A Review Of The Research On Religion And Spirituality.

Mental Health, Religion & Culture
Volume 6, Number 3, 2003
A systematic review of research on religion and
spirituality in the Journal of Traumatic Stress: 1990–1999
ANDREW J. WEAVER*
, LAURA T. FLANNELLYy
,
JAMES GARBARINOz
, CHARLES R. FIGLEY§
&
KEVIN J. FLANNELLY*
*
The HealthCare Chaplaincy, New York, New York, USA; y
School of Nursing, University
of Hawaii, Honolulu, Hawaii, USA; z
College of Human Ecology, Cornell University,
Ithaca, New York, USA; §
The Traumatology Institute, Florida State University,
Tallahassee, Florida, USA
AB S T R A C T Surveys reveal that religion and spirituality are highly valuable to many people
in times of crisis, trauma, and grief. The relationship between coping with trauma and the use of
various spiritual beliefs is well established. The importance of clergy in trauma recovery is also well
documented. A review of the 469 research and non-research articles published between 1990 and
1999 in the Journal of Traumatic Stress revealed that 8.7% (6/69) of non-research articles,
4.1% (15/366) of quantitative research articles and 2.9% (1/34) of qualitative research articles
considered religion or spirituality in their work. Analysis of variance found a significant overall
increase in the percentage of articles that mentioned religion/spirituality between the first half
(1990–1994) and the second half (1995–1999) of the study period. The results are discussed in
the context of the trauma research and in comparison to related disciplines. Recommendations for
future research and clinical application are suggested for both traumatologists and religious
scholars.
Introduction
Being part of a religious community and engaging in spiritual practice are
important to the lives of a substantial number of people in the United States.
According to a recent Gallup poll, approximately 70% of the nation claim member-
ship in a church or synagogue, and about 40% attend services weekly. Almost
90% of Americans want some form of religious education for their children, and
82% of adults feel a need for spiritual growth in their lives. Three out of five
Correspondence to: Andrew J. Weaver, M.Th., Ph.D., Director of Research, The HealthCare
Chaplaincy, 307 East 60th Street, New York, New York 10022-1505, USA;
email: aweaver@healthcarechaplaincy.org
Mental Health, Religion & Culture
ISSN 1367-4676 print/ISSN 1469-9737 online ! 2003 Taylor & Francis Ltd
http://www.tandf.co.uk/journals
DOI: 10.1080/1367467031000088123

consider religion ‘very important’ to themselves—80% indicate that they use
prayer in times of crisis, and 95% of those believe that their prayers are answered.
These rates of religious commitment and involvement have remained fairly
constant in the United States from the mid-1960s through the 1990s (Gallup &
Lindsay, 1999).
Faith and coping with trauma
Religious and spiritual practices are traditional ways through which many people
develop personal values and their own beliefs about human meaning and purpose.
The experience of psychological trauma shatters an individual’s sense of order
and continuity of life. Questions of meaning and purpose emerge as a person
experiences a loss of control over his or her future. Widely respected clinical
scholars, including Herman (1992), Lifton (1988), and van der Kolk (1987), have
indicated that traumatic events often bring about a ‘crisis of faith’. Figley (1989)
has noted that, in order to answer the question of ‘Why did it happen?’, the
traumatized often turn to faith and spirituality.
Studies investigating the roles of religion and spirituality in the facing of
traumatic experiences have found that personal faith and religious communities
are primary means by which people cope (Weaver et al., 1996). Weinrich et al.
(1990) studied the effects of stress, in the wake of the terror and destruction
caused by the class IV Hurricane ‘Hugo’ in South Carolina, on 61 nursing
students and 10 faculty involved in disaster relief. After three weeks of disaster
relief work, three quarters of those in the study reported that religion was a
primary positive coping strategy. In a similar vein, a study of Jewish teenagers in
Israel, who were facing the threat of missile attack during the 1992 Persian Gulf
War, found they used religion and prayer to positively cope with traumatic stress
(Zeidner, 1993). Other researchers investigated religious coping methods used by
individuals who experienced the devastating impact of a major midwestern flood.
Frequent prayer and worship attendance were associated with better mental
health (Smith et al., 2000). It is possible, of course, that individuals with better
mental health are more likely to engage in religious activities.
Researchers have found evidence that religiously committed women who are
battered suffer less severe PTSD symptoms than women without a faith
commitment (Astin et al., 1993). In addition to offering the social support of
community, religion provides a healing means of addressing traumatic experience
that can facilitate recovery (Pargament, 1997). In a long-term study of 124
parents who lost a child to sudden infant death syndrome, McIntosh et al. (1993)
found that greater religious participation was related to increased emotional
support from others and finding meaning in the loss of the child. Religion appears
to offer these parents an effective means for making sense of the death, which
enhances well-being, lowers distress and facilitates recovery.
A well-designed investigation of persons grieving the loss of a family member
or very close friend discovered a strong link between the ability to make sense of
the death through religious belief and practice and positive psychological
216 Andrew J. Weaver et al.

adjustment (Davis et al., 1998). In a third study, fathers of children being treated
for cancer in a hospital clinic were asked about various methods of coping.
Among 29 separate strategies used, prayer was both the most common and most
helpful according to the fathers (Cayse, 1994).
Culture, religion and trauma
In the past two decades, there have been an increasing number of refugees
globally, reflecting the political and economic instability in several regions of the
world (Carter et al., 1993). From 1983 to 1990, Western countries received more
than 2.2 million asylum applicants (Widgren, 1993). The traumatic circum-
stances that trigger a decision to leave one’s home because of well-founded fear of
persecution are central to understanding the deep distress found in asylum
seekers. In addition, many refugees that immigrate to North America and Europe
have suffered severe maltreatment and torture (Mollica, 2000). High numbers of
the refugees from war-torn nations, groups with which many religious
communities are actively involved (Hopkins, 1990; Lorenz,1990), are suffering
from psychological trauma (Cervantes et al., 1989; Kinzie et al., 1990; Fox &
Tang, 2000). The need for more research in this area and other topics is
discussed in the final section of this paper.
In the United States, the mental health benefits of religious practice and belief
for African-Americans (Levin et al., 1995) and Hispanic-Americans (Levin et al.,
1996) have been widely documented across the lifespan. Historically, the church
has promoted social and psychological support in the African-American and
Hispanic-American communities. Three out of four African-American adults
surveyed responded ‘very often’ or ‘often’ to the statement, ‘The religious beliefs
I learned when I was young still help me’ (Seaborn-Thompson & Ensminger,
1989). In a survey of 1,805 Hispanic-Americans (the majority of Mexican,
Cuban, or Puerto Rican heritage) over the age of 55, researchers discovered that
individuals were twice as likely to seek help from the church than from any other
community service when addressing family problems, depression, worry, or fear
(Starrett et al., 1992).
Clergy as traumatologists
At the same time that most Americans turn to their faith to cope with trauma
(Schuster et al., 2001; Weinrich et al., 1990), they are also turning to the clergy to
help them do so. In this way, the clergy are perhaps the first traumatologists.
Indeed, chaplains have been part of armies, police and other uniformed services
for centuries. Members of the faith community have a long history of helping in
times of grief, crisis, and trauma.
Indeed, clergy are front-line mental health workers for millions of Americans
and play a prominent role in community mental health (Weaver, 1995). The
353,000 Christian and Jewish clergy in the United States (4,000 rabbis, 49,000
Catholic priests and 300,000 Protestant ministers, according to the US
Review of religion and trauma literature 217

Department of Labor, 1998) are among the most trusted professionals in society
(Gallup & Lindsay, 1999). The US Surgeon General’s recent Report on Mental
Health found that each year one in six adults and one in five children obtain
mental health services either from a health care provider, the clergy, a social
service agency or a school (Satcher, 2000). Clergy are most often called upon in
crisis situations associated with grief, depression, or trauma reactions, such as
personal illness or injury, death of a spouse or close relative, divorce or marital
separation, serious change in health of a family member or death of a close friend
(Weaver et al., 1999; Weaver et al., 2002). People in crisis involving the ‘death of
someone close’ reported almost five times more likelihood of seeking the aid of a
clergyperson (54%) than all other mental health sources combined (54% vs. 11%)
(Veroff et al., 1981).
Purpose of the Study
Given the role religion and spirituality have been found to play in dealing with
personal crisis and traumatic stress, the authors conducted a systematic review of
articles on religion and spirituality in the Journal of Traumatic Stress during the
most recent decade. The Journal of Traumatic Stress was the focus of the review
because it is the pre-eminent journal in the field of traumatology, and the official
journal of the International Society for Traumatic Stress Studies.
The purpose of the study was to answer the following questions. (1) How
frequently were issues associated with religion and spirituality discussed in articles
published in the journal in the 1990s? The answer provides a rough measure of
the relative importance of these topics to psychological researchers working in this
field. (2) Were there any differences in frequency between research and non-
research articles that addressed religion and spirituality? The answer may help
determine the degree of interest in the topics among researchers compared to
non-researchers, such as practitioners. (3) What differences were there in the way
qualitative and quantitative studies operationalized the concepts of religion and
spirituality? The answer may help suggest better ways to measure the two
concepts. (4) Were there any differences in frequency between the first and
second half of the 1990s decade? The answer may help determine the trend of
publishing more or fewer articles with this focus. (5) Collectively, what do these
articles tell us about the connection between trauma and religion/spirituality? The
answer will help to characterize the contributions of traumatologists to the
interface of the fields of traumatology and religious studies and to the emerging
understanding of the general role of faith in trauma recovery.
Methods
All articles in the Journal of Traumatic Stress that were published between 1990
and 1999 were examined and read, except for editorials and commentaries. Each
was identified as being either research or non-research in content. Research articles

were defined as those containing a statement of purpose and a description
of research methods and findings/results, regardless of whether such topical
headings were present. Articles were further classified as either qualitative or
quantitative research. To be consistent with the methodology used in other
research reviews on religion and spirituality, studies were identified as
quantitative if they contained descriptive or inferential statistics (Weaver et al.,
1998) and qualitative if they discussed observations and other data but did not
utilize statistics. Articles that did not contain method or result sections or report
study findings were classified as non-research articles. These included articles
that described programs or treatments and review articles.
All articles included in the study were also classified with respect to whether
they mentioned religion. The following keywords were utilized: religious belief;
practice; affiliation; spirituality; spiritual health; spiritual distress; and spiritual
needs. Those articles that mentioned either religion or spirituality were combined
in the analyses.
To ensure the reliability of the review, randomly selected articles from each
journal year were evaluated by two trained reviewers and coded separately. Initial
agreement on the articles to be included in the survey and their classification were
both greater than 98%.
Results
Research vs. non-research articles
A total of 469 articles were examined and read, of which 400 (85.3%) were
classified as research and the remainder were classified as non-research articles
(see Table 1). Some 85.5% of the non-research articles were general topical
reviews, while the remaining 14.5% described specific treatments and programs.
Among the 400 research papers that were examined, 91.5% were quantitative and
8.5% were qualitative studies.
In total, 4.1% of all articles published in the Journal of Traumatic Stress
during the 1990s addressed some aspect of religion or spirituality. About 8.7% of
non-research articles, 4.1% of quantitative research studies and 2.9% of
qualitative research studies mentioned religion to some extent (see Table 1).
All research articles that referred to religion or spirituality contained at least one
empirical measure of these concepts (e.g., religious affiliation, worship
attendance, scripture reading, spiritual distress, prayer, faith in God). Despite
the proportionately greater number of non-research articles that mentioned
religion/spirituality, this difference was not statistically significant according to the
Chi-square test.
While three of the six non-research articles that addressed religion or
spirituality made only a passing mention of them, the other three (Obenchain &
Silver, 1992; Johnson et al., 1995; Weaver et al., 1996) gave considerable discus-
sion to these concepts.

There was wide variation in the extent to which research articles dealing with
religion/spirituality approached and dealt with these concepts. Seven of the 15
quantitative studies that measured religion/spirituality only measured religious
affiliation, and none of these contained citations from the literature on religion
and health (see Table 2). Three of the 15 studies used two questions about
religion or spirituality and two of the three studies that measured religious coping
used multiple-item scales as their dependent measure (Bjork & Klewicki, 1997;
Murphy, et al., 1999). In all, only three quantitative studies cited one or more
articles from the religion and health literature.
Analysis of variance revealed a significant overall increase in the percentage of
all articles that mentioned religion/spirituality between the first half (1990–1994)
and the second half (1995–1999) of the study period, F(1,8) ¼ 6.41, p < 0.05.
Whereas, only 3.2% of all the articles published between 1990 and 1994
mentioned religion/spirituality, on average, 6.0% did so between 1995 and 1999.
Non-research articles showed the greatest change, increasing from a mean of
3.8% in 1990–1994 to 9.5% in 1995–1999. Research studies containing religious/
spiritual variables increased from 3.0% in 1990–1994 to 4.5% in 1995–1999.
The quantitative analysis naturally leads to a consideration of what these
articles on religion/spirituality say about salient clinical issues. The subjects
include religious and spiritual coping among emergency workers and genocide
survivors, spiritual growth after traumatic events and collaboration with clergy.
Two non-research articles, which discussed the use of rituals and ceremonies in
treatment, are also worth noting.
Genocide survivors
Two quantitative research studies in our sample addressed the use of religion and
spirituality when coping with the horrific and lasting effects of witnessing
genocide. Carmil & Breznitz (1991) analyzed a random national sample of 533
Jews of European origin, based on the Israel Central Bureau of Statistics. When
they compared Holocaust survivors and their children to two control groups in
TABLE 1. Number of different types of articles published in Journal of Traumatic Stress in
1990-1999 and the number and percentage of those that mentioned religion or spirituality
All Articles Articles Containing Religion/Spirituality
Number Number Percent
Non-research Articles 69 6 8.7%
General Topical 59 4 6.8%
Treatment or Program 10 2 20.0%
Research Articles 400 16 4.0%
Qualitative 34 1 2.9%
Quantitative 366 15 4.1%
All Articles 469 22 4.7%

regard to religious identity and future orientation, they found that both survivors
and their children expressed significantly greater belief in God and hope in the
future than did the controls.
Hope for a better future was strongly related to belief in God
In a separate study Kalayjian et al. (1996) interviewed 36 elderly Armenian-
Americans who survived the Ottoman-Turkish genocide during the First World
War. On the killing of 1.5 million Armenians, most of the adults, with a mean age
of 88.6, had personal memories of witnessing death and torture as children. They
were asked, ‘What do you feel gave you the strength to endure this difficulty?’
Religion or spirituality was the most frequent response (39%), followed by group
support (14%). The researchers reported that ‘[s]trength, inspired by prayer and
faith in the Almighty, was both a source of energy for coping and a coping
method’ (p. 92).
Emergency Workers
In the United States, it is estimated that there are 450,000 trained emergency
medical workers who may experience frequent, repetitive, and cumulative
exposure to trauma and high levels of extreme stress (McCammon & Murphy,
1995). Emergency workers must cope with persistent threats to their safety and
that of their co-workers, gruesome victim incidents, injuries to/death of children,
multiple causality events and body handling.
TABLE 2. Quantitative research containing religious or spiritual variables published in the Journal of
Traumatic Stress between 1990 and 1999
Research Topic Research Method Spiritual and Religious Variables
Altruism and PTSD Symptomology Questionnaire Religious Affiliation
Childhood Sexual Abuse Questionnaire Religious Affiliation
Japanese American Internment Questionnaire Religious Affiliation
Partners’ Recognition of PTSD Questionnaire Religious Affiliation
Predisposition to PTSD Questionnaire Religious Affiliation
Treatment Outcomes Experiment Religious Affiliation
Utilization of Mental Health Services Questionnaire Religious Affiliation
Armenians’ Coping with Genocide Interview Religious Coping
Bereaved Parents Questionnaire Religious Coping
Type of Stressor and Coping Experiment Religious Coping
Battered Women Questionnaire Support from Clergy
Bone Marrow Transplant Interview Relationship with God
Emergency Workers Questionnaire Meaning in Work and
Reliance on Religion
Holocaust Survivors Questionnaire Religious Identification and
Belief in God
Personal and Spiritual Growth Questionnaire Strength of Faith and
Spiritual Understanding

Beaton et al. (1999), who examined 220 urban fire fighters to understand their
coping strategies, found that religion and spirituality emerged as components of
two different factors on their scale of the coping responses of rescue workers. The
first was in relation to workers’ appraisal of their experience of specific events,
their outlook about their jobs and the meaning of life in general. The second was
more specifically related to the introspective modes of coping used by the
workers. This is consistent with other findings that emergency medical personnel
who work with the traumatized have high rates of religious belief and practice
(Backus et al., 1995).
Spiritual Growth
There is research suggesting that some people exposed to traumatic events
perceive benefits coming as a result of their difficulties, including an increased
appreciation for being alive (Janoff-Bulman & Frantz, 1997). Among survivors of
a cruise ship sunk at sea, more than 7 in 10 indicated that they enjoyed each day
of their life to the fullest as a result of the traumatic experience (Joseph et al.,
1993). Other studies have found that survivors often rely upon their faith for help
in crisis situations, leading to increased meaning and purpose in life (Pargament,
1997).
Among our sample of articles, one described the development of a
Posttraumatic Growth Inventory (PGI) to assess possible positive effects
(including spiritual growth) in persons who experience traumatic events
(Tedeschi & Calhoun, 1996). The researchers investigated 404 men and
women who reported a significant traumatic experience in the past 5 years.
Ninety-two per cent of this group of college students was single and all were
between the ages of 17 and 25. The 21-item scale analysed five categories:
personal strength; appreciation of life; relating to others; spiritual change; and
new possibilities. Women college students scored higher than the men on the PGI
suggesting that males and females differ in their response to traumatic events.
Factor analysis indicated that the greatest difference between men and women
occurred in the areas of relating to others and spiritual change. This is generally
consistent with population survey findings that women are more religious than
men (Gallup & Lindsay, 1999).
Clergy
One quantitative research article mentioned the role of clergy as counsellors to
incarcerated women in California, but did not present data on this topic
(O’Keefe, 1998). A non-research review article focused its discussion on the need
for collaboration between clergy and mental health specialists working with
survivors of traumatic events (Weaver et al., 1996). Rabbis, priests, imams and
ministers are often in long-term relationships with individuals and their families,
giving them ongoing contacts in which they can observe changes in behaviour that
may greatly assist in the assessment of PTSD. They are visible and available

caregivers in communities that offer a sense of continuity with centuries of human
history and an established pattern of responding to crises. Unfortunately, despite
substantial evidence that clergy are extensively involved with the care of persons
exposed to traumatic events, there continues to be little published research in the
mental health literature on the topic (Weaver et al., 1996).
Rituals and Ceremonies
Two non-research articles addressed the therapeutic use of ceremony in the
treatment of PTSD for Vietnam veterans, using knowledge gained from Western
spiritual and Native American rituals. In Veterans Affairs Medical Centers in
Pennsylvania (Obenchain & Silver, 1992) and Connecticut (Johnson et al., 1995),
clinicians reported that the ceremonies were highly effective in accessing and
managing intense emotions that fostered therapeutic work. One ritual called the
‘Ceremony for the Dead’ used religious images and included the words, ‘It is now
the time to release the souls of the dead to God and to the earth.’ The rituals
enhanced social bonds within the veteran groups, their families and with staff. At
discharge, veterans reported that the ceremonies and rituals were of the most
therapeutic value of any treatment offered, including group treatment, individual
therapy and medications (Johnson et al., 1995).
Discussion
The answer to our first question of interest was, 4.7% of all articles that appeared
in the Journal of Traumatic Stress in the 1990s dealt with religion or spirituality to
some degree. There is only limited data to compare with this finding, since most
reviews of this kind have been restricted to research studies alone. But this
percentage is not much lower than we found (5.1%) for all articles published
between 1991 and 1997 in Geriatric Nursing and the Journal of Gerontological
Nursing (Weaver et al., 2001).
In relation to our second question, however, the research studies in those
journals were more likely than non-research articles to address religion (7.7%
versus 2.8%). Non-research articles in the present study were more likely than
research articles to address religion/spirituality (8.7% versus 4.0%), but this
difference was not statistically significant. This might suggest that practitioners in
the field of traumatology are somewhat more interested in religion and spirituality
than their research counterparts.
The third question we posed was whether differences between quantitative
and qualitative studies might provide insight into ways in which the concepts of
religion and spirituality are operationalized. Since only one qualitative study was
found that measured religion, the question would appear to be moot. However, in
Table 2 we see that the quantitative studies themselves looked at religion and
spirituality in different ways. Nearly half only looked at religious affiliation. Since
these same studies did not cite any literature on religion, the measurement of

religion was clearly incidental to the research. Only a few studies used multiple-
item measures of religion and citations of research on religion were rare, probably
because religion/spirituality were not central to the purpose of the research. Yet,
even the one study we found that contained the term ‘religious beliefs’ in its title
had only one citation on religion.
The fourth question we asked was whether the frequency of articles on religion
and spirituality would change over time. Our analyses revealed that significantly
greater attention has been given to religion/spirituality during the last half of the
past decade, with non-research articles leading the change in this direction.
With respect to our fifth question, although the number of studies addressing
religion/spirituality was relatively few, their findings provide important contribu-
tions to the field of traumatology and to mental health and the social sciences
generally. Compared to such fields as nursing (Flannelly et al., 2002; Weaver
et al., 1998; Weaver et al., 2001) and family therapy (Weaver et al., 2002b), the
rate of quantitative studies in the Journal of Traumatic Stress that measured
religion is low, but the rate is somewhat higher than that published in psychology
(2.7%) and psychiatry (1.2%) in the 1990s (Weaver et al., 1998). Indeed, the low
rate of such studies in the Journal of Traumatic Stress may reflect the fact that many
of the researchers in the field are psychologists and psychiatrists—professional
groups who tend to have low rates of religious involvement (Politics of the
professoriate, 1991) and who traditionally receive very little exposure to religious
issues in their professional training (Sansone et al., 1990; Shafranske & Maloney,
1990).
Research is needed to understand the role of religious community and
spiritual practice among refugees, especially since these groups report that their
faith involvement is a strong protective factor against distress (Holtz, 1998;
Hovey, 2000). Research also is needed to better understand the role of religion
and spirituality for ethnic minority survivors of traumatic events, especially since
these groups have much higher rates of involvement in faith communities than
does the general population (Gallup & Lindsay, 1999). Only one study in the
sample addressed these populations.
Given the importance of faith to children and adolescents and their exposure
to stress and trauma, researchers need to help us understand the effects on
adolescents of psychological trauma from exposure to violence and how religious
involvement may or may not be helpful. The role of magical thinking (e.g., Terr,
1988) in the way children conceptualize and cope with trauma should be
thoroughly investigated in light of the importance of spirituality in adapting to
traumatic memories.
In the past few years several studies in the Journal of Traumatic Stress have
employed multiple regression analyses to model the influence of various factors
on aspects of PTSD in veterans (e.g., Flack et al., 2000; Litz et al., 1997; Radnitz
et al., 1998). Another study used multiple regression modelling to determine the
relative contributions of an array of variables (including experiential, social,
psychological and physiological variables) on the PTSD symptoms displayed by
women following treatment for breast cancer (Andrykowski & Cordova, 1998).

The inclusion of religion and spirituality among the variables tested in such
models would be of interest. For example, a multiple regression model of
psychological adjustment after a traumatic event that included measures of
religious beliefs and practices, along with measures of physical health, social
support and demographic variables, would be able to estimate the unique
contribution of religion to healthy psychological functioning after removing the
effects of other factors—such as physical health, social support, age and
education. Indeed, a study in the Journal of Traumatic Stress by Calhoun et al.
(2000) that used multiple regression found that religion made a unique, positive
contribution to recovering from PTSD.
At the same time that more traumatologists recognize and study the role of
spirituality in recognizing, recovering from and being inspired by trauma, it is
important that the faith community recognize and study the role of trauma in the
spiritual health and practice of people of faith. For example, Keshgegian’s (5)
recent book, Redeeming Memories: A Theology of Healing and Transformation, notes
that ‘trauma theory’ helps the faith community understand that trauma can
happen to everyone and is most often beyond the control of the traumatized.
Acknowledgements
This article is dedicated to the renowned human rights activist of Guatemala,
Bishop Juan Gerardi Conedera who was bludgeoned to death outside his home in
April 1998, two days after publishing a report finding that most of the 200,000
deaths during Guatemala’s 36-year civil war were the responsibility of the
country’s armed forces (1 Thess. 4:13–18). We are deeply grateful to The Clark
Foundation, The Henry Luce Foundation Inc. and the Fannie E. Rippel
Foundation for their generous and long-time support of The HealthCare
Chaplaincy. We wish to also express our gratitude to The Rev. Carolyn L.
Stapleton, Eileen Gorey, R.N., M.P.H. and Lisa Matsumoto, M.LIS. for their
generous help in the development of this project, and Julia E. Oppenheimer, B.A.
and Karen G. Costa, B.A. for their assistance preparing and editing the
manuscript.
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