The Effects of Poor Dental Hygiene on Food Choices for the Homeless Population

 The effects of poor dental hygiene on food choices for the homeless population:

 

Everyone deserves proper oral care, especially when met with dire need and assistance. The homeless community is no exception, as they should also receive the utmost care and respect regarding oral healthcare. An issue that may be overlooked is the proper food choices that may be accessible to the homeless population, as they are usually met with either unhealthy food choices, or foods that may be hard for them to process because of bad dental hygiene that may affect their ability to eat. Ignoring these choices could also impact the homeless community's oral care, as it may worsen the symptoms they may already be experiencing. Providing heart-healthy food can improve a person's health. This is why the homeless community should also be allowed to access foods with essential nutrients (1). 

Access to proper food: 

Accessing these necessary foods may be difficult for the homeless community, as they sometimes cannot be picky about what is given to them and may not have food elsewhere to receive. 

Some resources the community can look at is https://www.hungercenter.org/wp-content/uploads/2018/04/NitschkeHFCRPracticalNutritionForHomelessYouth.pdf

This is an insightful guide about the food choices the homeless community may already have accessible to them, and how they can use it to form a healthy diet. This site provides instructions on how to prepare the food, and it is made available with the intent of helping people make better food choices with limited resources. The goal of this information is to help boost the intention of having people who lack the resources for healthy foods, try something that may be available to them, and adjust that food item to make it healthier. Overall, healthy teeth need these nutrients to thrive and to continue to provide health benefits to their owners. 

1. https://www.heart.org/en/health-topics/oral-health

2. https://pmc.ncbi.nlm.nih.gov/articles/PMC10271043/

Helpful Dental Products to Donate to Portland's Unsheltered Community

 

The Issue At Hand

                 Many houseless individuals suffer from preventable oral health conditions due to a lack of regular access to proper dental care and hygiene products. Without consistent access to these fundamental resources and human rights, many members of the unsheltered community face serious risks of detrimental and painful oral infections. By providing basic dental products to those in need, we can effectively prevent and lessen the effects of dental diseases among unsheltered individuals, giving them the essential care they deserve while making their lives a bit easier. This can be done by assembling hygiene kits and donating them to local shelters in your area, or by offering them to someone you notice is in need of care.

Why It Matters

  The unhoused community deserves the same level of access to basic oral health and hygiene resources as any other members of our society. By offering the resources that we are privileged to have access to, we can help reduce the risk of preventable tooth decay, gum disease, and other oral health issues that unsheltered individuals are forced to endure. These are people who are just trying to get by in their lives, living in unsuitable conditions that can negatively impact their health and further contribute to societal stigma against them. If we take time to understand their needs and how to provide assistance, we can hopefully make a positive difference in their lives, and make living just a little bit easier for them.

Local Shelters and Community Hubs

Hygiene4all At 824 SE MLK Jr Blvd

Phone Number: (971) 236-2524

https://www.h4apdx.org/

Blanchet House at 310 NW Glisan St

Phone Number :503-241-4340

https://blanchethouse.org/get-involved

Rose Haven at 1740 Northwest Glisan Street

Phone Number :(503) 248-6364

https://rosehaven.org/

Links to More Hygiene Products

Portable Mouthwash Packets: 

https://www.amazon.com/Oidooin-Mouthwash-Packets-Airline-Approved/dp/B0BRSC68DF/ref=sr_1_20_sspa?crid=1ODJT5VRLJZES&dib=eyJ2IjoiMSJ9.5apW3G8fNOVDwVC5w2mHpK9BigMLjTh1VbtAMXEcTT2EP5Tg81wcAdCzRZJMR1Yk0UigJ5RGw_YdWjfGs_kUmSqSN24mE8kiRmqgx7txXxmajl1Rmf0Jeao6tW3AWNCH_4XO1ABSlb9ka3wXSjP8fpww4KJcyd21YqVfBAEL7JAisqxmjc8qw0nMdkvRAhGn6VQY0_rMoib0Uz__rfQw4F99AKbL4XELDpFYvqVzkTIEpJmyc18VDNFOffn6JL7C6MAF5Wpr0WoGumkCQVZGMmu1rMB_tM2p-092wjOWQf4.C4crwNrelA6n4ZGmjaPQ7tzJfq_zKDKW1KUB7ocgOxA&dib_tag=se&keywords=Travel%2Bmouthwash&qid=1739316696&sprefix=travel%2Bmouthwash%2Caps%2C158&sr=8-20-spons&sp_csd=d2lkZ2V0TmFtZT1zcF9tdGY&th=1

Floss picks:

 https://www.amazon.com/Plackers-Twin-Line-Dental-Floss-Picks/dp/B003N2DXPG/ref=pd_bxgy_d_sccl_2/139-6582905-2783711?pd_rd_w=PymCt&content-id=amzn1.sym.52395280-70da-442b-acda-fca52ac79a0b&pf_rd_p=52395280-70da-442b-acda-fca52ac79a0b&pf_rd_r=X7X9VF6GFQ99JCVZVPCB&pd_rd_wg=dYnwL&pd_rd_r=ded727ed-58b7-4790-95c0-e3f03375e7d4&pd_rd_i=B003N2DXPG&th=1

Dental Travel Packs:

https://www.amazon.com/Practicon-Toothbrush-Toothpaste-Mouthwash-Friendly/dp/B0C8QQP6JC/ref=sr_1_5?crid=7XTETZJKEFER&dib=eyJ2IjoiMSJ9.BljBi2CUJtmkqFQsvVXtrA1r6f_pgc_b3pgDms5jIAYMhoKJgZKRwkxiGm1SprSKrTzRoGhv0hrAxsUwyOy0p70sx9Vk9BI9X7V-obcKClQEp5JQXrO4lm3i96rj-ShflXIWRiCgnBAWy_sOro7A_kGwOE7hJLYUTXv8ZK4DSbJVpP3LiGoY2hTVKnXKEBU3bx0OvgCeLbcpmLZLTuz0JQzDwHtVyOEKIblb63r83pJqsYyulrzl-wDjeCbCrnqfuJ0q5R7r7UrXeQfcFJva7r9bEdU7GMrbpcDrUan4svsY1W_7brtf1XXjx8KriWfHADu6TeCpIKvSOq7mX4R9bbunGcagEgx6guIP4COANUamNIK7JZkqeJn8TwFT-iKpxD6x58uzWtfJbuPnixT-NLUStIo7HvGOOIhEKapiIchcU0id1Uk6zBf9RuwUVMAP.j4_dIPTmwC7JbG1oC2Ubnk1N06J94Eckufdqsk5z8pM&dib_tag=se&keywords=dental+kits+travel&qid=1739316925&sprefix=dental+kits+travel%2Caps%2C187&sr=8-5

Sources:

https://doi.org/10.1371/journal.pwat.0000019

https://doi.org/10.1353/dem.2005.0002

Attitudes Towards the Homeless and Oral Care

 

The Homeless and the Need for Oral Care

Oral hygiene and preventative dental care are necessary to maintain satisfactory oral health. There are societal barriers that prevent certain groups of people from receiving the oral care they need to live a healthy life. Homeless people often lack the necessary oral health care. As of 2023, the "Tri-County recorded 6,297 unsheltered individuals in Multnomah, Clackamas, and Washington counties, representing one of the highest totals in the country" (KGW, 2025). Considering the number of homeless people in the Portland Metropolitan Area, it is unjust, but also natural that this group of people in the area suffer from poor oral health due to a lack of basic human resources like sufficient food, shelter, finances, and health services.

The Importance of Oral Care Resources

The homeless population in the Tri-County area needs local support from their neighbors and humanitarian organizations to receive proper dental care as they do not have the appropriate means to seek such health care by themselves. The Mobile Dental Program is an international program that provides emergency oral care services to those who suffer from poverty and homelessness (Medical Teams International). Mobile dental care services need oral health professionals, donors, and those who benefit from the services to serve their true humanitarian purpose. Although people in the Portland Metropolitan area realize that homelessness is a disparity that occurs around and among them, they refuse to learn about the societal issues and barriers that prevent the homeless face from achieving a better quality of life.

Oral Care Providers and their Attitudes Towards the Homeless

The ascription to negative attitudes about the homeless prevents people from becoming aware of the oral health injustices that they face. A population that will encounter homeless individuals with poor oral health are dentists and dental students. For the homeless to achieve good dental health, it is critical to understand the attitudes that oral care professionals hold for those needing oral care. Suppose dentists and dental students lean towards thinking negatively about homeless patients. In that case, it is important to understand why they hold those attitudes so that they convert to realistic and more positive attitudes about the vulnerable population. Habibian et al. studied the attitudes that dental students have "toward homeless people while providing oral health care" (2010). Habiban et al. found that "students’ overall attitudes toward homeless people improved after spending only seven days (one day per week) treating" a homeless population" (2010). As the students in this study worked with a homeless population in need of oral care, they learned to lower their stigmatization against this community and worked well under the supervision of experienced dental staff. Overall, the attitudes of dental students towards homeless patients positively changed after interacting with them interpersonally. It is a beneficial and prosocial goal that "dental [...]education should [...] help dental students understand the social factors that relate to and impact health for all special needs groups. Experiential opportunities to care for disadvantaged individuals in community sites help to drive this message home" (Habibian et al., 2010).

The Need For Properly Trained Oral Care Professionals and the Homeless

Providing donations to humanitarian organizations focused on delivering oral care to people in need and training oral care professionals who will devote time to serving vulnerable populations are sizable solutions to fighting the homeless oral care disparity. A reputable program worthy of donation is the Mobile Dental Program. Dental care professionals must be taught to work with populations who face multiple health and societal injustices.

 

References

Habibian, M., Elizondo, L., & Mulligan, R. (2010). Dental students’ attitudes toward homeless people while providing oral health care. Journal of Dental Education, 74(11), 1190-1196.

Haskins, D. (2025, January 21). Tri-County homeless count begins in Portland area with new survey tools. KGW. https://www.kgw.com/article/news/local/homeless/multnomah-clackamas-washington-county-2025-homelessness-point-in-time-count/283-6f2cab0b-c6a4-4037-8b08-18a34254a7e7

Medical Teams International. (2025, January 25). Mobile dental program. https://www.medicalteams.org/how-we-heal/mobile-dental-program/

Oral Health is a Human Right: Bridging the Gap for Houseless Individuals

The Importance of Oral Health

Oral health is integral to overall health, well-being, and quality of life. It enables essential functions such as eating, speaking, and socializing without discomfort or embarrassment. Neglecting oral health can lead to severe health complications, including chronic pain, malnutrition due to difficulty eating, and systemic infections that exacerbate other conditions. Additionally, poor oral health can hinder employability and social integration, perpetuating the cycle of homelessness.

Oral Health as a Human Right

Access to oral healthcare is recognized as a fundamental human right. However, underserved populations, including houseless individuals, often face significant barriers to accessing compassionate, accessible, collaborative, and affordable oral healthcare. Addressing these disparities is essential for promoting social justice and health equity.

Challenges Faced by Houseless Individuals

Houseless individuals experience higher levels of dental caries and periodontal diseases compared to the general population. Barriers such as high costs, lack of accessible dental services, and other social and economic factors contribute to delayed or missed diagnoses and worse clinical outcomes.

Call to Action

Recognizing oral health as a human right shows the importance of prioritizing efforts to remove barriers and ensure equitable access to dental care for all individuals, regardless of their socioeconomic status. This includes advocating for policy changes, supporting organizations that provide free or low-cost dental services, and raising awareness about the critical role oral health plays in overall well-being. By addressing these challenges and promoting oral health equity, we can improve the quality of life for houseless individuals and work towards breaking the cycle of homelessness.

References:

• World Health Organization. (n.d.). Oral health. Retrieved from https://www.who.int/health-topics/oral-health
• Harm Reduction Journal. (2022). Access to oral care is a human rights issue. Harm Reduction Journal, 19(1), Article 6. https://doi.org/10.1186/s12954-022-00626-4 
• Lione, R., Ralli, M., De Razza, F. C., D’Amato, G., Arcangeli, A., Carbone, L., & Cozza, P. (2024). Oral health epidemiological investigation in an urban homeless population. Dentistry Journal, 12(10), 324. Retrieved from https://www.mdpi.com/2304-6767/12/10/324.
• Hayes, B. The Medical Team International mobile dental clinic provides basic dental care during a community wellness event. Statesman Journal. Retrieved from https://www.statesmanjournal.com/story/news/local/oregon/2022/10/25/free-mobile-medical-dental-care-clinics-oregon-washington-kaiser-mti-free-food-health-care-barriers/69587760007/=
• Bridgeview Smiles. (n.d.). Community services [Photograph]. Bridgeview Smiles. Retrieved from https://www.bridgeviewsmiles.com/our-practice/community-services/

                                                                    

Clean water access for the homeless in Portland and its impact on Dental Hygiene

 

Dental Hygiene is important for everyone including those living on the streets of Portland. There are many things to be done to improve this within the community. Whether it is eating a healthy diet, avoiding harmful substances, or staying hydrated which is important for various other reasons. A major barrier that many face are their access to clean water. How accessible is clean water for one living on the street?

Clean water access for washing up and laundry along with clean water to brush one’s teeth. Luckily there are some ways the homeless can access clean water such as, through the Joint Office of Homeless Services. https://johs.us/street-outreach/ Their website provides ways in which one could access clean water. They provide services like mobile showers, mobile laundry services and hygiene products for those in need.

There are other ways the homeless can improve their dental health which would require them to have access to healthy foods some places in Portland like the Blanchet House https://blanchethouse.org/ and Feed the Mass https://www.feedthemass.org/volunteer These places offer healthy meals for those in need. If you are interested in volunteering at either location, just visit their website and sign up. You can make a difference by volunteering and helping those in need of access to healthy food.

The roadway to good dental hygiene starts with better access to healthy food and clean water. Along with information to help inform those living on the street the importance of dental hygiene. Get involved today to help better our communities!

 

Places to Volunteer to make a difference in your community today!

https://www.greaterportlandhealth.org/services/healthcare-for-the-homeless-program

https://blanchethouse.org/

https://www.feedthemass.org/volunteer

https://johs.us/street-outreach/

The Impact of Food Insecurity on Oral Health Among Homeless Individuals

(Weston, 2024.)

 

 

Increased Food Insecurity Among Homeless Individuals

Food insecurity disproportionately affects the homeless population, with individuals experiencing homelessness facing a six-fold increased risk of food insecurity (Wetherill et al., 2023). This lack of stable access to food often leads to diets high in processed foods, sugars, and sodium, which negatively impact overall health, particularly oral health. Limited access to nutritious foods and inconsistent meal patterns increase the risk of tooth decay and gum disease, and with dental care often out of reach, existing oral health issues can worsen over time.

 

https://pmc.ncbi.nlm.nih.gov/articles/PMC10609710/#:~:text=The%20loss%20of%20housing%20severely,needs%20of%20people%20without%20homes

 

Poor Nutrition and Its Impact on Oral Health

Many homeless folks individuals rely on food banks, which often provide shelf-stable foods like snacks rather than balanced meals. These processed foods, along with frequent consumption of high-sugar items such as soda and candy, contribute to poor dietary habits and unbalanced nutrition. Additionally, irregular mealtimes—fluctuating between periods of hunger and overeating—can lead to increased stomach acid production, further damaging teeth. The lack of basic oral hygiene supplies, such as toothbrushes and toothpaste, combined with food insecurity and limited health education, exacerbates these issues.

 

https://pmc.ncbi.nlm.nih.gov/articles/PMC7641484/#:~:text=Our%20findings%20underscore%20the%20importance,among%20high%2Drisk%20homeless%20adults

 (Lift UP. Free Food Market)

 

Solutions for Better Nutrition and Oral Care

Improving access to healthier foods, including fresh fruits and vegetables through assistance like free food markets, help promote better nutrition and oral health outcomes. Nutrition education programs provide individuals with knowledge about food choices and available food assistance programs. Mobile dental clinics and more access to oral hygiene supplies, such as toothbrushes, toothpaste, and clean water, would also support better dental health among the unhoused population. By implementing these solutions, we can help lessen the impact of food insecurity on both diet and oral health among the homeless population.

 

Resources

Dental Services for Adults and Children in Portland:

https://www.greaterportlandhealth.org/services/dental

 

Nutrition Education/ SNAP Orientation:

https://outsidein.org/young-adult-services/snap/

 

Free Food Market:

https://www.lifturbanportland.org/prestons-pantry-and-free-food-market

Mobile Dental Care In PDX- What it is and Where to Access it

 

Background

In 2023, the local non-profit organization Central City Concern (CCC) launched the Mobile Health program to help those struggling with homelessness. Under this program, two mobile health vans provide care to Portland's homeless population. The program was done as part of a collaboration with the Non-profit organization Medical Teams International (MTI). The vans are operated by the two organizations, with CCC offering primary care services while MTI provides dental. These vans arrived in 2024, and are currently active in providing care to the community on a schedule. 

Independently from this program, MTI offers urgent mobile dental care to various communities in Oregon and Washington. In Oregon, they provide service to Tualatin, Hillsboro, Beaverton, Vancouver, Oregon City, Eastport, Gresham, Vancouver, and Portland. 

How It Works 

The mobile clinics provide care free of charge. Patients who lack dental insurance, are underinsured, and cannot afford or access emergency dental treatments are eligible. It is important to note that some sites could potentially have further eligibility requirements. These vans rely on volunteer professionals in the dental hygiene space who donate their time to help citizens. Currently, they are only offering urgent dental procedures such as extractions or fillings for patients with bleeding, pain, or swelling. However, they are considering less urgent services, such as dental cleanings, provided they can find volunteers for it. It is unknown at this point if or when this might be enacted.

Patients are screened for COVID-19 symptoms before being allowed to enter the intake tent. If they are exhibiting at-risk symptoms, they will be turned away. At the intake tent, the patients complete paperwork before being seen inside the mobile clinic. 

Where to access it

The mobile clinics are available at different locations on different days. The CCC mobile healthcare vans operate Tuesday through Friday from 10 am to 5:30 pm. They visit sanctioned and unsanctioned camps, congregate shelters, motel shelters, and day centers. MTI's clinics are far easier to track than the former. They operate on a schedule that can be accessed on MTI's website using the provided link: here. Additionally, they also offer numbers to call to schedule appointments at each location. 

Conclusion 

Those in need of urgent medical care without access to the traditional means of care have options. These mobile health clinics provide important care and resources to anyone in dire need of assistance. However, those afflicted with COVID-19 should wait before seeking dental care. Similarly, some clinics may have stipulations for eligibility. For more information, see this article's sources. 

Sources:

KGW Staff. (16AD). Central City Concern Launches Mobile Health Program for People Experiencing Homelessness. kgw.com. https://www.kgw.com/article/news/local/solutions/central-city-concern-mobile-health-people-experiencing-homelessness/283-b16a93fb-98bc-457b-8ab7-5f456cce5734 

Mobile Health - Health Location. Central City Concern. (2024, December 18). https://centralcityconcern.org/health-care-location/mobile-health/ 

Mobile Dental Program. Medical Teams International. (2025, January 29). https://www.medicalteams.org/how-we-heal/mobile-dental-program/ 

         Noreen, K. (2024, September 18). Mobile Community Dental Care offers compassion and connection.                 WhatcomTalk. https://www.whatcomtalk.com/2024/09/24/mobile-community-dental-care-offers-                           compassion-and-connection/

Fluoride in Portland: How this Major Resource can Impact Dental Health

Portland’s History with Fluoride

Portland is the largest city in the United States that does not have fluoride in its water. The topic was highly debated by the city in the early 2000s, and a loud majority of voters argued against the chemical due to its potential adverse health effects and the lack of personal freedom regarding the issue. A 2013 vote confirmed that Portlanders did not want fluoride included in their water, although city officials continue to push for its addition.

https://www.opb.org/news/article/portland-oregon-water-fluoridation-history-explained/

Benefits of Fluoride

Daily intake of fluoride has been proven to increase bone density, thus acting as a preventative measure toward cavities. It also kills off harmful bacteria in the mouth and helps re-mineralize cavities that may already exist. The main fear of fluoridation is that people will consume too much, but that is a rare occurrence that tends to affect children who swallow higher concentrated dental products like toothpaste and mouthwash. Since Portland is the largest city without fluoride in its water, it is clear that fluoride can be utilized in a safe and healthy way.

https://pmc.ncbi.nlm.nih.gov/articles/PMC6195894/

The Impact on Houseless Individuals

This seems cut and dry. Especially as inflation continues to spike the costs of dental hygiene products, drinking city water with fluoride is the cheapest way for homeless people to care for their oral hygiene. Since we are one of the few cities that provides public drinking fountains, adding fluoride to their water would greatly benefit those who use it, without impacting homeowners who do not want their water fluoridized. As Portlanders, it is vital that we care for our neighbors, and adding fluoride to certain water sources may be the first step to offering a helping hand.

Chronic Illness Due to ADDICTION in Homelessness

 

Addiction:

    Addiction can affect people of different ages, genders, and races. While some individuals manage to prevent their addiction from worsening, many struggle to overcome it. The way drugs and alcohol compel individuals to return to harmful habits demonstrates how strongly addiction can grip one’s life. Often, people are not fully educated on the long-term health consequences of alcohol, drug, and tobacco use. Among individuals experiencing homelessness, addiction can lead to a lack of access to healthcare, delayed treatment, and an increased risk of infectious diseases, resulting in both physical and emotional health issues. These effects are often visible through physical signs such as tooth decay and poor oral health.

https://pmc.ncbi.nlm.nih.gov/articles/PMC4453891/

Factors Associated with Tooth Decay:

    In a study of 350 homeless adults in 2018, illicit substance use from cocaine, cannabis, opioids, methamphetamine, and the use of nicotine/tobacco was significant in those who lost more than half of their teeth compared to those who lost less than half of their teeth. The significance was around 20%. This is justified by how drugs and alcohol can "diminished salivary flow and altered salivary composition, which can exacerbate upper respiratory irritation, including gastric acid regurgitation, further worsening oral health." 

https://doi-org.proxy.lib.pdx.edu/10.1111/jphd.12288

How Can We Improve Oral Healthcare?

Increasing access to affordable dental care through community health centers or mobile dental clinics can help individuals who are unable to travel long distances or rely on walking. This approach would improve oral healthcare and educate those who are unaware of their conditions, helping to prevent their illnesses from worsening. Having access to a provider who is familiar within the community may create long-term trust and connections with the homeless population, encouraging other public health providers to follow their example. In fact, there are many mobile clinics around Portland and Washington. Click the link below to find the location and time of each clinic.

https://www.medicalteams.org/emergency-dental-clinics/

Food is Medicine: A Lack of Healthy Fresh Food Can Lead to Dental Decay

 

The issue at hand:

Food insecurity is an issue within the houseless community that can lead to a multiplicity of other issues. One of these

major issues is dental decay. “Limited food choices likely contribute to multiple nutritional risks identified in unsheltered

populations, including inadequate micronutrient intake and low consumption of core food groups, such as fruits and

vegetables”. Without proper nutritional foods and inconsistencies in meal availability dental decay begins to happen,

leading to even more difficulties with eating proper nutritious foods. “Dental issues that caused avoidance of certain foods

were commonly reported (43.1%) with hard fruits (30.4%), raw vegetables (25%), and meat (20.7%) being the most

frequent types of foods avoided.”

https://doi.org/10.1111/jhn.12130

https://pmc.ncbi.nlm.nih.gov/articles/PMC10609710/#sec1-nutrients-15-04417

What is being done:

                One initiative set up to address these issues is the “Food is Medicine at Iron Gate” project.“The first phase consisted of a

two-part nutrition needs assessment that was followed by a second phase menu standards redesign. These formative

planning activities were included in the project timeline to help ensure the final healthy menu re-design would be acceptable

for Iron Gate guests, feasible for Iron Gate staff to implement, and financially sustainable”. Programs like these not only

provide healthy food access with dignity, but allow feedback from the communities they serve to create healthier, nutritious,

and tailored meals for the houseless community. The feedback they received also includes requests from those with dental

issues and the foods they avoided due to dental issues. “Due to the frequent occurrence of dental issues in this population,

culinary staff should be trained on strategies for preparing fruits and vegetables that are easier to chew, such as finely

shredding, blending, mashing, and even possibly juicing techniques.” Programs such as these are important in taking care

of the houseless community. All of us are people who deserve access to nutritious reliable food that keeps us healthy. “To

improve the dietary intake of the homeless population, understanding the factors driving this group's eating habits is crucial.

A limited body of literature addresses homeless people's experiences of food insecurity and suggests that multiple and

complex factors underpin food consumption; lack of income and access to food storage and preparation facilities stand out

as factors governing food choices”. Learning about these issues is the first step towards a solution. Action such as

volunteering or donating can help to better our urban community as a whole. Find ways to help your community of Portland

Oregon in the links below!

https://www.lifturbanportland.org/volunteer 

https://www.oregonfoodbank.org/get-involved/give

https://doi.org/10.1080/19320248.2018.1484315

https://www.tandfonline.com/doi/abs/10.1300/J013v16n01_04