PARENTING STYLES AS PREDICTORS OF RISKY SEXUAL BEHAVIORS AMONG SELECTED PUBLIC SECONDARY SCHOOL STUDENTS IN EMBU COUNTY, KENYA
1Maasai Mara University, Kenya
2Department of Educational psychology, South Eastern Kenya University
3School of Education, Maasai Mara University, Kenya
4Department of Educational Foundations and Psychology, Maasai Mara University, Kenya
ABSTRACT
Secondary school students are faced with challenges of navigating safely through their adolescence in a world where the culture of sexual immorality is growing fast. Parents play a key role in socializing their children on social norms; however the extent to which parenting styles predetermine students’ risky behaviors remains obscure. The study investigated parenting styles, as predictors of risky sexual behavior among secondary school students. The study was objective was; to investigate the extent to which parenting styles significantly predict secondary school students’ risky sexual behaviors. Survey research design was adopted for the study. Stratified random sampling was used to select a sample of 15 schools. Stratified random sampling and systematic random sampling were used to select 399 participants (221 girls and 178 boys). Purposive sampling was used to select 15 Guidance and counseling teachers and 70 secondary school dropouts. A reliability of cronbach alpha (α) of α = 0.82 for parenting styles questionnaires was reported and α = 0.78 for risky sexual behaviour. The major findings of the study based on the objective of the study showed that parenting styles have a positive and significant prediction of risky sexual behaviors among secondary school students, and that parenting styles accounts for ; 57.2% (R2=0.572, p< 0.05) of secondary school students risky sexual behaviors, The study therefore recommended that school boards of management in conjunction with the Parents Teachers Association, develop intervention measures by organizing seminars for parents to sensitize them on good parenting with the aim of addressing adolescence sexuality. The seminars should be aimed at building the capacity of parents to enable them carry out discussions on sex issues with their adolescent children.
Keywords:Parenting styles Authoritative Authoritarian Permissive indulgence permissive Neglectful Risky sexual behaviors.
ARTICLE HISTORY: Received:12 October 2017, Revised:: 16 November 2017, Accepted: 22 November 2017, Published:30 November 2017.
Contribution/ Originality: The paper contributes the first logical analysis of role of parenting styles in predetermining the secondary school students’ risky sexual behaviours in Embu County. Though there is evidence of increased risky sexual behaviours in the county, no study was found focusing on risky sexual behaviors of secondary school students in relation to parenting styles. Previous studies in the county, concerning risks faced by school going adolescents, focused on peer pressure or drugs in relation to parental economic status and peer pressure.
Majority of the secondary school students are in adolescence stage, a period of transition into adulthood, such transition exposes them to many risks (Kimanthi, 2014). Globally, adolescence is one of the riskiest phases of a persons’ life, due to the complexity and magnitude of biosocial changes that occur during this stage (Robinson, 2006). The stage is characterized by increased exploration and experimentation with many risky behaviors such as drug abuse, risky sexual activities, involvement in violent activities and students’ premature ending of school programmes among others (Adams and Berzonsky, 2006). The large number of adolescents involved in risky sexual behavior implies that, they are at a risk of contracting sexually transmitted diseases including HIV/AIDS.
In the recent times, there has been an increase in risky behaviors among secondary school students in Embu County, top on the list being risky sex, behaviors and premature ending of academic programs. These threaten educational goals in the County and career progression for the students (Kyalo, 2010; Maundu, 2013). Risky sexual activities among learners in secondary schools are on the rise in the County. A study by Nyaga (2010) found that among the school dropout rate of girls in the County 96% is contributed by early pregnancies. Female students in the county have also been found to invite male students into their dormitories at nights for sex (Ngari, 2014; Wanyoro, 2014; Gaitho, 2015). Data from Embu county education office show that dropout rate in year 2015 for form two and form three was 6.9% (Embu County Education Office Report, 2015).
Parents, through their parenting roles (expressed through parenting styles) are important in determining and predicting adolescents’ decisions on various social issues. These decisions influence the actual adolescent involvement in social activities including those which are risky (Ikramulah et al., 2009). The decisions students make at times has far reaching implications on their learning. Some decisions, such as students dropping out of school, interfere with learning process by disengaging from school programs prematurely (Center for Mental Health, 2008). This is because parenting represents the primary setting in which most of the child’s emotions are shaped and their future determined (Yeung and Leadbeater, 2010). Albert (2007) contends that 47% of the adolescents perceive parents as the most influential people on their decisions about sex. According to Nikoogoftar and Seghatoleslam (2015) parenting styles can influence development of good or bad behaviors in adolescents. Parents help to shape the way adolescents view and interpret the world around them and the way they act. Parental-adolescent influence can occur either through strict control, responsiveness, a combination of both or lack of both depending on parenting styles adopted. Parenting styles are composed of two main elements: parental demandingness (control) and parental responsiveness (warmth) (Yusefi et al., 2016).
Authoritative parenting style is characterized by high: monitoring, supervision and moderate control of the child. At the same time the authoritative parent provides warmth to the child (Macobby and Martins, 2003). The authoritative parent also provides a two way communication, by giving strict rules as well as explaining why the rules must be followed, while at the same time listening to the concerns of the child (Devore and Ginsburg, 2005). Permissive indulgent parent provides little control to the child with a lot of warmth. The parent-child communication is child centered, with parent not giving rules to be followed but listens to the demands of the child. There is little or no monitoring or supervision, the child is allowed to regulate his/her own behavior (Baumrind et al., 2010). Permissive neglecting parent are uninvolved with childs’ activities and do not offer control or warmth to the child. Neglectful parents do not provide rules, monitoring or supervision to children and provide little or no communication. The child is left to determine his behaviors with no parental involvement (Yusefi et al., 2016). Research findings on parenting of adolescents differ from one culture to another which makes it difficult to use any findings from one cultural background as “normative” thus such findings are difficult to generalize. Thus, parenting outcomes need to be considered in their cultural settings. According to Bornstein (2012) each culture is different from the other based on deeply rooted practices, beliefs and attitudes which guide how a person feels, thinks and acts in order to be a fully functional entity of that culture. This study therefore sought to fill the gap by investigating how parenting styles predetermine adolescent risky behaviors and school dropout rate in Embu County, Kenya.
To investigate whether parenting styles significantly predict risky sexual behaviors among secondary school students’ in Embu County.
Ho: Parenting styles have no statistically significant prediction on risky sexual behavior among secondary school students.
Research has consistently shown that risky sexual activities are a common challenge among adolescents (Kao and Carter, 2013). A study by Doyle et al. (2012) showed that in Sub-Sahara Africa up to 25 % of adolescents aged 15-19 years have hand sex before they were 15years of age. In Kenya, a survey done by Mitchell et al. (2003) in Nairobi reports that 47% of adolescent males and 95% of girls’ had vaginal sex at least once. The report further reveals that 75% of boys and 50% of girls had their first sexual experience by age 15years.
Previous studies show that risky sexual behaviors among young people are complex some of which are linked to various familial factors (Higgins et al., 2013). Cherie and Berhanie (2015) studied parenting styles and adolescent sexual behavior among high school students in Ethiopia. The study used a sample of 3840 high school adolescents. The results show that students from authoritative and authoritarian parents have a higher probability of having safe sex compared to students of permissive parents. Parental communication within an environment of authoritative parenting was found to have protective of adolescents from risky sexual behavior. A study by Hutcinson and Motgomery (2007) on a sample drawn from American college students of African American origin reveal that girls who reported good levels of communication with parents about sex matters were more than 60%, and had low chance to report having been pregnant compared to those reporting low communication. This study implies that parent-child communication may either reduce incidence of early sex or promotes safe sex among adolescents. Most of the foregoing studies used samples of students mainly from developed countries. The findings may not be applied secondary school students from developing country since the cultural practices are not the same, this study focused on secondary students to find out how their risky behavior are predicted by parenting styles.
Effect of parenting behaviors such as monitoring of adolescents’ sexual activities show that, parental monitoring have been shown to be protective against adolescent sexual risks. Moussa (2016), carried out a study on influence of parenting styles on adolescent risky sexual behavior of college students. The study used a sample drawn from college students. Multiple linear regression analysis found that permissive parenting style was predictor of adolescent risky sexual behaviors. Wang’eri and Otanga (2013) conducted a study on family factors related to adolescents’ sex behavior, using a sample of 217 secondary school adolescents from Kenya, aged 12-20 years. The findings reveal that child monitoring is protective against adolescents’ sexual risk. The study found that adolescents who were monitored reported fewer incidents of engagement in sexual behavior. Other studies with similar results include (Kabiru et al., 2014) who studied premarital sex among students. The studies mainly used samples of college students from developed countries and focused on a few parenting styles, on the other hand the study in Kenya by Wange’ri focused on parental monitoring. This study involved all the four main parenting styles so as to be in a position to understand the extent to which parenting style predetermine students’ risky behaviors
Studies in sub-Sahara Africa show that culture limit parent–child communications to marriage issues and traditional rites, and not sex related challenge adolescent face across different communities (Markham et al., 2010). Research on parent-adolescent communication on risky sex behaviors has been significantly linked with rise in likelihood of sexual activity among adolescents’ male students in Malawi and adolescent female students in Uganda (Biddlecom et al., 2009). However, a study done in Kenya a study by Magadi and Agwanda (2008) show that communication reduced risky sexual activities among adolescents. On the other hand a longitudinal study done in Tanzania by Kawai et al. (2008) using adolescents aged between 12-14years reveal that, “parent-child communication is not associated with the odds of sexual initiation”. This differing result across communities necessitates more studies to be done in the area of adolescent risk taking. The studies review focused on risky behaviors mainly among college students from developed countries while those from developing world focused on a few parenting attributes like parental communication and parental monitoring. This study focused on comprehensive parenting styles articulated by Macobby and Martins (2003) for a more comprehensive understanding of predictive effect of adolescent risky behaviors by parenting styles.
The target population for this study all the form 2 and form three students in public secondary schools in Embu County. The study adopted survey research design. Stratified random was used to select 15 schools. This was done in order to ensure all the categories of schools were represented. From each category of schools simple random sampling was used to get 399 students proportionately from form 2 and form three. Simple random sampling was used to select 8 participants in focus group discussion from the sampled students. Focus group discussion was used in order to get students feelings on the subject of the study. Purposive sampling was use to select 15 guidance and counseling teacher school dropouts from the selected schools and 70 school dropouts. Data was collected by use of a four-point liket scale questionnaires, focus group discussion schedule and interview schedule. The questionnaires were administered to ongoing students and school dropouts. Data from guidance and counseling teachers were collected by use of interview schedule.
The study findings were represented by use of descriptive and inferential statics
Questionnaires on parenting style were rated on a five point Likert scale. There were 15 items for each of the four parenting styles measured on a 5 point likert scale. The lowest score for each style was 15 while the highest score was 75 and the average for each parenting style was 45 (that is, 15+75=90/2=45). For each of the parenting styles the defining score was 45. A score of 45-90 on the authoritative questionnaire was considered high on authoritative while a score of 15-44 was considered low on authoritative. A score of 45-90 on the authoritarian questionnaire was considered high on authoritarian style; while a score of 15-44 was considered low on authoritarian style. A score of 45-90 on the permissive indulgent questionnaire was considered to be high on permissive indulgent while a score of 15-44 was considered to be low on permissive indulgence. A score of 45-90 on permissive neglectful questionnaire was considered to be high on permissive neglectful while a score of 15-44 was considered low on permissive neglectful. The results for the scoring were presented in Table 4.10 below.
Table-1.0. Results on Scoring of Parenting Style Questionnaires
Parenting styles | Low | High | Total | |||
Frequency | % | Frequency | % | Frequency | % | |
Authoritative | 116 | 29.1 | 283 | 70.9 | 399 | 100 |
Authoritarian | 162 | 40.6 | 237 | 59.4 | 399 | 100 |
Permissive Indulgence | 194 | 48.6 | 205 | 51.4 | 399 | 100 |
Permissive neglectful | 199 | 48.9 | 200 | 50.1 | 399 | 100 |
Average | 168 | 42.1 | 231 | 57.9 | 399 | 100 |
N=399 |
Table 1.0 shows that, majority (70.9%) of the responses score very high on Authoritative style, followed by Authoritarian parenting style. This means that authoritative parenting is the commonest among the parents of the target population. This is followed by authoritarian (59.4%). The least common parenting style is permissive neglectful with 50.1% of the responses. It was further revealed that on average all the factors scored relatively high (57.9%). This was an indication that the four parenting styles are common within the target population.
Table-1.1. Results on Scoring of School Dropouts Rate
Low | High | Total | |||||
Parenting Styles | Frequency | Percent | Frequency | Percent | Frequency | Percent | |
Authoritative | 31 | 60 | 21 | 40 | 52 | 100 | |
Authoritarian | 17 | 30.3 | 35 | 69.7 | 52 | 100 | |
Permissive Indulgence | 26 | 50.0 | 26 | 50.0 | 52 | 100 | |
Permissive neglectful | 16 | 30 | 36 | 70.0 | 52 | 100 | |
Average | 22 | 36.7 | 30 | 57.4 | 52 | 100 |
N= 52 (Source: Author)
Table 1.1 shows that, majority (70 %) of the responses scored high on permissive neglectful style, followed by Authoritarian parenting style (69.4%), permissive indulgence with 50 % responses and the lowest score for high scoring was authoritative (40%). It was further revealed that on average all the factors scored relatively high (57.4%). This was an indication that the four parenting styles influenced the children dropout rate. Bledsoe (2002) argues that the irony of school dropout is that the problem is shared by both richest and poorest countries in equal measure. The findings concur with a study by Chirteş (2010) which found that family factors such as parenting styles are among the factors that lead to school dropout. The findings also concur with a study by Kato (2015) which linked school dropout especially of girls to lack of strict parental supervision as well as monitoring.
The study collected views from 15 focus groups, one group from each selected school; each group was made up of 8 students selected randomly from those students who participated in answering the questionnaires. Responses from the focused group discussion were analyzed under three broad themes; ease of students discussing risky behaviors with parents, people students prefer to discuss risky behaviors with and students expectations of their parents in handling risky behavior. The responses are given in tables, 1.2, 1.3 and 1.4
Table-1.2. Ease of Students Discussing Risky sexual Behaviors with Parents
N=15 | ||
Freq | % | |
Not easy | 13 | 85 |
Easy | 2 | 15 |
Total | 15 | 100 |
Table 1.2 shows that, most (85%) of the groups, agreed that sex issues are not easy to discuss with parents because they considered the topic shameful. Respondents found most of the issues under investigation; risky sex, suicidal behavior and dropping out of school not easy to discuss mainly because of fear of their parents. This concurs with Lavin (2012) who argue that some parenting styles such as authoritarian may create fear and anger in the child who is likely to become resentful and disrespectful to authority figures.
Table-1.3. People Students Preferred to Discuss Risky sexual Behaviors with.
N=15 | |||||||||
Parents | Relatives | Peers | counselors | Totals | |||||
Freq | % | Freq | % | Freq | % | Freq | % | Freq | % |
0 | 0 | 4 | 27 | 6 | 40 | 5 | 33 | 15 | 100 |
Table 1.3 shows that, discussing risky behaviors with parents is not popular among secondary school students. Most (40%) of the groups, agreed that they prefer to talk about sex related issues with their peer or counselors (33%) or relatives other than parents order to avoid the embarrassment. This is consistent with Markham et al. (2010) who argues that in African culture sex matters is a taboo and discussions are limited to the confines of marriage. These findings concur with Cur et al. (2010) contends that there is a reluctance of parents to discuss sex issues with teenagers; this reluctance promotes the presence of misconceptions about sexual health, sexual risks and its consequences. Poor dialogue about sexual health between parents and teenagers is one of the contributory factors of high teenage sexual risks.
Table-1.4. Students’ Expectation from Parents
N=15 | ||
Students’ Expectations | Freq | % |
Understanding and respect | 9 | 60 |
Advice giving and being listened to | 2 | 13 |
Honesty and role modeling | 4 | 27 |
Total | 15 | 100 |
Table 1.4 shows responses from the focus group discussion on how students expect their parents to deal with risky behaviors. The students’ expectations were analyzed under three broad themes; understanding and respect, advice giving and being listened to, honesty and role modeling. The studies show that majority (60%) expected their parents to understand and respect their feelings. This findings concur with Rosenthal (2011) contend that adolescents feel they deserve respect from their parents. They said that they felt that their expectations were not met. The study also found that 27% expected their parents to be honest and be good role models, since some parents were alcoholics and were also involved in other vices; the students agreed that their expectations of their parents were more often not met. As a result the students engaged in risky behaviors and easily lie to their parents and teachers that they were innocent. According to Cumsille et al. (2010) if parents are not honest they play a major role in influencing their adolescents’ lying. For example, adolescents who believe that parental authority is legitimate are less likely to lie to their parents.
The tables also show that 13% expected parents to give them advice and also listen to their views and feeling; they felt many parents were not available for them. The findings concur with Tyzack (2015) who contend that parents who are there physically and emotionally for teenagers are able to meet their children’ expectations, a factor which associated with better adolescent behavior during the hormonally-turbulent years. The findings also concur with Amour et al. (2007) who contend that effects of fatigue and stress experienced at work can affect family life at home thus affecting parent child relationship. This means while the adolescent children at home expect the parent to be available n order to provide advice on various challenges they are facing, the parent is either not physically available at home and even when they are tired from their busy schedule. Such parents are unable to meet their children’s expectation.
The study collected responses from 15 guidance and counseling teachers from the 15 selected schools. The teachers were to report on the incidences of risky behaviors they commonly deal with on a term period of three months. The responses are given in tables 1.5
Table-1.5. Number of sexually related Cases in a Period of Three Months.
N=15 | |||||||||
None | 1-10 | 11-30 | above 30 | Total | |||||
Freq | % | Freq | % | Freq | % | Freq | % | Freq | % |
0 | 0 | 9 | 60 | 5 | 33 | 1 | 7 | 15 | 100 |
Table 1.5 shows responses from guidance and counseling teachers on the risky behaviors commonly dealt with in periods of three months. The table shows that majority of schools (60%) records up to 10 cases sex related issues, with some schools (33%) recording up to 30 cases per term. The findings imply that secondary school students are facing a high risk of sexual related challenges which also expose them to sexually related problems like STIs and HIV/AIDS
To test the hypothesis Ho, the researcher performed a multiple linear regression to establish whether parenting styles has a statistically significant prediction of the risky sexual behaviors among secondary school students. The model summary results were presented in Table 1.6
Table-1.6. Model Summary for Risky Sexual Behavior
Model | R | R Square | Adjusted R Square | Std. Error of the Estimate |
1 | .701(a) | .492 | .572 | 5.467 |
a Predictors: (Constant), Authoritative, Authoritarian, Permissive indulgent and permissive neglectful
Table 1.6 shows that 57.2% (R2=0.572) of variations in the risky sexual behaviour is explained by the parenting styles (Authoritative, Authoritarian, Permissive indulgent and permissive neglectful). The remaining 42.8% is accounted for by other factors not related to parenting styles. The test the fitness of the model ANOVA was used. The results were presented in Table 1.7 below.
Table-1.7. ANOVA (b) Risky Sexual Behavior
Model | Sum of Squares | df | Mean Square | F | Sig. | |
1 | Regression | 147.500 | 4 | 36.911 | 5.796 | .000(a) |
Residual | 152.500 | 395 | 21.812 |
a Predictors: (Constant), Authoritative, Authoritarian, Permissive indulgence, and Permissive neglectful
b Dependent Variable: Risky sexual behavior.
Analysis of variance (ANOVA) was done to establish the fitness of the model used. The ANOVA table: 1.6 shows that the F (4,395) statistic was 5.796 with a p-value of0.000 indicating that the model was statistically significant in explaining the effect of parenting styles on risky sexual behaviors . This means that the model used was appropriate and the relationship of the variables shown could not have occurred by chance. Regression coefficients were presented in table 1.8 below.
Table-1.8. Multiple Regression Coefficients (a) for Risky Sexual Behavior
Model | Unstandardized Coefficients | Standardized Coefficients | t | Sig. | ||
B | Std. Error | Beta | B | Std. Error | ||
1 | (Constant) | 1.546 | 1.189 | 1.300 | .000 | |
Authoritative (X1) | .031 | .084 | .124 | .371 | .001 | |
Authoritarian (X2) | .022 | .134 | .103 | .165 | .000 | |
Permissive indulgence(X3) | .210 | .110 | .972 | 1.906 | .000 | |
Permissive neglectful (X4) | .191 | .092 | 1.047 | 2.079 | .000 |
a Dependent Variable: Risky sexual behaviour
Table 1.8 shows that 57.2% (R2=0.572) of variations in the risky sexual behaviour is explained by the parenting styles (Authoritative, Authoritarian, Permissive indulgent and permissive neglectful). The remaining 42.8% is determined by other factors not related to parenting styles. The findings concur with Stanton et al. (2004) adolescent risky sexual behavior, have a positive relationship with parenting and those strategies for reducing adolescents sexual risks targeting parents are more effective than those that target adolescents only. Table 1.8 shows that all the independent variables (Authoritative, Authoritarian, Permissive indulgence, and Permissive neglectful) significantly (P<0.05) predict the change in the risky sexual behavior. On that bases hypothesis H01is rejected
The regression model is;
Y = 1.546 + 0.031X1 + 0.022X2 + 0.210X3 + 0.191 X4
Table 4.16 shows that all the parenting styles significantly predicts risky sexual behaviors (p<0.05). The results are consistent with findings by Cherie and Berhanie (2015) who argued that parenting styles and adolescent sexual behaviors among high school students from authoritative and authoritarian parents are more likely to have safe sex compared to students of permissive parents. This model shows that the permissive indulgence parenting has the highest contribution to the model (0.210, p<0.05) this means that an increase in indulgence parenting predicts higher risky sexual behaviors of secondary school students by 0.210 at 5% significance level. Permissive neglectful parenting follows with 0.191 at 5% significance level. Authoritative parenting style has the least contribution to the model (0.031, p<0.05). This means that a unit positive change in authoritative parenting style increases risky sexual behavior by a factor of 0.031 at 5% significant level. The study concurs with the findings of a study by Garcia and Garcia (2009) who reported that authoritative parents have optimum adolescent outcomes compared to authoritarian and permissive neglectful parenting. However the findings differs from a study done by Biddlecom et al. (2009) which found that communication within authoritative parenting styles increases sexual risk among adolescents. The study also differs from another study by Kawai et al. (2008) which found that communication within authoritative parenting style has no association with early adolescence sexual initiation. The study suggested that sexual initiation is related to other factors and not parental authoritativeness. This study therefore concurs with a study by Higgins et al. (2013) that found that risky sexual behaviors among young people are complex. This implies that to fully understand adolescents various factors need to be considered a, parenting styles being one of them among others.
The study concludes that parenting styles significantly predetermine secondary school students’ risky sexual behaviors. The different parenting styles; authoritative, authoritarian, permissive indulgent or permissive neglectful provide a variety of psychological Microclimate for the growing adolescents at home. Each Micro system influences the adolescents’ developmental Process differently over the time the adolescent child is with the parent. The relationships within each micro system bring about development of various competencies or hinder development of such competencies in the adolescent child. Such competencies may include those that help the adolescent to navigate safely through risky situations. Authoritarian parenting accounts for the highest styles of students’ risky behavior making it the worst parenting style. On the other hand, authoritative parenting style accounts for the least risky sexual behaviors among adolescent students. The study concludes that adolescent risky sexual behavior prevention strategies have to involve building capacity of the parents to engage their adolescent children in healthy sex education in addition to providing role modeling.
On the basis of these findings, the study recommends that school boards of management in conjunction with the Parents Teachers Association (PTA) develop intervention measures by organizing capacity building seminars for parents to sensitize them on good parenting with the aim of addressing adolescence sexuality. The seminars should also be aimed at building the capacity of parents to enable them carry out discussions on sex issues with their adolescent children.
The study found that students expect their parents to be role models, given that not all of them have parents who meet the expectations of their adolescent children of honesty understanding and role modeling. The study also found that even those students with parents find it difficult to discuss sex related issues. The study therefore recommends that schools star mentorship programs. The mentors should be selected from among people of integrity in the society and assign them to specific students. The mentors should also be those who are easily available for the students. By mentors interacting regularly with the mentors and sharing life experiences students could benefit immensely from the program.
Students, who engage in risky sexual activities, do so, mainly out of curiosity and the need to proof that they are mature as opposed to their parents’ view that they are kids. The situation is worsened if their parents are too punitive on adolescence relationships. In search of freedom and autonomy, they may rebel and seek solace in the company of sexual partners. The study recommends that the schools organize regular youth programs such as seminars to equip students with knowledge on sexual risks and help them develop social skills. Such skills would enable them deal with relationship in a healthy manner.
Funding: This study received no specific financial support. |
Competing Interests: The authors declare that they have no competing interests. |
Contributors/Acknowledgement: All authors contributed equally to the conception and design of the study. |
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