Category: Nevin Manimala

Bull Menninger Clin. 2025 Fall;89(4):262-281. doi: 10.1521/bumc.2025.89.4.262.

ABSTRACT

Cultural competence is crucial for achieving health equity in mental health care, as systemic barriers and sociocultural factors significantly impact access, diagnosis, and treatment. This paper examines cultural competence and related concepts, including cultural humility, cultural safety, and structural competence, while addressing critiques and misconceptions. We examine its applications at micro, meso, and macro levels, emphasizing its role in diverse clinical settings. In mental health assessment, frameworks like the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision’s (DSM-5-TR) Outline for Cultural Formulation and the Contextual Formulation highlight the importance of understanding patients’ cultural identities and values. In psychotherapy, cultural adaptations, including mindfulness-based interventions such as acceptance and commitment therapy (ACT), can enhance effectiveness. At the systemic level, we advocate for inclusive organizational practices, ongoing training, and policies that address structural inequities. Integrating cultural competence into mental health care enables clinicians and institutions to better serve diverse populations.

PMID:41343231 | DOI:10.1521/bumc.2025.89.4.262

JAMA Netw Open. 2025 Dec 1;8(12):e2544515. doi: 10.1001/jamanetworkopen.2025.44515.

ABSTRACT

IMPORTANCE: Preexposure prophylaxis (PrEP) is highly effective at preventing HIV-1 when taken as prescribed; however, barriers to uptake persist.

OBJECTIVE: To assess clinical practice formulary coverage and PrEP uptake barriers and the association between those factors and cumulative HIV-1 incidence.

DESIGN, SETTING, AND PARTICIPANTS: Retrospective observational cohort study from January 2021 to December 2023 using US pharmacy claims data from HIV-1-negative adults who received daily oral brand emtricitabine and tenofovir disoproxil fumarate (F/TDF), generic F/TDF (gF/TDF), or emtricitabine and tenofovir alafenamide fumarate (F/TAF), or intramuscular injection of cabotegravir every 2 months, for PrEP (after a 180-day washout period for previous PrEP use).

EXPOSURES: Formulary coverage evaluated by claim rejection reasons, dispensing status (dispensed, rejected, or abandoned), payer types, and copayment costs.

MAIN OUTCOMES AND MEASURES: HIV-1 incidence was described based on PrEP dispensing status. Logistic regression was used to estimate odds ratios (ORs) and 95% CIs of dispensing PrEP claims across key demographic and formulary characteristics.

RESULTS: Overall, 399 902 individuals with 2 680 545 PrEP claims were analyzed. A total of 348 773 (87.2%) were male; 281 452 (70.4%) were aged 18 to 39 years; 42 549 10.6%] lived in predominantly Hispanic neighborhoods, 4114 [1.0%] lived in predominantly non-Hispanic Asian and Pacific Islander neighborhoods, 20 214 [5.1%] lived in predominantly non-Hispanic Black neighborhoods, and 238 292 [59.6%] lived in predominantly non-Hispanic White neighborhoods). Of 265 833 individuals with 12 or more months of follow-up, 238 271 (89.6%) had 1 or more PrEP claims dispensed (DISP), 17 917 (6.7%) never had PrEP dispensed with 50% or more of claims rejected by payer (ND-R), and 9645 (3.6%) never had PrEP dispensed with more than 50% of claims abandoned (ND-A). Individuals in the ND-R and ND-A groups had higher HIV-1 incidence (662 [3.7%] and 270 [2.8%], respectively) vs the DISP group (4811 [2.0%]). In the DISP group, a 1- to 7-day dispensation delay was associated with higher odds of acquiring HIV-1 (OR, 1.29; 95% CI, 1.13-1.47). Most claims were for gF/TDF (1 400 389 claims [52.2%]); compared with gF/TDF, the likelihood of claims being dispensed was lower for other PrEP regimens (brand F/TDF: OR, 0.36; 95% CI, 0.36-0.37; cabotegravir: OR, 0.52; 95% CI, 0.49-0.55; F/TAF: OR, 0.93; 95% CI, 0.91-0.95). As cost sharing increased, the likelihood of dispensation decreased. The most common reason for claim rejection was that the product was not covered by the formulary (49 690 rejected claims [29.2%]).

CONCLUSIONS AND RELEVANCE: In this cohort study, HIV-1 incidence was higher in individuals with abandoned or rejected PrEP claims compared with those with dispensed claims. These findings highlight the importance of targeted strategies to improve PrEP claim dispensation and remove payer barriers to reduce HIV-1 transmission.

PMID:41343217 | DOI:10.1001/jamanetworkopen.2025.44515

JAMA Netw Open. 2025 Dec 1;8(12):e2546517. doi: 10.1001/jamanetworkopen.2025.46517.

ABSTRACT

IMPORTANCE: The US Food and Drug Administration (FDA) has recommended, but not required, age ranges for pediatric age labeling in devices, despite regulation existing for drugs, and this policy perpetuates off-label use of devices and creates several issues in practice for safety and monitoring. Proper device labeling is an important regulatory component that impacts risk stratification, clinical use, marketing, and reimbursement.

OBJECTIVE: To evaluate the variability in pediatric medical device age labeling among all pediatric class III devices approved by the FDA from 2008 to 2017 and their adherence to nonbinding FDA age range recommendations, and to review the device type, clinical use, and whether the pediatric population was included in clinical trials.

DESIGN, SETTING, AND PARTICIPANTS: This retrospective cross-sectional study reviewed data from public databases to understand pediatric age labeling practices. Data included in the 2008 to 2017 Reports to Congress: Premarket Approval of Pediatric Uses of Devices were reviewed in 2022. Additional data were extracted from the FDA Databases. Two physicians independently reviewed the data and assigned clinical descriptors to each device. Descriptive analysis was performed.

EXPOSURE: Device approval by the FDA from 2008 to 2017.

MAIN OUTCOMES AND MEASURES: The primary outcomes were whether approved devices had age labeling, whether they described the approved pediatric population, and whether pediatric populations were included in clinical studies of the devices. Pairwise comparison was done with Student t test and P < .05 to indicate statistically significant differences.

RESULTS: Of 101 unique devices, 26 (25.7%) did not include any specific age ranges and among the remaining 75 devices, 51 (50.5%) were not indicated for patients younger than 18 years. There was significant variation in age labeling, with only 4 devices using fully structured age ranges (eg, 2 to 17 years). Only 8 (7.9%) devices used the FDA recommended pediatric age ranges. The review of clinical trials evaluating device safety and efficacy revealed that 60 (59.4%) included pediatric patients (aged 0 to <22 years); however, only 33 (32.7%) included patients younger than 18 years. In contrast, the Indications For Use statements for the same devices indicate 52 (51.5%) did not include any specific age ranges and 29 (28.7%) were indicated for adults 18 years or older.

CONCLUSIONS AND RELEVANCE: In this cross-sectional analysis of devices included the 2008 to 2017 Reports to Congress, most high-risk devices were not evaluated or specifically indicated for children younger than 18 years. This poses substantial problems for clinical use, reimbursement, research, and policy evaluation. To address this gap, the FDA should establish pediatric labeling requirements that consider age and other relevant factors.

PMID:41343216 | DOI:10.1001/jamanetworkopen.2025.46517

JAMA Netw Open. 2025 Dec 1;8(12):e2546822. doi: 10.1001/jamanetworkopen.2025.46822.

ABSTRACT

IMPORTANCE: While several studies have assessed the impact of COVID-19 vaccination on short-term mortality, none have compared long-term mortality by vaccination status, particularly in young individuals who are less likely to experience severe disease following SARS-CoV-2 infection.

OBJECTIVE: To compare 4-year all-cause mortality in individuals aged 18 to 59 years vaccinated with the mRNA COVID-19 vaccine vs unvaccinated individuals.

DESIGN, SETTING, AND PARTICIPANTS: This cohort study used data from the French National Health Data System for all individuals in the French population aged 18 to 59 years who were alive on November 1, 2021. Data analysis was conducted from June 2024 to September 2025.

EXPOSURE: Exposure was defined as receiving a first mRNA dose between May 1 and October 31, 2021. Individuals who were unvaccinated by November 1, 2021, were assigned a random index date based on vaccinated individuals’ vaccination dates.

MAIN OUTCOMES AND MEASURES: Cox models weighted for sociodemographic characteristics and 41 comorbidities were used to estimate 4-year all-cause mortality. Time to event was censored at all-cause death, COVID-19 vaccination for unexposed individuals, or study termination on March 31, 2025. Complementary analyses were performed, including a comparison of the main causes of death available up to December 31, 2023. Follow-up began 6 months after the index date in both groups to address immortal time bias. Short-term mortality within 6 months after vaccination was assessed in a separate, independent study using adapted self-controlled case series models.

RESULTS: A total of 22 767 546 vaccinated and 5 932 443 unvaccinated individuals were followed up for a median (IQR) of 45 (44-46) months. Vaccinated individuals were older than unvaccinated individuals (mean [SD] age, 38.0 [11.8] years vs 37.1 [11.4] years), more frequently women (11 688 603 [51.3%] vs 2 876 039 [48.5%]) and had more cardiometabolic comorbidities (2 126 250 [9.3%] vs 464 596 [7.8%]). During follow-up, 98 429 (0.4%) and 32 662 (0.6%) all-cause deaths occurred in the vaccinated and unvaccinated groups, respectively. Vaccinated individuals had a 74% lower risk of death from severe COVID-19 (weighted hazard ratio [wHR], 0.26 [95% CI, 0.22-0.30]) and a 25% lower risk of all-cause mortality (wHR, 0.75 [95% CI, 0.75-0.76]), with a similar association observed when excluding severe COVID-19 death. Sensitivity analysis revealed that vaccinated individuals consistently had a lower risk of death, regardless of the cause. Mortality was 29% lower within 6 months following COVID-19 vaccination (relative incidence, 0.71 [95% CI, 0.69-0.73]).

CONCLUSIONS AND RELEVANCE: In this national cohort study of 28 million individuals, the results found no increased risk of 4-year all-cause mortality in individuals aged 18 to 59 years vaccinated against COVID-19, further supporting the safety of the mRNA vaccines that are widely used worldwide.

PMID:41343214 | DOI:10.1001/jamanetworkopen.2025.46822

JAMA Netw Open. 2025 Dec 1;8(12):e2546865. doi: 10.1001/jamanetworkopen.2025.46865.

ABSTRACT

IMPORTANCE: Sodium-glucose cotransporter-2 inhibitors have emerged as important therapeutic options for heart failure (HF). However, their comparative clinical effectiveness remains uncertain.

OBJECTIVE: To compare the outcomes associated with dapagliflozin and empagliflozin use in patients diagnosed with HF.

DESIGN, SETTING, AND PARTICIPANTS: This cohort study used a clinical data warehouse platform shared by 8 medical centers affiliated with The Catholic University of Korea to screen all patients who were diagnosed with HF between January 2021 and November 2023 at these 8 medical centers. Patients were taking either dapagliflozin or empagliflozin and underwent transthoracic echocardiography. One-to-one propensity score matching was performed to ensure comparable baseline characteristics between groups. The propensity score-matched cohort was stratified by left ventricular ejection fraction (LVEF) into subgroups: HF with reduced ejection fraction group had an LVEF of 40% or lower, HF with mildly reduced ejection fraction group had an LVEF of 41% to 49%, and HF with preserved ejection fraction group had an LVEF of 50% or higher. Statistical analyses were performed from December 2023 to July 2025.

EXPOSURE: All patients received either dapagliflozin or empagliflozin.

MAIN OUTCOMES AND MEASURES: The primary outcome was a composite of cardiovascular death or hospitalization for heart failure. Secondary outcomes included the individual primary outcome components, all-cause death, and cardiovascular hospitalization.

RESULTS: After propensity score matching, the balanced cohort included 4930 patients (2465 each in the dapagliflozin and empagliflozin group; mean [SD] age, 68.8 [13.4] years; 2944 males [59.7%]). The median (IQR) follow-up duration was 16.0 (8.0-27.0) months. In the propensity score-matched cohort, dapagliflozin and empagliflozin showed no significant difference in the primary outcome: a composite of cardiovascular death or HF hospitalization occurred in 9.8% of patients (241 of 2465) taking dapagliflozin vs 9.3% of patients (229 of 2465) taking empagliflozin (adjusted hazard ratio [AHR], 0.99; 95% CI, 0.83-1.19; P = .95). The results did not change after stratifying the cohort by LVEF 40% or lower (14.9% [126 of 844] vs 15.4% [132 of 855]; AHR, 1.06 [95% CI, 0.83-1.35; P = .64]), LVEF 41% to 49% (5.0% [17 of 343] vs 6.3% [22 of 350]; AHR, 1.28 [95% CI, 0.68-2.42; P = .45]), and LVEF 50% or higher (7.7% [98 of 1278] vs 6.0% [75 of 1260]; AHR, 0.80 [95% CI, 0.60-1.09; P = .32]), without between-group heterogeneity (P for interaction = .32). For the secondary outcomes, there were also no significant differences between the dapagliflozin and empagliflozin groups.

CONCLUSIONS AND RELEVANCE: In this cohort study of patients with HF, dapagliflozin and empagliflozin had similar clinical outcomes in HF management. Further research and clinical trials are necessary to validate these findings and inform clinical decision-making.

PMID:41343213 | DOI:10.1001/jamanetworkopen.2025.46865

JAMA Netw Open. 2025 Dec 1;8(12):e2546876. doi: 10.1001/jamanetworkopen.2025.46876.

ABSTRACT

IMPORTANCE: Medicaid eligibility for nursing home care is determined in part by an individual’s (or a couples’, if married) financial resources, including income and assets. To qualify, individuals must “spend down” their resources to meet states’ Medicaid eligibility asset thresholds. Little empirical work has examined the rate of Medicaid spend-down in nursing homes over the past 2 decades.

OBJECTIVE: To identify the rate of spend-down in nursing homes, defined as the share of total residents who began their stay as non-Medicaid enrolled (after accounting for Medicare-covered skilled nursing facility [SNF] days, where applicable) and became Medicaid enrolled before discharge or death.

DESIGN, SETTING, AND PARTICIPANTS: This cohort study used a combination of administrative, enrollment, and claims data from 2018 to 2022 to build a panel of 191 416 US nursing home residents enrolled in traditional Medicare-including those admitted for postacute and long-term care-who newly entered a facility in 2018 and either stayed beyond their Medicare SNF days or did not have any Medicare-covered SNF days. Statistical analysis was performed from July 2024 to October 2025.

EXPOSURE: Newly entering a nursing home in 2018 as non-Medicaid enrolled.

MAIN OUTCOMES AND MEASURES: The main outcome was whether an individual spent down their assets and became enrolled in Medicaid during their nursing home stay. Multivariate regression was used to identify factors associated with spend-down.

RESULTS: The study included 191 416 individuals (mean [SD] age at time of admission, 81.0 [11.4] years; 58.0% women; mean [SD] time in nursing home, 331.0 [485.8] days) with traditional Medicare who newly entered a nursing home in 2018, of whom 33.9% either began their stay as Medicaid enrolled or enrolled in Medicaid after the completion of their Medicare-covered SNF days. The remaining 66.2% of individuals were initially not enrolled in Medicaid on admission or after the completion of their Medicare-covered SNF days. Of those who were initially not Medicaid enrolled, 16.4% spent down their assets during their stay and enrolled in Medicaid (mean [SD] time to spend-down, 6.1 [7.9] months). The likelihood of spend-down increased with length of stay and was higher among Black, Hispanic, North American Native, and younger residents.

CONCLUSIONS AND RELEVANCE: In this cohort study of nursing home residents, those who entered a nursing home as initially non-Medicaid enrolled, especially those with longer stays, were at risk of spending down their assets and enrolling in Medicaid. This finding raises concerns both about individuals impoverishing themselves because of the high cost of care and the long-term financial sustainability of the Medicaid program.

PMID:41343212 | DOI:10.1001/jamanetworkopen.2025.46876

JAMA Netw Open. 2025 Dec 1;8(12):e2546883. doi: 10.1001/jamanetworkopen.2025.46883.

ABSTRACT

IMPORTANCE: Limited evidence exists concerning access to abortion facilities from Native lands. To address this gap, travel times from Native lands to abortion facilities before and after the Dobbs v Jackson Women’s Health Organization (Dobbs) decision were compared.

OBJECTIVE: To compare travel times to abortion facilities from Native lands before and after the Dobbs decision.

DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study, conducted from July 1, 2023, to September 30, 2025, measured the proportion of Native lands served by abortion facilities (coverage) and the minimum travel times to abortion facilities. For coverage, the census-designated Native lands (N = 650) within and outside 30-, 60-, and 90-minute drive times to an abortion facility were quantified. For minimum travel, the drive times from Tribal headquarters (N = 577) and Native land population-weighted centroids (N = 650) to the nearest facility were estimated.

MAIN OUTCOMES AND MEASURES: The primary outcomes were the estimates of the median travel time from Native lands to the nearest abortion facility and the pre- and post-Dobbs differences in the contiguous US. Primary analyses compared median drive times in the contiguous US before and after Dobbs. The pre-Dobbs period included facilities active in 2021, while the post-Dobbs period excluded facilities in states with total abortion bans (n = 14) or total or 6-week bans (n = 16) in effect as of October 31, 2023. For Alaska and Hawaii, Euclidean distance was estimated to account for varied travel modes; because no such bans were imposed, pre- and post-Dobbs differences were not examined.

RESULTS: Across 650 Native lands, with an estimated 950 991 female residents of reproductive age (15-44 years), less than half (289 [44.5%]) were within a 90-minute drive of any abortion facility after Dobbs. In the contiguous US, the median drive time significantly increased from 65.5 minutes (IQR, 31.9-103.1 minutes) before Dobbs to 72.3 minutes (IQR, 32.5-147.3 minutes) (total bans only) and 74.0 minutes (IQR, 32.6-152.4 minutes) (total and 6-week bans) after Dobbs. The median distance was 470.1 km (IQR, 270.7-665.9 km) in Alaska and 63.1 km (IQR, 22.9-179.1 km) in Hawaii, where 56.4% of Native lands (31 of 55) required travel to a different island.

CONCLUSIONS AND RELEVANCE: This cross-sectional study of access to abortion facilities from Native lands found that individuals on Native lands faced disproportionately long travel times to abortion facilities, which became longer after Dobbs. Addressing these inequities is critical for advancing health equity for Indigenous communities.

PMID:41343211 | DOI:10.1001/jamanetworkopen.2025.46883

JAMA Netw Open. 2025 Dec 1;8(12):e2547104. doi: 10.1001/jamanetworkopen.2025.47104.

ABSTRACT

IMPORTANCE: Pediatric obesity rates are rising, and adverse childhood experiences (ACEs) may contribute by promoting stress-induced weight gain. Few studies have examined the association of ACEs with body mass index (BMI) and youth-reported protective factors, particularly among Latinx and Hispanic youths, who face higher rates of ACEs and obesity.

OBJECTIVE: To evaluate the association of ACEs with BMI in a population-based cohort and determine whether youth-reported protective factors (eg, self-coping skills, caregiver or friend support, or overall support) moderate this association, with a focus on Latinx and Hispanic youths.

DESIGN, SETTING, AND PARTICIPANTS: This large, cross-sectional study of youths aged 11 to 12 years was conducted using year 2 data (July 2018 to March 2020) of the Adolescent Brain Cognitive Development (ABCD) study, a prospective, 10-year longitudinal, 21-site dataset comprised of a population-cohort of US youths. Data were analyzed between August 2024 and March 2025.

EXPOSURES: Cumulative ACEs (12 categories) and youth-reported protective factors (4 categories).

MAIN OUTCOME AND MEASURES: The primary outcome was the ability of self-reported protective factors to moderate the hypothesized association of ACEs with BMI in Latinx and Hispanic youths. Linear mixed-effects models explored associations of ACEs, protective factors, and ethnicity (ie, Latinx and Hispanic or non-Hispanic) with BMI, while controlling for confounders (eg, sex, age, puberty, and socioeconomic status).

RESULTS: There were 5435 youths with available data at ages 11 to 12 years (1141 Latinx and Hispanic [21.0%]; 2636 female [48.5%]; mean [SD] age, 143.1 [7.6] months). Compared with non-Hispanic youths, Latinx and Hispanic youths had greater BMI (mean [SD], 22.1 [5.0] vs 20.3 [4.6]; P < .001) and more ACEs (mean [SD], 2.1 [1.7] vs 1.7 [1.7]; P < .001). Across all youths, ACEs were significantly associated with BMI, with a 0.431 BMI increase for every 1.7-point increase (1 SD) in ACE score. In Latinx and Hispanic youths only, self-coping (β = -0.74; 95% CI, -1.03 to -0.46; P < .001), caregiver support (β = -0.38; 95% CI, -0.66 to -0.11; P = .006), and overall protective score (β = -0.55; 95% CI, -0.61 to -0.06; P < .001) moderated the association of ACEs with BMI.

CONCLUSIONS AND RELEVANCE: These findings highlight the clinical importance of early ACE screening to identify at-risk youths for targeted, trauma-informed weight management interventions, and gather support for the cultivation of resiliency-focused skills like self-coping and caregiver support. Pediatric obesity is a pressing public health issue, and these strategies hold potential to alter weight trajectories, which may improve health outcomes and reduce health disparities.

PMID:41343209 | DOI:10.1001/jamanetworkopen.2025.47104

J Glob Health. 2025 Dec 5;15:04326. doi: 10.7189/jogh.15.04326.

ABSTRACT

BACKGROUND: Most medical research on pneumonia in children focuses on those <5 years, leaving a gap in understanding pneumonia in children aged 5-9. We aimed to identify the characteristics of children from this age group who had pneumonia and required hospital care, including critical care service.

METHODS: In this retrospective chart analysis, we examined clinical, demographic, and laboratory characteristics of children aged 5-9 years with clinical and radiologic pneumonia admitted to Dhaka Hospital, International Centre for Diarrhoeal Disease Research, Bangladesh, from 2011 to 2020. We categorised the children into two groups: those who required critical care (admitted to the intensive care unit (ICU)) and those who did not. We compared the two groups to identify factors independently associated with the need for critical care using a log binomial regression model.

RESULTS: Among a total of 154 children who fulfilled the enrolment criteria, 34 were admitted to the ICU requiring critical care, and 120 children were treated in the inpatient ward, as they did not require any critical care. The median age of the children requiring critical care was 69 (interquartile range (IQR) = 60-81) months, compared to 72 (IQR = 62-84) months for those who didn`t require critical care (P = 0.259). Using a log binomial regression model we found hypoxemia (odds ratio (OR) = 10.1; 95% confidence interval (CI) = 1.42-71.92, P = 0.021), convulsion (OR = 281.37; 95% CI = 12.99-6091.72, P < 0.001], sepsis (OR = 27.69; 95% CI = 3.33-230.39, P = 0.002), hypokalaemia (OR = 10.37; 95% CI = 1.40-76.96, P = 0.022) were the independently associated with critical care service among children aged five to nine with pneumonia.

CONCLUSIONS: Our results suggest that early recognition and prompt treatment of hypoxemia, convulsions, sepsis, and hypokalaemia may significantly reduce the need for critical care and possibly avert fatal consequences in children with pneumonia, aged 5-9, especially in resource-limited settings.

PMID:41343207 | DOI:10.7189/jogh.15.04326

Am J Speech Lang Pathol. 2025 Dec 4:1-16. doi: 10.1044/2025_AJSLP-25-00141. Online ahead of print.

ABSTRACT

PURPOSE: The Speech Assessment of Children’s Home Language(s) (SACHL) offers a new, evidence-based clinical protocol for speech-language pathologists (SLPs) to assess speech in unfamiliar languages. This study used implementation science to investigate SLPs’ current multilingual speech assessment practices, determine the prospective acceptability of the SACHL, and compare current confidence to prospective confidence with the SACHL.

METHOD: The Consolidated Framework for Implementation Research and the Theoretical Framework of Acceptability were used to explore innovation deliverers’ (SLPs and student SLPs) prospective acceptability of the innovation (SACHL). Attendees at in-person and online SACHL presentations were invited to participate. A total of 360 participants responded to an online questionnaire exploring current practices, transcription skills, confidence, and acceptability of the SACHL. Statistical tests compared attendees at different presentations, SLPs and student SLPs, and monolingual and multilingual participants.

RESULTS: The majority of participants indicated low current confidence in assessing multilingual children. Most SLPs assessed, transcribed, and analyzed multilingual children’s speech in English but rarely or never applied these practices in children’s home language(s). The majority of participants rated the SACHL as being culturally responsive, well designed, and easy to understand and that it could increase diagnostic accuracy. There were concerns around the time burden in using the SACHL. Most (87.45%) indicated they would like to use the SACHL in clinical practice, and there was a statistically significant improvement between current confidence and prospective confidence.

SUPPLEMENTAL MATERIAL: https://doi.org/10.23641/asha.30716981.

PMID:41343205 | DOI:10.1044/2025_AJSLP-25-00141