福島県立医科大学 学術機関リポジトリ

Title

The mental health status of children who have been evacuatedor migrated from rural areas in Fukushima prefecture after the
Fukushima daiichi nuclear power station accident: results fromthe Fukushima health management survey

Author(s)Tokunaga, Akiko; Yoshida, Koji; Orita, Makiko; Urata,
Hideko; Itagaki, Shuntaro; Mashiko, Hirobumi; Yabe, Hirooki;
Maeda, Masaharu; Oishi, Kazuyo; Inokuchi, Shigeru; Iwanaga,
Ryoichiro; Tanaka, Goro; Nakane, Hideyuki; Takamura,
NoboruCitation

Fukushima Journal of Medical Science. 67(1): 8-16

Issue Date

2021

URL

http://ir.fmu.ac.jp/dspace/handle/123456789/1379

Rights© 2021 The Fukushima Society of Medical Science. This
article is licensed under a Creative Commons [AttributionNonCommercial-ShareAlike 4.0 International] license.

DOI

10.5387/fms.2020-15

Text Version publisher

This document is downloaded at: 2024-10-16T11:54:41Z

Fukushima Medical University

8 Fukushima J. Med. Sci.,
Vol. 67, No. 1, 2021

A. Tokunaga
et al.
[Original article]

The mental health status of children who have been evacuated or
migrated from rural areas in Fukushima prefecture after
the Fukushima daiichi nuclear power station accident :results from the Fukushima health management survey
Akiko Tokunaga1)2)†, Koji Yoshida2)†, Makiko Orita3), Hideko Urata4), Shuntaro Itagaki5),
Hirobumi Mashiko5), Hirooki Yabe5), Masaharu Maeda6), Kazuyo Oishi2), Shigeru Inokuchi2),
Ryoichiro Iwanaga1), Goro Tanaka1), Hideyuki Nakane1)‡ and Noboru Takamura3)
1)

Department of Psychiatric Rehabilitation Science, Nagasaki University Graduate School of Biomedical
Sciences, Nagasaki, Japan, 2)Department of Health Sciences, Nagasaki University Graduate School of
Biomedical Sciences, Nagasaki, Japan, 3)Department of Global Health, Medicine and Welfare, Atomic
Bomb Disease Institute, Nagasaki University, Nagasaki, Japan, 4)Division of Disaster and Radiation
Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan, 5)Department of Neuropsychiatry, Fukushima Medical University School of Medicine, Fukushima, Japan,
6)
Department of Disaster Psychiatry, Fukushima Medical University School of Medicine, Fukushima, Japan(Received July 17, 2020, accepted January 18, 2021)
Abstract
Introduction : We evaluated the mental health status of children residing in Kawauchi village(Kawauchi), Fukushima Prefecture, after the 2011 accident at the Fukushima Daiichi Nuclear Power
Station, based on the children’s experience of the nuclear disaster.
Methods : We conducted this cross-sectional study within the framework of the Fukushima HealthManagement Survey (FHMS) ; FHMS data on age, sex, exercise habits, sleeping times, experienceof the nuclear disaster, and the “Strengths and Difficulties Questionnaire (SDQ)” scores for 156 children from Kawauchi in 2012 were collected. Groups with and without experience of the nuclear disaster — “nuclear disaster (+)” and “nuclear disaster (−)” — were also compared.
Results : Our effective response was 93 (59.6%) ; the mean SDQ score was 11.4±6.8 among elementary school-aged participants and 12.4±6.8 among junior high school-aged ones. We statistically compared the Total Difficulties Scores (TDS) and sub-item scores of the SDQ between “elementary school” and “junior high school” or “nuclear disaster” (+) and (−). There was no
significant difference between these items.
Conclusions : We found indications of poor mental health among elementary and junior highschool-aged children in the disaster area immediately following the accident, but no differences
based on their experience of the nuclear disaster. These results indicate the possibility of triggering stress, separate to that from experiences related to the nuclear disaster, in children who lived inaffected rural areas and were evacuated just after the nuclear disaster.
Key words : children, mental health status, Strengths and Difficulties Questionnaire, Fukushima
Nuclear Accident, Great East Japan Earthquake
Corresponding author : Koji Yoshida, RN, PhD.   E-mail : koujiy@nagasaki-u.ac.jp (KY)†
These authors contributed equally to this work.
‡
Deceased 2 March 2020©2021 The Fukushima Society of Medical Science. This article is licensed under a Creative Commons [Attribution-NonCommercial-ShareAlike 4.0 International] license.
https://creativecommons.org/licenses/by-nc-sa/4.0/
8

Mental health states of children after the nuclear disaster

Introduction
On 11 March 2011, the Great East Japan Earthquake struck the east coast of Japan. This natural
disaster caused immense devastation in Japan andseverely damaged the Fukushima Daiichi Nuclear
Power Station (FDNPS)1,2), resulting in the releaseof large amounts of radionuclides into the environment3 7). After the accident, the Japanese and Fukushima prefectural governments issued instructions for the immediate evacuation of areas within a
20 km radius of the FDNPS. Consequently, many
residents of Fukushima Prefecture were evacuatedto areas farther away from FDNPS or outside of Fukushima Prefecture due to the fear of radiation exposure2). The external and internal exposure doses
just after the accident itself were estimated to bevery low, but concerns were raised about the effecton residents’ health following evacuation after theaccident.
A report into the health impact of the Chernobyl nuclear accident, prepared 20 years after the accident by the World Health Organization (WHO),
showed that mental health issues were the most serious public health problem resulting from that nuclear accident8,9). In particular, Bromet et al. pointed out issues regarding the mental health status ofchildren10). Other studies have also reported on themental health status and the neurobehavioral andcognitive performances of mothers with young children11,12). Ongoing investigations continue to focus
on the problem of health effects, including mental
health effects, in children after the Chernobyl nuclear accident13).
The lessons learned from past nuclear disasters
led to the implementation of the Fukushima HealthManagement Survey (FHMS) by the Fukushima
prefectural government and Fukushima Medical
University, to assess the health impact on residents
in Fukushima Prefecture, including on their mental
health14,15). The FHMS report included data on theradiation dose at the time, lifestyle-related disease,and the mental health of residents. A survey of themental health status of Fukushima residents also indicated the same problem observed after the Chernobyl nuclear accident, so these investigations
should continue in the future15,16). We reported themental health status of children, as measured by theStrengths and Difficulties Questionnaire (SDQ), in
the FHMS about one year after the nuclear accident.
The proportions of those who scored above the cutoff (≥16) of the SDQ, reflecting a mental health status in the clinical range, were 22.0% (aged 7 - 12-9years) and 16.3% (aged 13-15 years), which is higher than those in the usual state (9.5%)17).
Previous studies have pointed out the problemof children’s poor mental health status, but the effects of disasters on their mental health are not always consistent 18 21) , and differences in mental
health status relative to environmental radiation levels have not been recognized17). Also, despite improvements in overall mental health22), long-term
PTSD after a nuclear disaster and mental healthproblems associated with evacuation and migration
have been pointed out23). Furthermore, it should
be noted that previous studies have reported thatthe mental health status of children living in rural
areas is worse than that of children in urban areas24,25).
Other surveys conducted to date have not considered the mental health status of children living inrural areas and the relationship between an experience of a nuclear accident and the mental health ofchildren who were evacuated following a nuclear accident. In addition, the mental health of children in
Kawauchi Village (Kawauchi), which is a rural area,
was not as good as that of children in other areas
who had been evacuated17). Kawauchi was selected
as a survey target as this data can be used for considering future support. Therefore, the aim of thepresent study was to evaluate the mental health status of children who lived in Kawauchi, which was a
town of fewer than 3,000 people at the time of theaccident.
-

Materials and methods
Study population and data collection
Kawauchi Village, Fukushima Prefecture, is located within a 30 km radius from FDNPS. Although there was damage from the earthquake there
was none from the tsunami ; however, due to theaccident at the nuclear power plant, almost all residents of the village, fewer than 3,000 people, were
evacuated. The radiation dose rate remained relatively low compared to other evacuation areas. On
January 31, 2012, the mayor of the village declaredthat residents who lived at least 20 km away fromFDNPS could return to their homes, because theJapanese Prime Minister had declared that the reactors had achieved a state of cold shutdown in December 2011. Kawauchi village was the first local
authority whose residents returned to their hometown after the evacuation due to the accident, andthe number of residents returning to the village has

10

A. Tokunaga et al.

gradually increased26).
This cross-sectional study used data from the2012 FHMS, which was collected between January
and October 2012. The aim of the FHMS was tomonitor the long-term health and daily lives of Fukushima residents and to provide them with propercare ; it was conducted via postal mail on about
200,000 residents who had been living in the evacuation area at the time of the disaster. The entire
protocol of this survey is published elsewhere 15).
The surveys included a self- administered mental
health questionnaire focusing on school year, gender,
exercise habits (four categories ; almost every day,
2-4 times a week, once a week, and almost never),sleep times (bedtime to wake-up time), “What did
your child experience during the disaster?” (earthquake, tsunami, nuclear power plant accident, noneof these), and the “Strengths and Difficulties questionnaire (SDQ)”27). We used survey data obtained
from children of elementary and junior high schoolage (7-12 years old and 13-15 years old, respectively) and their parents in Kawauchi, who were included in the FHMS. In principle, the children’s parents answered the questionnaire by recalling thechild’s circumstances at the time of the earthquake
and beyond.
The mental health status of the children wasassessed using the Japanese version of the SDQ
scales. This Japanese version has been validated inprevious reports28,29), and consists of 25 questions to
the parents concerning both positive and negative
behaviors of their child. One subscale evaluates
prosocial behavior (social strength), and four subscales evaluate difficult behaviors (emotional symptoms, conduct problems, hyperactivity/inattention,and peer relationship problems). Each question
was scored on a 3-point Likert scale from zero (noneof the time) to two (all of the time). For SDQ-prosocial behavior, higher scores indicated a more positive behavior (range : 0-10), and for SDQ-difficult
behavior, higher scores indicated more problematic
behavior (range : 0-40). The total score of the four
subscales for SDQ-difficult behavior is shown as a
Total Difficulties Score (TDS), and we used the scoring classification of the previous study to classify theneed for support into three types : normal range(low), borderline range (middle), and clinical range(high)28), as follows. Normal range (scores) : TDS= 0-12, emotional symptoms, behavioral and peer
relationship problems = 0-3, hyperactivity/inattention = 0-5, prosocial behavior=6-10. Borderline
range (scores) : TDS = 13 - 15, emotional symptoms, behavioral and peer relationship problems = 4,

hyperactivity/inattention = 6, prosocial behavior =5. Clinical range (scores) : TDS = 16- 40, emotional symptoms, behavioral and peer relationshipproblems = 5-10, hyperactivity/inattention = 7-10,
prosocial behavior = 0-4.
Statistical analysis
We compared two groups of children, elementary and junior high school-aged (7-12 years and 1315 years, respectively) based on each questionnaire
item. We also compared the children’s mental
health status by classifying the group that had experienced the nuclear accident as “nuclear disaster(+)”, and the group that had not “nuclear disaster(−).” The exercise habits “almost every day,” “2-4times a week,” and “once a week” were classified as“Yes,” whereas “almost never” was classified as“No.” We used the chi - square test, the Mann Whitney U test and covariance analysis to compare
the data for the two areas. In this study, the dependent variable was “nuclear disaster (+/−),” the exposure variables were “TDS,” “Emotional symptoms,” “Conduct problems,” “Hyperactivity/
inattention,” “Peer relationship problems,” and “Social strength.” P values of less than 0.05 were considered statistically significant. Statistical analysis
was performed using SPSS Statistics 23.0 (IBM Japan, Tokyo, Japan).
Ethics statement
This study was approved by the ethics committee of Fukushima Medical University (No. 2046) before commencement. Prior to the study, we distributed the instructions for the FHMS and othersurveys to residents. We considered that residents
who responded to the questionnaires had agreed toparticipate in the study.

Results
We sent questionnaires to 156 families in
Kawauchi. Of these families, 99 (63.5%) sent responses, and 93 (59.6%) answered all the questions
and were included in the study analysis. The demographics of children whose families returned thesurveys are presented in Table 1. The study included 65 elementary school students and 28 juniorhigh school students. There were no differences in
the gender ratios between elementary school andjunior high school students (P=0.66). There werealso no differences in the exercise habits or experience of the nuclear disaster between elementaryand junior high school-aged children (P=1.00, re-Mental health states of children after the nuclear disaster11

Table 1. Comparison of gender, lifestyle, experience of nuclear disaster, and the SDQ score between elementary and junior high school students.
Elementary schooln = 65

Junior high schooln = 28Alln = 93

n (%)

n (%)

n

36 (55.4%)
29 (44.6%)
22 (33.8%)
43 (66.2%)
8.4±0.924 (36.9%)
41 (63.1%)

17 (60.7%)
11 (39.3%)
10 (35.7%)
18 (64.3%)
7.3±1.4
10 (35.7%)
18 (64.3%)

53
40
32
61
8.1±1.2
34
59

SDQ score

mean±SD

mean±SD

mean±SD

Total difficulties score
Emotional symptoms
Conduct problems
Hyperactivity/inattention
Peer relationship problems
Prosocial behavior

11.4±6.8
3.0±2.7
2.6±1.9
3.6±2.6
2.2±2.2
5.5±2.0

12.4±6.8
2.9±2.3
3.3±2.1
3.7±2.7
2.6±1.75.4±1.7

11.7±6.7
3.0±2.6
2.8±2.0
3.6±2.6
2.3±2.1
5.5±1.9

GenderExercise habits
Sleeping time (Hour)
Experience of nuclear disaster

Boy
Girl
Yes
No
mean±SD
Yes
No

p†

0.66
1.00
<0.001
1.00

0.47
0.98
0.15
0.98
0.20
0.71

SDQ ; Strengths and difficulties questionnaire; Chi-square test and the Mann-Whitney U test†

Table 2.

Classification of the need for support in elementary and junior high school students.
Elementary schooln = 65

Total difficulties score

n%Emotional symptomsn%Conduct problemsn%Hyperactivity/inattentionn%Peer relationship problemsn%Social strengthn%†Junior high schooln = 28low

middlehighlow

middle

high

41
63.1
40
61.5
47
72.3
49
75.4
48
73.8
31
47.7

10
15.4
9
13.9
7
10.8
4
6.1
8
12.3
20
30.8

14
21.5
16
24.6
11
16.9
12
18.5
9
13.8
14
21.5

15
53.6
19
67.9
16
57.1
19
67.8
20
71.4
11
39.3

3
10.7
3
10.7
5
17.9
4
14.3
3
10.7
14
50.0

10
35.7
6
21.4
7
25.0
5
17.9
5
17.9
3
10.7

p†

0.35
0.84
0.35
0.44
0.88
0.17

; Chi-square test

spectively). Furthermore, there was no significant
difference in the sub-items and SDQ scores between
the elementary and junior high school-aged children.
Table 2 shows the need for support in elementary school and junior high school students, as calculated from the SDQ. Their TDS showed no significant differences in their need for assistance, basedon differences among all elementary and junior highschool-aged children (P=0.35). Similarly, for otheritems, there was no significant difference in the needfor assistance based on differences among the elementary and junior high school-aged children.
Table 3 shows a comparison of lifestyle andSDQ score results for children based on differencesin their experience of the nuclear disaster. There
was no significant difference in the presence or absence of exercise or the average sleep time due tothe difference in experience (P=0.07 and P=0.90,
respectively). The SDQ results also showed nosignificant difference in each item.

A. Tokunaga et al.

12

Table 3. Comparison of gender, age, lifestyle and SDQ score due to differences in experience of nuclear disasters.
Nuclear disaster (+) Nuclear disaster (−)
n = 34n = 59GenderAge
Exercise habits
Sleeping time (Hour)
SDQ score
Total difficulties score
Emotional symptoms
Conduct problems
Hyperactivity/inattention
Peer relationship problems
Prosocial behavior

n (%)

n (%)

Boy
Girl
mean±SD
Yes
No
mean±SD36 (55.4%)
29 (44.6%)
11.0±2.3
16 (47.1%)
18 (52.9%)8.1±1.1

17 (60.7%)
11 (39.3%)
10.6±2.4
16 (27.1%)
43 (72.9%)8.1±1.3

mean±SD
mean±SD
mean±SD
mean±SD
mean±SD
mean±SD10.9±6.7
2.8±2.8
2.4±1.7
3.1±2.6
2.5±1.95.7±1.812.2±6.8
3.1±2.5
3.0±2.2
3.9±2.6
2.2±2.1
5.3±2.0

p†

0.52
0.34
0.07
0.90
0.31
0.42
0.37
0.19
0.32
0.34

SDQ ; Strengths and difficulties questionnaire†; Chi-square test and the Mann-Whitney U test
Table 4.

Classification of the need for support due to differences in experience of nuclear disasters.
Nuclear disaster (+)
n = 34

Total difficulties score

n%Emotional symptomsn%Conduct problemsn%Hyperactivity/inattentionn%Peer relationship problemsn%Social strengthn%†Nuclear disaster (−)
n = 59p†

low

middlehighlow

middle

high

22
64.7
22
64.7
24
70.6
28
82.4
23
67.6
17
50.0

4
11.8
6
17.6
5
14.7
0
0
6
17.6
11
32.4

8
23.5
6
17.6
5
14.7
6
17.6
5
14.7
6
17.6

34
57.6
37
62.7
39
66.1
40
67.8
45
76.3
25
42.4

9
15.3
6
10.2
7
11.9
8
13.6
5
8.5
23
39.0

16
27.1
16
27.1
13
22.0
11
18.6
9
15.2
11
18.6

0.79
0.41
0.67
0.07
0.42
0.76

; Chi-square test

Table 4 shows the need to support children due
to their different experience of the nuclear disaster,
as calculated with the SDQ. Their TDS showed nosignificant differences due to a difference in experience (P=0.79). Similarly, for other items, there
were no significant differences in the need for assistance based on the different experience of the nuclear disaster.

Discussion
This mental health survey, conducted in Kawau-

chi within the framework of the FHMS ten months
after the nuclear disaster, had the objective of providing adequate mental health care and lifestyle support for evacuees14,15). In addition, this study was
analyzed to assist with problems related to the evacuation and migration of children living in the countryside at the time of the accident.
SDQ was employed in this survey to estimate
the mental health states of the children. The results of the SDQ study, conducted within the FHMS
framework during the same period as this study15,17),
indicated ratios of children in elementary and juniorMental health states of children after the nuclear disasterhigh school who scored above the cut-off points of
22.0% and 16.2%, respectively. These ratios aresubstantially higher than reported previously (9.5%)
for the usual condition28). Kawauchi is located relatively far from the surveyed towns and villages. It
was damaged by the earthquake, but not by the tsunami, because of its inland location. Due to the accident at the nuclear power plant, almost all residents who lived in the village, fewer than 3,000
people, were evacuated. The radiation dose rate
remained relatively low compared to other evacuation areas. By contrast, the proportions of those
who scored above the cutoff (≥16) of the SDQ were23.5% (aged 7 - 12 years) and 33.3% (aged 13 - 15
years), were relatively higher than that of other areas in FHMS17).
Overall, more than half the children of Kawauchi had no regular exercise habits, and the average
sleep time was about 8 hours. Itagaki et al. suggested that a lack of regular exercise and the shortening of sleep time among Fukushima’s children
may lead to the further deterioration of their mental
health31,32). Also, a short sleep duration was reported in children who experienced the earthquake disaster, and a relationship was noted between shortsleep duration and increased traumatic symptoms18,33).
In this way, the lack of exercise and shortening of
sleep time need attention, not only in terms of their
physical effects on children, but also the mental effects. Furthermore, Chen et al. suggested thatchildren living in rural areas and rural-to-urban migrant children had poorer mental health than children in urban areas24). Several other studies havereported that indicators of social disadvantage (single-parent families, parents who are unemployed orhave low incomes) are associated with poor mental
health in children34 36). This finding appears to havearisen due to the experience of a major disaster andevacuation during adolescence, however it should be
carefully evaluated in terms of socioeconomic factors, including region (rural or urban, etc.) and for
migrant children, factors including time course andparental income.
There are several reports related to the mental
health states of children after the Great East Japan
Earthquake. A comparative survey of SDQ in children in other areas who experienced the same disaster indicated that the experiences of loss in children
who had been displaced due to the tsunami was related to their higher SDQ scores19). Fujiwara et al.
found that more than 90% of the children who experienced the Great East Japan Earthquake are undergoing trauma, and according to the clinical zone for-13

the Child Behavior Checklist (CBCL), 27.7% areshowing introverted problem behaviors, 21.2% areshowing diplomatic problem behaviors, and 25.9%
are showing overall behavioral problems20). In another post-disaster report, McLaughlin et al. investigated emotional disturbance in children from 4 to 16
years old after hurricane damage ; they reported
that the proportion of children with emotional disorders decreased with the passage of time, but remained at a higher rate than normal37). These results suggest the need to identify the problems
present in the children from the disaster area, to increase sensitivity to children’s mental health status,
and to provide them with appropriate support. Although the children of Kawauchi village are expected
to improve overall as time goes on, our opinion isthat continued support is necessary, including support tailored to dealing with the effects of long-term
trauma following a disaster.
In this study, we found no differences in mental
health status related to experience of the nuclear accident. Since the SDQ actually captured the viewsof the children from their parents’ perspective, it
may have affected the SDQ outcomes, as it is not a
direct reflection of the children’s self-reported mental health. The children’s mental health may also
be affected by their parents’ mental health status23,29),
so the results of other surveys conducted during thesame period as this study may have also been influenced by their parents’ mental health status30). On
the other hand, a longitudinal study by Oe et al. suggested a link between the experience of nuclear disasters and the emotional symptoms noted in the
SDQ. Therefore, when assessing a child’s mental
health, it is also necessary to consider whether thechild experienced the nuclear disaster38).
Although there were no differences in the mental health status of children due to the experience ofthe nuclear disaster, there is no doubt that the effects of radiation exposure and related anxiety
should be taken into consideration when thinking
about the situation of the affected areas in Fukushima Prefecture. The FHMS estimates of the external radiation doses to residents living in Fukushima
Prefecture during the accident were based on their
behaviors during the four subsequent months 14).
The doses were evaluated as less than 5 mSv in
99.8% of all respondents ; for residents of Kawauchi, it was less than 1 mSv in 72%, and less than 2
mSv in 99%39). Nonetheless, radiation exposure tochildren causes anxiety among their parents 40).
Since the accident, risk communication is ongoing inFukushima and will continue to be needed for every

A. Tokunaga et al.

14

generation in order to avoid misunderstandings
about radiation exposure and its health effects41).
The present study has several limitations.
First, the study was only conducted in Kawauchi, inthe disaster area, and it is a cross-sectional study
completed one year after the earthquake. For
these reasons, the number of subjects is small andthe generalizability of the results is limited. Second, because the FHMS SDQ results show recovery
to the control level over time22), interpretation islimited when assessing acute psychological responses. Furthermore, since the definition of the experience of the nuclear accident is ambiguous, and therange of experiences is wide, the answers will varydepending on the perceptions of the research subjects. The SDQ and experience of disasters arealso an evaluation of the children based on their parents’ perceptions, so it does not directly reflect themental health of the children themselves. We mustalso keep in mind that some differences emerge
based on the assessors themselves29). Nevertheless, the SDQ is considered highly reliable because
it is an evaluation by guardians who live in close
contact with the children, and is a meaningful way ofassessing such factors and their impact on mental
health. Thirdly, the lack of survey items regarding
socio-economic factors and living conditions in rural
areas, and the fact that they are not compared withurban areas, is another limitation of this survey.
Another factor to bear in mind is the suitability of
the SDQ cut-off, which has been reported for Japanese subjects, but is not a world standard. With
these possible limitations, further study is needed tounderstand the situation of the affected area, the regional lifestyle circumstances, and how quickly children can return to their original lives.

Conclusions
In this study, we investigated the mental healthstates of children who were evacuated from rural areas following the Fukushima nuclear accident. We
found indications of poor mental health among elementary and junior high school-aged children in thedisaster area immediately following the accident, but
no differences based on their experience of the nuclear disaster. These results suggest harmful effects on the development of the affected children.
Our findings indicate a need to provide those children who experienced evacuation, especially migrant children and children returning to rural areas,
with continuous mental health support to facilitate
the recovery of Fukushima.

Acknowledgments
This survey was conducted as a part of Fukushima Prefecture’s post-disaster recovery plans andwas supported by the national “Health Fund forChildren and Adults affected by the Nuclear Incident.” We also thank the Nagasaki University teamfor supporting this research.

Study funding
This survey was supported by the Ministry of
the Environment. The funders had no role in study
design, data collection and analysis, decision to publish, or preparation of the manuscript.

Disclosure
The author(s) declared no potential conflicts ofinterest with respect to the research, authorship,
and/or publication of this article.

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