

Discussion

Participants in the TLC—Monitor Your Blood Pressure session were African American older adults with hypertension. Many discussed various experiences with technology with limited use for managing their health. The current study results suggest that African American older adults have embraced mobile telephone technology, but its use is mainly restricted to social media or as a platform to communicate. Although technology has the potential to assist in managing one's health, many African American older adults with hypertension are not exposed to or prefer not to engage with technology in this respect. In addition, few participants used mobile telephone technology beyond communication. Concerns primarily centered on the reluctance of African American older adults to engage with newer technologies were evident in the current study. Participants provided insights that future investigations should educate and train African American older adults about various technology platforms to manage their health.

According to the current study results, participants' use of technology and engagement included various platforms of social media via smartphones. A common misconception is that African American older adults do not use technology, when in fact, trends in certain technology (i.e., mobile or smartphone ownership) are changing. Although national data regarding technology use among African American individuals are limited, a recent study by the Pew Research Center found that 77% of African American individuals (age 65 and older) own mobile telephones with 18% owning smartphones, which is comparable to ownership of White individuals (Smith, 2014). In the same study, 45% of African American older adults were internet users compared to 63% of White older adults (Smith, 2014). Data from the National Health and Aging Trends Study examining a diverse sample of Medicare beneficiaries 65 and older (8% African American) found that older adults' use of technology increased over time and that greater use of technology for health was observed among individuals taking medications and individuals with multiple comorbidities (Gell et al., 2015). Hence, adoption of technology has implications beyond means of communication for older adults and opportunities to help address health care disparities. Buis et al. (2017) explored using mobile telephone technology (text messaging) to support medication adherence to antihypertensive medications among middle-aged African American individuals from primary care (n = 58) and emergency department (n = 65) settings. Although the results of Buis et al. (2017) demonstrate nonsignificant improvements in blood pressure, this research has laid the ground work and demonstrated feasibility for future research using mobile technology as support for hypertension self-management in African American individuals 65 and older.

The adoption of technology is a complex issue that may be influenced by several factors, such as age, education, race, socioeconomic status, general knowledge and attitudes toward a particular technology, and computer self-efficacy (Choi & DiNitto, 2013; Czaja et al., 2006; Wagner, Hassanein, & Head, 2010). For these reasons, digital disparities exist among minority populations in terms of adoption and use of technology to manage their health and chronic conditions such as hypertension (Czaja et al., 2006; Gibbons, 2011). Other factors include the perceived benefits of technology use, access, and safety and security concerns (Gibbons, 2011). Participants in the current study did not express safety or security concerns regarding using technology. However, other research has suggested that older adults report less comfort and confidence when using technology, which in part drives one's anxiety related to using technology and lack of interest (Czaja et al., 2006; Gibbons, 2011). These findings also demonstrate an important factor that may impede the ability of African American older adults to use technology in the context of managing their health—lack of knowledge of or exposure to such technology (e.g., mHealth technology, apps). Participants in the current study expressed concerns about not being informed or trained sufficiently to integrate technology for hypertension self-management (Choi & DiNitto, 2013; Gibbons, 2011).

Studies suggest that individuals who take part in higher levels of engagement and interactivity with technology (e.g., social networking, e-mailing, obtaining directions, downloading apps) are ideal to engage in technology-enabled interventions to promote behavioral change and self-management, including individuals age 50 and older (Gibbons, 2011; Smith, 2014). Specifically, the internet, e-mail, and text messaging might be viable mediums to facilitate African American older adults to manage their health (Gibbons, 2011). Thus, there is a need to develop novel hypertension self-management interventions that integrate technology and training programs for this marginalized population that may help improve hypertension self-management and blood pressure control. These implications could address important clinical and public health priorities of uncontrolled hypertension.

Limitations and Strengths

The current qualitative exploration provided an understanding of whether technology can be integrated for behavior change and self-management of hypertension in African American older adults. However, there were a few limitations. Focus group participants were a convenience sample comprising predominantly women from one geographical location. It may have also been of benefit to have captured male participants' perspectives using one-on-one, semi-structured interviews. Because participants were part of a larger mixed methods study, existing demographic data (age, gender, and ethnicity) did not allow for further data interpretation with socioeconomic status (education and income). Although qualitative analysis is a creative process, another limitation is that this qualitative inquiry comprised one focus group as part of an intervention study, which did not allow for data saturation. Despite these limitations, the knowledge and insight gained from the current findings add valuable data to the limited existing literature on this important disparity. This work, though incremental, also provides evidence to support use of technology for health promotion toward improving self-management behaviors of African American individuals with chronic conditions such as hypertension.

Conclusion

Hypertension self-management practices, adherence to antihypertensive medication, and lifestyle modification have been shown to be associated with improved blood pressure control and better cardiovascular outcomes. Opportunities to integrate technology to promote behavioral change and self-management in African American older adults with hypertension are warranted. Relevant education and training are needed to address digital disparities that exist among minority populations in terms of adoption and use of technology to manage their health and chronic conditions.

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Authors

Dr. Harmon Still is Assistant Professor, Dr. Moss is Post-Doctoral Fellow, and Ms. Variath is Nursing Instructor and PhD Candidate, Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, and Dr. Wright is Assistant Professor and Chief Diversity Officer, College of Nursing, The Ohio State University, Columbus, Ohio; and Dr. Jones is Assistant Professor, Department of Health Behavior and Biological Sciences, School of Nursing, University of Michigan School of Nursing, Ann Arbor, Michigan.

The authors have disclosed no potential conflicts of interest, financial or otherwise. This publication was made possible by the Clinical and Translational Science Collaborative of Cleveland (KL2TR000440) from the National Center for Advancing Translational Sciences component of the National Institutes of Health (NIH) and NIH Roadmap for Medical Research and the National Institutes of Nursing Research of the NIH (P30NR015326-02S and T32 NR014213). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

The authors acknowledge Dionne Williams (PhD nursing student, Frances Payne Bolton School of Nursing, Case Western Reserve University) and Gabrielle Blackshire (undergraduate nutrition student, College of Arts and Sciences, Case Western Reserve University) for assisting with organization and interpretation of the focus groups and data.

Address correspondence to Carolyn Harmon Still, PhD, MSM, AGPCNP-BC, CCRP, Assistant Professor, Frances Payne Bolton School of Nursing, Case Western Reserve University, 2120 Cornell Road, Cleveland, OH 44106-4904; e-mail: cwh11@case.edu.

Received: November 28, 2017
Accepted: June 06, 2018

10.3928/19404921-20180809-02

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