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author:("Chee, doshik")
1.  Menopausal symptoms and physical activity in multiethnic groups of midlife women: A secondary analysis 
Journal of advanced nursing  2012;69(9):1953-1965.
Aims
To explore the effect of diverse types of women’s physical activity on menopausal symptoms among multiethnic groups of midlife women in the USA.
Background
Although physical activity is one of the most widely used non-pharmacological methods for managing menopausal symptoms, there is a paucity of clinical guidelines for women and healthcare providers because the relationship between physical activity and menopausal symptoms has been found inconsistent in previous studies.
Design
A secondary analysis of the data from a lager Internet survey study conducted in 2008 – 2010.
Methods
A total of 481 midlife women among four ethnic groups were selected from the original study. The data were collected using the Kaiser Physical Activity Survey and the Midlife Women’s Symptom Index. Bivariate correlation analyses and hierarchical multiple regression analyses were used to analyze the data.
Results/Findings
The household/caregiving activity index was positively associated with the prevalence scores of the psychological symptoms in both Non-Hispanic Asians and Non-Hispanic African Americans. The increased sports/exercise activity index was negatively associated with the severity scores of the physical symptoms in both Hispanics and Non-Hispanic Whites. The occupational activity index and the active living activity index significantly predicted the severity scores of the psychosomatic symptoms in Hispanics and Non-Hispanic African Americans, respectively.
Conclusion
Nurses who take care of multiethnic groups of midlife women who experience menopausal symptoms should be aware of diverse types of women’s physical activities within the cultural context.
doi:10.1111/jan.12056
PMCID: PMC3646080  PMID: 23171423
Menopause; Symptom; Physical activity; Midlife; Women; Nursing
2.  Racial/Ethnic Differences in Midlife Women’s Attitudes toward Physical Activity 
Introduction
Women’s racial/ethnic-specific attitudes toward physical activity have been pointed out as a plausible reason for their low participation rates in physical activity. However, very little is actually known about racial/ethnic commonalties and differences in midlife women’s attitudes toward physical activity. The purpose of this study was to explore commonalities and differences in midlife women’s attitudes toward physical activity among four major racial/ethnic groups in the United States (whites, Hispanics, African Americans, and Asians).
Methods
This was a secondary analysis of the qualitative data from a larger study that explored midlife women’s attitudes toward physical activity. Qualitative data from four racial/ethnic-specific online forums among 90 midlife women were used for this study. The data were analyzed using thematic analysis, and themes reflecting commonalties and differences in the women’s attitudes toward physical activity across the racial/ethnic groups were extracted.
Results
The themes reflecting the commonalities were: (a) “physical activity is good for health”; (b) “not as active as I could be”; (c) “physical activity was not encouraged”; (d) “inherited diseases motivated participation in physical activity”; and (e) “lack of accessibility to physical activity.” The themes reflecting the differences were: (a) “physical activity as necessity or luxury”; (b) “organized versus natural physical activity”; (c) “individual versus family-oriented physical activity”; and (d) “beauty ideal or culturally accepted physical appearance.”
Discussion
Developing an intervention that could change the social influences and environmental factors and that could incorporate the women’s racial/ethnic-specific attitudes would be a priority in increasing physical activity of racial/ethnic minority midlife women.
doi:10.1111/j.1542-2011.2012.00259.x
PMCID: PMC3741674  PMID: 23931661
physical activity; attitude; women; race/ethnicity
3.  Asian American Midlife Women’s Attitudes toward Physical Activity 
Objectives
To explore Asian American midlife women’s attitudes toward physical activity using a feminist perspective.
Design
A qualitative online forum study.
Settings
Internet communities/groups for midlife women and ethnic minorities.
Participants
A total of 17 Asian American women recruited through the internet using a convenience sampling method.
Methods
A six-month qualitative online forum was conducted using 17 online forum topics. The data were analyzed using thematic analysis.
Results
Three major themes related to Asian American midlife women’s attitudes toward physical activity were extracted from the data: keeping traditions, not a priority, and not for Asian girls. Because Asian American midlife women were busy in keeping their cultural traditions, they rarely found time for physical activity. The women gave the highest priority to their children, and physical activity was the lowest priority in their busy lives. Also, the women were rarely encouraged to participate in physical activity during their childhoods, and they perceived that their weak and small bodies were not appropriate for physical activity.
Conclusions
Several implications for future development of physical activity promotion programs for this specific population have been suggested based on the findings.
doi:10.1111/j.1552-6909.2012.01392.x
PMCID: PMC3496028  PMID: 22789126
physical activity; attitudes; midlife; women; online forum; Asian American
4.  Practical Guidelines for Qualitative Research Using Online Forums 
With an increasing number of Internet research in general, the number of qualitative Internet studies has recently increased. Online forums are one of the most frequently used qualitative Internet research methods. Despite an increasing number of online forum studies, very few articles have been written to provide practical guidelines to conduct an online forum as a qualitative research method. In this paper, practical guidelines in using an online forum as a qualitative research method are proposed based on three previous online forum studies. First, the three studies are concisely described. Practical guidelines are proposed based on nine idea categories related to issues in the three studies: (a) a fit with research purpose and questions; (b) logistics; (c) electronic versus conventional informed consent process; (d) structure and functionality of online forums; (e) interdisciplinary team; (f) screening methods; (g) languages; (h) data analysis methods; and (i) getting participants’ feedback.
doi:10.1097/NXN.0b013e318266cade
PMCID: PMC3727223  PMID: 22918135
online forums; qualitative research; issues
5.  “Symptom-Specific or Holistic”: Menopausal Symptom Management 
Our purpose in this study was to identify differences in menopausal symptom management among four major ethnic groups in the U.S. This was a secondary analysis of the qualitative data from a larger Internet-based study. We analyzed data from 90 middle-aged women in the U.S using thematic analysis. We extracted four themes during the data analysis process: (a) “seeking formal or informal advice,” (b) “medication as the first or final choice,” (c) “symptom-specific or holistic,” and (d) “avoiding or pursuing specific foods.” Health care providers need to develop menopausal symptom management programs while considering ethnic differences in menopausal symptom management.
doi:10.1080/07399332.2011.646371
PMCID: PMC3486633  PMID: 22577743
6.  Attitudes toward Physical Activity of White Midlife Women 
Objective
To explore attitudes toward physical activity of White midlife women in the United States using a feminist perspective.
Design
A cross-sectional qualitative study using a thematic analysis.
Setting
Internet communities for midlife women.
Participants
Twenty-nine White midlife women in the United States recruited using a convenience sampling method.
Methods
We used 17 topics on attitudes toward physical activity and ethnic-specific contexts to administer an online forum. We analyzed the data using thematic analysis.
Results
We found three themes: “thinking without action”; “gendered and sedentary culture”; and “motivating myself.” The women knew and understood the necessity of physical activity for their physical and mental health but in most cases had not been able to take action to increase their physical activities. Although the culture that circumscribed the women's physical activity was sedentary in nature, the women tried to motivate themselves to increase their physical activities through several creative strategies.
Conclusion
The findings strongly suggest that although women were doing their best, American culture itself needs to be changed to help women increase physical activity in their daily lives.
doi:10.1111/j.1552-6909.2011.01249.x
PMCID: PMC3098456  PMID: 21585528
physical activity; attitudes; midlife; women; online forum
7.  “A Waste of Time”: Hispanic Women's Attitudes toward Physical Activity 
Women & health  2010;50(6):563-579.
Despite a lack of studies on Hispanic midlife women's physical activity, the existing studies have indicated that Hispanics' ethnic-specific attitudes toward physical activity contributed to their lack of physical activity. However, little is still clearly known about Hispanic midlife women's attitudes toward physical activity. The purpose of this study was to explore Hispanic midlife women's attitudes toward physical activity using a feminist perspective. The study was a 6-month qualitative online forum among 23 Hispanic women who were recruited through Internet communities/groups. The data were collected using 17 online forum topics on attitudes toward physical activity and ethnic-specific contexts. The data were analyzed using thematic analysis. Three major themes emerged from the data analysis process: (a) “family first, no time for myself,” (b) “little exercise, but naturally healthy,” and (c) “dad died of heart attack.” Although some of the women perceived the importance of physical activity due to their family history of chronic diseases, the study participants thought that physical activity would be a waste of time in their busy daily schedules. These findings provided directions for future health care practice and research to increase physical activity among Hispanic midlife women.
doi:10.1080/03630242.2010.510387
PMCID: PMC2967448  PMID: 20981637
physical activity; attitudes; midlife; women; online forum
8.  Menopausal Symptoms Among Four Major Ethnic Groups in the U.S 
The purpose of the study was to explore ethnic differences in symptoms experienced during the menopausal transition among four major ethnic groups in the U.S. This study was done via a cross-sectional Internet survey among 512 midlife women recruited using a convenience sampling. The instruments included: questions on background characteristics, health, and menopausal status, and the Midlife Women’s Symptom Index. The data was analyzed using descriptive and inferential statistics. Significant ethnic differences in the total number and severity of the symptoms were found. The most frequently reported symptoms and predictors of the total number and severity of the symptoms differed by ethnic identity. More in-depth cultural studies are needed to understand the reasons for the ethnic differences in menopausal symptom experience.
doi:10.1177/0193945909354343
PMCID: PMC3033753  PMID: 20685910
Ethnicity; Menopausal Symptom; Midlife Women
9.  Psychometric Evaluation of the Midlife Women’s Symptom Index (MSI) in Multiethnic Groups 
Western journal of nursing research  2010;32(8):1091-1111.
The Midlife Women’s Symptom Index (MSI) was designed to measure menopausal symptoms specifically in a multiethnic sample of midlife women. This study is a psychometric property test to evaluate MSI among 512 multiethnic groups of midlife women (White, Hispanic, African American, and Asian American). Across the ethnic groups, MSI had an adequate internal consistency in all subdomains except psychosomatic symptoms. The item-to-total correlation coefficients of “lost weight” and “nosebleeds” were less than 0.20 among all ethnic groups. The discriminant validity was confirmed among all ethnic groups except Asian Americans. Overall, MSI may work better for Whites and not as well for Asian Americans, compared with other ethnic groups. Additional studies with diverse groups of multiethnic midlife women are needed, however, to confirm MSI psychometric properties.
doi:10.1177/0193945910362066
PMCID: PMC3037418  PMID: 20606074
psychometric property; reliability; validity; menopausal symptom; ethnicity
10.  “Shielded from the Real World”: Perspectives on Internet Cancer Support Groups by Asian Americans 
Cancer nursing  2010;33(3):E10-E20.
Background
Despite positive reports about Internet cancer support groups (ICSGs), ethnic minorities, including Asian Americans, have been reported to be less likely to use ICSGs. Unique cultural values, beliefs, and attitudes have been considered reasons for the low usage rate of ICSGs among Asian Americans. However, studies have rarely looked at this issue.
Objective
The purpose of this study was to explore (a) how Asian Americans living with cancer who participated in ICSGs viewed ICSGs, (b) what facilitated or inhibited their participation in ICSGs, and (c) what cultural values and beliefs influenced their participation in ICSGs.
Methods
The study was a one-month qualitative online forum among 18 Asian American cancer patients recruited through a convenience sampling method. Nine topics on the use of ICSGs organized the forum discussion, and the data were analyzed using thematic analysis.
Results
Four themes emerged from the data analysis process: (a) “more than just my family,” (b) “part of my family,” (c) “anonymous me,” and (d) “shielded from the real world.”
Conclusions
The overarching theme was Asian Americans’ marginalized experience in the use of Internet cancer support groups.
Implications for Practice
Offering the most current information on cancer and cancer treatment is essential for nursing practice in developing a culturally competent ICSG for Asian Americans. Also, emotional familiarity should be incorporated into the design of the ICSG, and the ICSG needs to be based on non-judgmental and non-discriminative interactions.
doi:10.1097/NCC.0b013e3181c8e5d5
PMCID: PMC2885150  PMID: 20357657
11.  Sub-Ethnic Differences in the Menopausal Symptom Experience: Asian American Midlife Women 
Purpose
To compare the menopausal symptom experiences of sub-ethnic groups of Asian American midlife women.
Design
A cross-sectional study among 91 Asian American women online. Questions about background characteristics, ethnic identity, and health and menopausal status, and the Midlife Women’s Symptom Index were used. The data were analyzed using descriptive and inferential statistics.
Findings
The most frequently reported and the most severe symptoms differed by sub-ethnicity. The total number of symptoms differed by sub-ethnicity, as did total severity scores for the symptoms.
Discussion, Conclusion, and Implications for Practice
Researchers and clinicians should be aware of sub-ethnic differences.
doi:10.1177/1043659609357639
PMCID: PMC2838208  PMID: 20220032
Asian; Menopausal Symptom; Experience; Culture
12.  Psychometric Properties of the KPAS in Diverse Ethnic Groups of Midlife Women 
Western journal of nursing research  2009;31(8):1014-1034.
Although the Kaiser Physical Activity Survey (KPAS) was a potential instrument for cross cultural research of midlife women, little information is available on its reliability and validity among multi-ethnic groups of midlife women. The purpose of the study was to evaluate the reliability and validity of the KPAS in estimating physical activity among 341 diverse ethnic women. Internal consistency was adequate for all ethnic groups except N-H African Americans. The construct validity was identified through group comparisons and factor analysis. In group comparisons, physical activity differences among diverse ethnic groups were similar to results of previous studies using the KPAS. Eight factors were extracted among all ethnic groups except N-H Asian Americans. In the convergent validity test, N-H African Americans and N-H Asian Americans showed particular patterns. Overall, the KPAS was a reliable instrument and was reasonably accurate in assessing physical activities for any multi-ethnic groups of midlife women. However, cultural sensitivity among N-H African Americans and N-H Asian Americans need to be further examined.
doi:10.1177/0193945909341581
PMCID: PMC3042151  PMID: 19745161
Internal consistency; construct validity; convergent validity; physical activity; ethnicity; midlife; women
13.  A National Multiethnic Online Forum Study on Menopausal Symptom Experience 
Nursing research  2010;59(1):26-33.
Background
Little is known about how culture influences menopausal symptom experience, and few comparative qualitative studies have been conducted among multiethnic groups of midlife women in the United States.
Objectives
To explore commonalities and differences in menopausal symptom experience among four major ethnic groups in the US (Whites, Hispanics, African Americans, and Asians).
Methods
This was a secondary analysis of qualitative data from a larger national Internet-based study. The qualitative data from 90 middle-aged women in the US who attended four ethnic-specific online forums of the larger study were examined using thematic analysis.
Results
The themes reflecting commonalities across the ethnic groups were: just a part of life, trying to be optimistic, getting support, and more information needed. The themes reflecting the differences among the ethnic groups were: open and closed, universal and unique, and controlling and minimizing. Overall, the findings indicated positive changes in women’s menopausal symptom experience, and supported the existence of cultural influences on women’s menopausal symptom experience across the ethnic groups.
Discussion
Systematic efforts need to be made to empower midlife women in their management of menopausal symptoms.
doi:10.1097/NNR.0b013e3181c3bd69
PMCID: PMC2882158  PMID: 20010042
ethnicity; menopause; symptoms; midlife; women
14.  Acculturation and Cancer Pain Experience 
Purpose:
Using a feminist perspective, the relationship between acculturation and cancer pain experience was explored.
Design:
This was a cross-sectional, correlational Internet study among 104 Hispanic and 114 Asian cancer patients. The instruments included both unidimensional and multidimensional cancer pain measures.
Findings:
There were significant differences in cancer pain scores by country of birth. Yet, there was no significant association of acculturation to cancer pain scores.
Discussion and Conclusions:
This study indicated inconsistent findings.
Implications for Practice:
To provide directions for adequate cancer pain management, further studies with a larger number of diverse groups of immigrant cancer patients are needed.
doi:10.1177/1043659609334932
PMCID: PMC2761967  PMID: 19376965
Acculturation; Cancer Pain; Asian; Hispanic
15.  Menopausal Symptom Experience of Hispanic Midlife Women in the U.S. 
Health care for women international  2009;30(10):919-934.
Using a feminist approach, we examined the menopausal symptom experience of Hispanic midlife women in the U.S. This was a qualitative online forum study among 27 Hispanic midlife women in the U.S. Seven topics related to menopausal symptom experience were used to administer the 6-month online forum. The data were analyzed using thematic analysis. Four themes were identified: (a) “Cambio de vida (change of life),” (b) “being silent about menopause,” (c) “trying to be optimistic,” and (d) “getting support.” More in-depth studies with diverse groups of Hispanic women are needed while considering family as a contextual factor.
doi:10.1080/07399330902887582
PMCID: PMC2782818  PMID: 19742365
Hispanic; Midlife Women; Menopause; Symptoms
16.  A National Online Forum on Ethnic Differences in Cancer Pain Experience 
Nursing research  2009;58(2):86-94.
Background
Cultural values and beliefs related to cancer and pain have been used to explain ethnic differences in cancer pain experience. Yet, very little is known about similarities and differences in cancer pain experience among different ethnic groups.
Objectives
To explore similarities and differences in cancer pain experience among four major ethnic groups in the United States.
Methods
A feminist approach by Hall and Stevens was used. This was a cross-sectional qualitative study among 22 White, 15 Hispanic, 11 African American, and 27 Asian cancer patients recruited through both Internet and community settings. Four ethnic-specific online forums were conducted for 6 months. Nine topics related to cancer pain experience were used to guide the online forums. The collected data were analyzed using thematic analysis involving line-by-line coding, categorization, and thematic extraction.
Results
All participants across ethnic groups reported “communication breakdowns” with their health care providers and experienced “changes in perspectives.” All of them reported that their cancer pain experience was “gendered experience.” White patients focused on how to control their pain and treatment selection process, while ethnic minority patients tried to control pain by minimizing and normalizing it. White patients sought out diverse strategies of pain management; ethnic minority patients tried to maintain normal lives and use natural modalities for pain management. Finally, the cancer pain experience of White patients was highly individualistic and independent, while that of ethnic minority patients was family-oriented.
Discussion
These findings suggest that nurses need to use culturally competent approaches to cancer pain management for different ethnic groups. Also, the findings suggest further in-depth cultural studies on the pain experience of multiethnic groups of cancer patients.
doi:10.1097/NNR.0b013e31818fcea4
PMCID: PMC2668932  PMID: 19289929
cancer; ethnic minority; experience; pain
17.  Characteristics of Cancer Patients in Internet Cancer Support Groups 
The purpose of this study was to describe characteristics of cancer patients who were attending Internet Cancer Support Groups (ICSGs) and to provide direction for future research. A total of 204 cancer patients were recruited through ICSGs by posting the study announcement on the websites of the ICSGs. The participants were asked to fill out Internet survey questionnaires on sociodemographic characteristics and health/disease status. The data were analyzed using descriptive and inferential statistics including t-tests, ANOVA, and chi-square tests. Findings indicate that cancer patients recruited through the ICSGs tended to be middle-aged, well-educated, female and middle class. The findings also indicate that there were significant differences in some characteristics according to gender and ethnicity. Based on the findings, some implications are suggested for future research using and developing the ICSGs.
doi:10.1097/01.NCN.0000299655.21401.9d
PMCID: PMC2504028  PMID: 18000430
Internet Cancer Support Groups; Cancer Patients; Sociodemographic Characteristics
18.  Internet Communities for Recruitment of Cancer Patients into an Internet Survey: A Discussion Paper 
The purpose of this paper is to provide future directions for the usage of Internet communities (ICs) for recruitment of research participants based on issues raised in an Internet survey among 132 cancer patients. 317 general and 233 ethnic-specific Internet Cancer Support Groups and 1,588 ethnic-specific ICs were contacted to recruit cancer patients. Research staff recorded issues and wrote memos during the recruitment process. The written memos and records were later analyzed using content analysis. The issues included: (a) difficulty in identifying appropriate ICs and potential participants, (b) meta-tags, (c) dominant white and women groups, (d) dynamics inside ICs, (e) difficulty in trust building, and (f) potential selection bias. The findings suggest that researchers thoroughly review the ICs’ information, be recognizant of potential gender and ethnic issues and current trends in Internet interaction, and consider potential selection bias.
doi:10.1016/j.ijnurstu.2006.07.003
PMCID: PMC2235818  PMID: 16962122
Internet Communities; Cancer Patients; Recruitment; Internet Research
19.  The Pain Experience of Hispanic Patients With Cancer in the U.S. 
Oncology nursing forum  2007;34(4):861-868.
Background:
Several plausible reasons for inadequate cancer pain management among Hispanic patients with cancer in the U.S. have been postulated; however, this issue is understudied.
Purpose:
The purpose of the study was to explore Hispanic patients' cancer pain experience from a feminist perspective in order to find explanations for inadequate pain management for Hispanic patients with cancer.
Design:
A qualitative online forum study.
Setting:
Both Internet and community settings.
Participants:
15 Hispanic patients with cancer recruited using a convenience sampling method.
Methods:
A 6-month online forum was conducted using nine discussion topics, and the data were processed using a thematic analysis.
Phenomenon of Interest:
Cancer Pain Experience
Findings:
Four major themes emerged: lack of communication with health care providers regarding undermedication; because of traditional gender roles guiding their behaviors, both women and men were enduring pain; participants placed the highest priority on family during the diagnosis and treatment process, thus setting aside their needs for pain management; finally, participants were enduring inconvenience and unfair treatment in the U.S. health care system while simultaneously appreciating what treatment they had been given.
Conclusions:
Because of cultural factors and marginalized status in the U.S. as Hispanics and as immigrants, most of the participants could not adequately describe and manage their pain.
Implications:
Findings suggest a need for further investigation of the influences of multiple factors, including financial issues, cultural norms, and gender stereotypes, on cancer pain experience among diverse subgroups of Hispanic patients with cancer.
Key Points:
Because of their Hispanic identity or immigrant status in the U.S., financial difficulties, language barriers, and cultural values placing family as the highest priority, most of the Hispanic participants of this study could not adequately describe and manage their pain.
Because of traditional gender roles emphasizing machismo, Hispanic men rarely complained about their pain.
Due to cultural traditions emphasizing women's obedience and obligation to sacrifice for their families, Hispanic women were also enduring pain while fulfilling their multiple roles and responsibilities.
Because of familism, Hispanic patients with cancer placed the highest priority on family while managing cancer pain.
doi:10.1188/07.ONF.861-868
PMCID: PMC2501107  PMID: 17723987
Hispanic; Cancer; Pain Experience
20.  An Online Forum As a Qualitative Research Method: Practical Issues 
Nursing research  2006;55(4):267-273.
Background
Despite positive aspects of online forums as a qualitative research method, very little is known about practical issues involved in using online forums for data collection, especially for a qualitative research project.
Objectives
The purpose of this paper is to describe the practical issues that the researchers encountered in implementing an online forum as a qualitative component of a larger study on cancer pain experience.
Method
Throughout the study process, the research staff recorded issues ranged from minor technical problems to serious ethical dilemmas as they arose and wrote memos about them. The memos and written records of discussions were reviewed and analyzed using the content analysis suggested by Weber.
Results
Two practical issues related to credibility were identified: a high response and retention rate and automatic transcripts. An issue related to dependability was the participants’ easy forgetfulness. The issues related to confirmability were difficulties in theoretical saturation and unstandardized computer and Internet jargon. A security issue related to hacking attempts was noted as well.
Discussion
The analysis of these issues suggests several implications for future researchers who want to use online forums as a qualitative data collection method.
PMCID: PMC2491331  PMID: 16849979
Issues; Online Forums; Cancer Patients; Qualitative Research
21.  Internet Cancer Support Groups 
Cancer nursing  2005;28(1):1-7.
Internet Cancer Support Groups (ICSGs) are an emerging form of support group on Internet specifically for cancer patients. Previous studies have indicated the effectiveness of ICSGs as a research setting or a data-collection method. Yet recent studies have also indicated that ICSGs tend to serve highly educated, high-income White males who tend to be at an early stage of cancer. In this article, a total of 317 general ICSGs and 229 ethnic-specific ICSGs searched through Google.com, Yahoo.com, http://Msn.com, AOL.com, and ACOR.org are analyzed from a feminist perspective. The written records of group discussions and written memos by the research staff members were also analyzed using content analysis. The idea categories that emerged about these groups include (a) authenticity issues; (b) ethnicity and gender issues; (c) intersubjectivity issues; and (d) potential ethical issues. The findings suggest that (a) researchers adopt multiple recruitment strategies through various Internet sites and/or real settings; (b) researchers raise their own awareness of the potential influences of the health-related resources provided by ICSGs and regularly update their knowledge related to the federal and state standards and/or policies related to ICSGs; and (c) researchers consider adopting a quota-sampling method.
PMCID: PMC1409749  PMID: 15681976
Analysis; Cancer; Feminist; Internet; Support groups

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