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18 March 2026

13 Pages

Depressive Symptoms, Campus Connectedness, and Campus Climate Related to Sexual Violence and Misconduct

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1
Department of Public Health, Montclair State University, Montclair, NJ 07043, USA
2
Georgia Department of Public Health, Atlanta, GA 30303, USA
*
Author to whom correspondence should be addressed.
Youth2026, 6(1), 38;https://doi.org/10.3390/youth6010038
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Abstract

Depression, although a consequence of sexual violence, has not been studied in the context of college students’ views of campus sexual violence climate. Depression is one of the most prevalent and impairing mental health concerns among college students and has well-established links to sexual violence victimization; therefore, it serves as a theoretically and clinically meaningful focal outcome. Therefore, we assessed perceptions of institutional climate in the context of self-reported depression. Undergraduates (n = 716) reported perceptions and experiences of campus sexual violence and misconduct, connectedness, attitude, and depressive symptoms in an online survey. More than a third of participants reported elevated depressive symptoms. This was associated with campus connectedness and attitude, perceived campus climate, and personally experiencing rape, assault, or harassment. In a multivariate model, only the perceived climate variables did not retain significance. Elevated depressive symptoms were associated with connectedness and attitude towards the university and experiencing sexual harassment/assault. Understanding and explicitly addressing these connections may be beneficial for the effectiveness of campus prevention and intervention.

1. Introduction

Campus climate in relation to sexual violence and misconduct has been studied from multiple perspectives, seeking to make institutions of higher education (IHE) safer and more inclusive (Holland, 2020; Maier & DePrince, 2020; Marques et al., 2020; Mennicke et al., 2020; Neal, 2018). Campus climate, which is the shared perceptions of institutional norms, policies, and practices regarding sexual misconduct. It includes perceptions of institutional prevention efforts, administrative response, and peer norms, and is shaped by interactions of structural and historical factors, social norms, and perceptions, as well as individual-level factors (Moylan et al., 2021). Therefore, it is likely that students’ own attitudes, values, and personal experiences impact their view of the campus climate with respect to sexual violence and misconduct.
At the same time, depression among students has become a growing concern for IHEs (Kruisselbrink Flatt, 2013; Meeks et al., 2023; Sandra, 2019). As a known consequence of sexual violence (Angelone et al., 2018; Carey et al., 2018; Dworkin et al., 2017; Rothman et al., 2021; Sachs-Ericsson et al., 2014; Santaularia et al., 2014), depression may also independently affect students’ perceptions and experiences at college more broadly, including perceptions of the campus climate related to sexual violence and misconduct. Having a negative outlook and view of self is common to many individuals’ experiences of depression (Harmer & Browning, 2020; Kube et al., 2020; Symptoms—Depression in adults, 2021), and these views could influence their sense of safety on campus. Similarly, negative affect associated with depression could amplify negative responses to experiencing, witnessing, or even hearing about incidents of sexual violence on campus, or make such incidents feel more salient. Most importantly, as both depression and campus climate are dynamic over time, they may influence one another reciprocally.
Depression may be one such factor that affects perceived campus climate with respect to sexual violence and misconduct and is commonly assessed in campus health surveys. Thus, it may be a proxy for other stress measures. Although depression is known to be a common consequence of sexual violence (Angelone et al., 2018; Carey et al., 2018; Dworkin et al., 2017; Rothman et al., 2021; Sachs-Ericsson et al., 2014), it may also independently and significantly affect college students’ perceptions and experiences at college more broadly, including their perceptions of the campus climate related to sexual violence and misconduct. Having a negative outlook and view of self is common to many individuals’ experiences of depression (Harmer & Browning, 2020; Kube et al., 2020; Symptoms—Depression in adults, 2021), and these negative views could influence their sense of safety on campus.
There is a growing literature noting connections between depression and a number of constructs that impact students, including associations with student sense of belonging (Dutcher et al., 2022; Chavez et al., 2025; Fisher et al., 2015), academic disengagement (Tang & He, 2023; Sinval et al., 2025), health-seeking behaviors (Raposa et al., 2025; Boerema et al., 2016), and threat perception (Beevers et al., 2019; Gotlib & Joormann, 2010). While direct articles linking campus climate to psychological safety in sexual violence research are limited, several studies in the broader school climate literature operationalize “psychological safety” in terms of feeling supported, respected, and secure—core elements of climate perceptions. Leurent et al. (2021), for example, found that positive school climate perceptions, especially supportive adult and peer relationships and safety, are significantly associated with better emotional well-being and fewer mental health problems, consistent with constructs of psychological safety, while Martinsone et al. (2026) noted that perceptions of a supportive and safe school climate correlate with healthier mental health outcomes, reflecting enhanced psychological safety in educational settings.
Therefore, understanding how depression and perceived campus climate are related would help inform efforts to improve both campus climate and other aspects of students’ mental health, connecting individuals and groups on campus who prevent sexual assault and those who promote and support student mental health. In the growing body of research examining factors associated with perceptions of sexual violence at IHEs, the role of depression as a contextual factor has received limited attention. A campus climate survey at a public university on the East Coast investigating students’ perceptions of the institutional climate related to sexual violence and misconduct explored whether and how these perceptions are associated with self-reported depressive symptoms.
In light of the high prevalence of depression on college campuses (Lipson et al., 2022), as well as the ongoing attention being paid to campus climate regarding sexual violence (Alonso, n.d.; Cantor et al., n.d.; Cantor et al., 2019; de Heer & Jones, 2017; Silvera et al., 2024), it is important to understand whether and how depression and perceived campus climate are related. Understanding such a relationship could inform efforts to improve campus climate, as well as efforts to address students’ mental health. It also has the potential to inform and connect individuals and groups on campus who are involved in preventing sexual assault and those who promote student mental health.
This study analyzed data from a campus climate survey at a public university on the East Coast to investigate students’ perceptions of the university’s institutional climate related to sexual violence and examine whether and how these perceptions are associated with self-reported depressive symptoms.

2. Materials and Methods

2.1. Study Population

Undergraduate students with a valid university email were invited to complete an online survey in 2017. Survey questions included closed- and open-ended items, developed by the research team, modified from previous studies wherever possible (2015 Penn State sexual misconduct climate survey summary report, 2015; Cantor et al., 2019; Freyd et al., 2015), and the survey was approved by the university’s institutional review board (IRB).

2.2. Survey Methods and Materials

This cross-sectional study, which has previously been described in detail (Silvera et al., 2024), sought to examine potential predictors of student perception of campus sexual violence climate using questions about respondents’ demographics and background, participation in campus activities, sense of connectedness to and attitudes towards the university, personal experience of campus sexual violence, perception of the campus climate regarding sexual violence and misconduct, and depressive symptoms, as described in detail in the next section. These analyses focused on potential associations between self-reported depressive symptoms, campus connectedness, and perception of the campus climate related to sexual violence.
In the survey, we asked questions about the following demographic information: age; year in program (“What is your student status?”); self-reported race/ethnicity (two items: “Which best describes your race/choose all that apply, and do you identify as Hispanic/Latinx?”); commuter status (yes/no); sexual orientation (“What is your primary sexual orientation: heterosexual, lesbian, gay, bisexual, pansexual, or other?”); and gender (“Which best describes your gender: man, woman, genderqueer/non-conforming, transgender, prefer not to say, or other?”).
We also asked about participation in sports (“Which sport(s) did/do you play at the club or varsity level?”), Greek life (“Are or were you a member of Greek Life—Fraternity/Sorority?”), and other university activities (“Are you a member of any other clubs or student organizations, not including the Greek system or athletics?”).
The survey included two questions asking about participants’ sense of connectedness and attitude towards the university: “How would you describe how invested/connected/engaged you are with the [institution] community?” and “How would you describe your current attitude towards [institution]?” Both used a 5-point Likert scale, ranging from extremely positive response to extremely negative response.
As described in previous analyses of these data (Silvera et al., 2024), perception of the campus climate in relation to sexual violence and misconduct was assessed using three items adapted from the Penn State University Sexual Misconduct Climate Survey (2015 Penn State sexual misconduct climate survey summary report, 2015): “The university is taking steps to prevent unwanted sexual experiences from happening”, which assesses perception of institutional efficacy and prevention visibility; “The university is creating an environment in which unwanted sexual experiences seem common or expected, measuring normative climate; and “The university is creating an environment in which unwanted sexual experiences are more likely to occur”, which measures the perception of institutional risk production. Responses were collapsed from a 4-point Likert scale (which included an additional “don’t know” option) into 3 categories: “Agree”, “Disagree”, and “Don’t know.”
Two additional questions related to campus sexual assault were included: “Are there any groups or individuals on campus who you feel are actively working toward a negative climate with respect to these issues?” and “In your opinion, how does [institution], as an institution, respond to issues of unwanted sexual attention compared to other colleges or universities?”
Questions about experiences of sexual violence at the university included “Which, if any, of the following, has happened to you while at [the university]? Select all that apply.” Response options included the following: “I have been sexually harassed”; “I have been raped”; “I have been sexually assaulted”; “None of these has happened to me”; and “Prefer not to answer”. Sexual violence items were self-labeled. While additional behaviorally specific survey questions were asked, these question items were not included in the analyses.
Finally, participants were asked to rate themselves on the Center for Epidemiologic Studies-Depression (CES-D) scale (The CES-D scale—Lenore sawyer radloff, 1977, n.d.). The 4 positively worded items on the CES-D were reverse-coded to match the direction of the other 16 items, and all responses were summed. Scores greater than 16 indicated elevated depressive symptoms; a binary variable (elevated depressive symptoms—no/yes) was used in analyses. Given the length and focus of the survey, additional mental health measures were not included in this study.

2.3. Data Analysis

The researchers first conducted bivariate analyses using chi-square tests to assess relationships between perceived campus climate items (agree, disagree, don’t know) and elevated depressive symptoms (high/low). In addition, bivariate comparisons of other potential explanatory variables were conducted using Analysis of Variance for continuous variables and chi-square tests for categorical variables.
Then, unconditional logistic regression was used to calculate adjusted odds ratios (ORs) and their corresponding 95% confidence intervals (CIs) for elevated depressive symptoms (high/low). Variables that were independently associated with elevated depressive symptoms in the bivariate analyses, plus all campus climate questions, were considered potential predictors and included in the multivariate model, using stepwise selection. Significance tests were two-sided, with a p-value of less than 0.05 considered statistically significant. All analyses were performed using SPSS version 27.0 (IBM Corp., 2017).

3. Results

A total of 1353 participants completed at least part of the survey. Those who were <18 years (n = 2), did not indicate age (n = 144), answered that they had been “somewhat or completely dishonest” (n = 3), or asked that their data not be used when reconsenting at the end of the survey (n = 46) were excluded from our analyses. Of the remaining n = 1158 participants, those who did not answer the depressive symptom items (n = 432) and those who did not answer the questions about campus climate (n = 2) were excluded from our analyses, leaving n = 716 participants.
The average age of the respondents was 21.1 (SD ± 3.3). The racial distribution of respondents was similar to that of the university overall, with 55.3% identifying as non-Hispanic white (NHW), 9.8% as non-Hispanic Black (NHB), 26.0% as Hispanic/Latinx, and 8.8% as Native Hawaiian/Native American or Asian/Pacific Islander (Table 1). Women made up approximately 63% of all undergraduate students during the 2016–2017 academic year; in this study, 76.1% of respondents were women, and 2.1% identified as transgender or gender-nonconforming (comparison data on non-binary gender were not collected by the university at the time). At the time of the survey, 75% of enrolled undergraduate students commuted or did not live on campus, while just over half (57.1%) of the survey respondents were commuters. Although the campus had several Greek organizations at the time, 90.5% of respondents had no Greek affiliation.
Table 1. Respondent characteristics.
Over a third (37.6%) of the sample reported elevated depressive symptoms. In bivariate comparisons (Table 2), a higher proportion of participants who identified as LGB+ and/or as transgender, non-binary, or genderqueer reported elevated depressive symptoms as compared with the rest of the sample. Compared with peers who did not participate in honors or academic societies, those who did also reported a higher proportion of elevated depressive symptoms. No other demographic or activity variables (age, race/ethnicity, year in the program, commuter status, or participation in either Greek life or organized campus sports) were associated with elevated depressive symptoms.
Table 2. Bivariate associations between student perceptions and self-reported elevated depressive symptoms.
In bivariate analyses, elevated depressive symptoms were positively associated with both feeling somewhat or extremely disconnected from the university, as well as with reporting a somewhat or extremely negative attitude towards the university (p < 0.001). Similarly, respondents who disagreed with the statement “the university is taking steps to prevent unwanted sexual experiences from happening (55.4% disagreed versus 35.1% agreed), as well as those who reported that there are groups/individuals on campus contributing to a negative climate regarding sexual assault (48.4% vs. 33.8%), were more likely to have elevated depressive symptoms (p < 0.001 for both). Respondents who indicated that they had been harassed, raped, or sexually assaulted while at the university were more likely to have elevated depressive symptoms (60.5% vs. 32.7%, p < 0.001).
Table 3 presents multivariate analysis results. In the final model, adjusting for connectedness, attitude towards the university, age, and having been harassed, assaulted, or raped, none of the perceived climate questions was significantly associated with elevated depressive symptoms. Students who reported feeling somewhat or extremely disconnected from the university were significantly more likely to report higher elevated depressive symptoms (OR = 1.88, 95% CI 1.15–3.06) compared to students who felt somewhat or extremely connected to the university. Similarly, students who reported negative attitudes towards the institution were more likely to report elevated depressive symptoms, compared to those who had a positive attitude (OR = 1.61, 95% CI 1.01–2.57), even after adjusting for having been harassed, assaulted, or raped. Students who reported having been harassed, raped, or sexually assaulted while at the university, however, were nearly three times as likely to report elevated depressive symptoms compared to those who did not (OR = 2.38, 95% CI 1.55–3.69). Notably, although gender was not associated with depression risk in these analyses, students who identified as LGB+ were significantly more likely to report elevated depressive symptoms (OR = 3.20, 95% CI 1.97–5.20) after controlling for other variables in the model. One variable significantly associated with elevated depressive symptoms in the bivariate analysis—whether there are groups on campus actively working to create a negative climate—was eliminated from the multivariate model, as it fell below the significance threshold compared to the other variables.
Table 3. Odds ratios * and 95% confidence intervals for the probability of self-reported elevated depressive symptoms.

4. Discussion

We expected to see significant associations between each of the climate variables and elevated depressive symptoms. In our bivariate analyses, we saw only two such associations. Students who disagreed that the university is taking steps to prevent unwanted sexual experiences from happening and those who agreed that groups or individuals on campus are actively working toward a negative climate with respect to these issues were significantly more likely than their peers to report elevated depressive symptoms. No other climate-related question was significantly associated with elevated depressive symptoms. This suggests that the relationship between campus climate and depressive symptoms may not be straightforward. It is possible that these climate perceptions are indirect measures of the broader campus culture, and they may not fully capture the nuanced ways in which students experience the mental health impacts of sexual violence. Cohen (1986) suggested that organizational culture, including perceptions of institutional responsiveness and normative behaviors, can shape individual perception but may not necessarily lead to direct outcomes such as depression. Thus, while perceptions of climate may influence behaviors or attitudes such as reporting, they may not immediately translate into a significant impact on mental health outcomes such as depression without additional mediating factors.
In contrast, two variables—university connectedness and positive attitude towards the university—were significantly associated with elevated depressive symptoms in both the bivariate and multivariate analyses. In the multivariate model, participants who reported feeling somewhat or extremely disconnected from the university were 1.84 times as likely to self-report elevated depressive symptoms as those who endorsed somewhat or extremely positive responses, and those who described their attitude towards the university as somewhat/extremely negative were 1.80 times as likely (p < 0.05 for both). In contrast, neither of the climate-related variables with significant bivariate associations with elevated depressive symptoms remained significant in the multivariate model. These findings are consistent with prior research on the role of school connectedness and student mental health (Reschly et al., 2008), which suggests that students who feel a strong sense of belonging at institutions are less likely to report depressive symptoms. Baumeister and Leary (1995) posited that individuals have a fundamental need to belong and that, when that need is unmet, either due to negative attitudes towards the institution or a lack of a connection to it, students may experience increased feelings of isolation, which can lead to depressive symptoms. This study’s findings reinforce the importance of fostering an institutional environment where students feel integrated and valued. The negative relationship between attitudes towards the university and depressive symptoms may also be understood through the lens of institutional trust theory (Cohen, 1986), which asserts that students’ trust in their institution to provide a safe and supportive environment significantly impacts their emotional well-being. The association between negative attitudes towards the university and higher depressive symptoms could reflect a broader disillusionment with institutional policies or a perceived lack of support, which may exacerbate feelings of powerlessness and hopelessness commonly experienced by students with depression,
As expected, participants who reported having been sexually harassed, assaulted, or raped were nearly three times as likely to self-report elevated depressive symptoms as those who reported without those experiences. Notably, however, the association of elevated depressive symptoms with both feeling disconnected from and reporting a negative attitude towards the university persisted, whether or not a respondent reported having been sexually harassed, assaulted, or raped while at the university. Thus, at this northeastern university, both attitude towards and connectedness with the institution were more important with respect to self-reported depressive symptoms than perceived climate related to sexual violence and misconduct—even among students who experienced sexual violence or misconduct at the university.
Studies in the literature consistently support a strong association between depression and sexual violence or misconduct. Survivors of sexual violence are at an increased risk of developing depressive symptoms (Dworkin, 2020). Additionally, depression can both increase susceptibility to sexual violence (Krahé & Berger, 2017) and exacerbate its mental health impacts (Acierno et al., 1999). We hypothesized that students with elevated depressive symptoms would have more negative perceptions of the campus climate regarding sexual violence and misconduct than their peers. Although we did not find support for this hypothesis, we did find that poorer attitudes towards, and a weaker sense of connectedness with, the university were significantly associated with elevated depressive symptoms. This finding suggests that mental health benefits may be stronger if efforts to improve campus climate and reduce the incidence of sexual violence and misconduct were connected with initiatives to foster students’ connectedness with the university.
A study of factors associated with reporting campus sexual assault (Mennicke et al., 2020) suggested that students who made formal reports of sexual assault on campus were more likely to have high campus connectedness than peers who reported only informally. School connectedness, which we and others (Adams et al., 2021; Leurent et al., 2021) have found to be inversely associated with depression, is also influenced by institutional characteristics and structures. Notably, a secondary analysis of Healthy Minds survey responses on 60 US campuses found a three-way interaction between sexual assault, sexual orientation, and school connectedness in predicting depressive symptoms (Backhaus et al., 2021). Among all students, but most notably in students who self-identified as “lesbian, gay, bisexual, and queer and questioning (LGBQ),” school connectedness mitigated the positive association between sexual assault and depressive symptoms. Noting that school connectedness was higher among the LGBQ students in their sample than among LGBQ students on average, they found that 60% of the campuses in their sample were identified by the Campus Pride Index as LGBQ-friendly. These campuses were more likely to have LGBQ-affirming policies, resources, and messaging, likely explaining the higher-than-average school connectedness.
Although more than half of our respondents (58.0%) reported feeling connected to the university and most (75.8%) reported having a positive attitude toward the university, this did not hold true among students with elevated depressive symptoms. If these sentiments undermine confidence in formally reporting incidents of sexual violence and misconduct, this has negative implications for healing and security at both individual and institutional levels. As the amount of attention being paid to mental health is increasing on college and university campuses (Healthy minds study, n.d.; Markoulakis & Kirsh, 2013), it is also increasingly important to conduct longitudinal studies that contribute to better understanding interactions between depression, sexual assault, perceptions of campus climate regarding sexual violence and misconduct, and overall attitude and connectedness to the institution.
The positive association of school connectedness with students’ mental health (Daley, 2019; Marraccini & Brier, 2017), combined with evidence that it may buffer students’ trauma responses to campus sexual violence or misconduct (Backhaus et al., 2021), make it appealing as a potential focus for initiatives to protect students’ mental health. A secondary analysis of the 2021 American College Health Association National College Health Assessment (Firkey et al., 2023) found that students’ sense of campus belonging was a beneficial mediator of the association between sexual assault and mental health problems. This, along with their finding that both campus belonging and resilience mediated the association between sexual assault and both mental health and alcohol use problems, supported their call for a strengths-based approach to research on sexual violence and misconduct.

4.1. Study Limitations

The most significant limitation of this study was its cross-sectional nature. Further, some subgroup and intersectional analyses that might have explored changes over time (e.g., first-year students vs. those who had been at the university longer) could not be performed due to the sample size.
In addition, perceptions of the overall campus climate regarding sexual violence and may not have adequately captured the interpersonal dynamics that affect students’ sense of psychological safely. For example, students may feel unsafe or unsupported due to social or peer group dynamics, even when they perceive the institutional polices as effective. This points to the need for a multi-dimensional model of campus climate, one that incorporates both macro-level perceptions, such as institutional actions, and micro-level experiences, such as interpersonal support and peer norms. Additionally, it is possible that students who are already experiencing depressive symptoms may be less likely to perceive their environment favorably or more likely to interpret neutral or negative aspects of the climate as threats, consistent with cognitive bias theory (Beck, 1967). Such biases in perception could explain why climate measures related to institutional prevention efforts were not significantly associated with depression, as depressed students may focus disproportionately on negative aspects of the environment, regardless of actual institutional actions.

4.2. Conclusions

To our knowledge, this is the first study to examine possible associations between campus sexual assault climate and a validated measure of elevated depressive symptoms, adding to the literature about the complexity of this relationship, by exploring additional associations with characteristics such as students’ connectedness to, and attitudes towards, their institution. Previously, the authors found that both school connectedness (OR = 2.49, 95% CI = 1.42, 4.35) and positive attitudes towards the university (OR = 2.72, 95% CI = 5.13) had strong positive associations with agreeing that the university is taking steps to prevent unwanted sexual experiences from happening (Silvera et al., 2024). An increasingly nuanced understanding of these interrelationships is vital for creating a safe and supportive campus environment.
Our findings highlight how students’ attitudes towards, and sense of, connectedness with the university play a role in both their perceptions of the campus climate related to sexual violence and misconduct and in their depressive symptoms. While progress has been made in assessing and improving campus climate related to sexual violence and misconduct, the epidemic of depression among students has grown, with a tremendous impact on colleges and universities. Interrelationships of perceived climate, school connectedness, and depressive symptoms are threaded through some of the most critical student life issues currently affecting campuses.
Future research should aim to disentangle these complex relationships by using prospective designs that can better capture the directionality of effects between depression, campus climate, and student well-being. It is critical to use a nuanced approach to understand how specific climate factors, such as student perception of institutional response to sexual violence, may protect them from or exacerbate the psychological impact of these experiences. Interventions to improve school connectedness may be an effective strategy for addressing depressive symptoms on campus (Zins et al., 2004).

4.3. Practical Applications

Our findings contribute to the growing understanding of how these dynamics interact, with important implications for practice—potentially helping to create intentional connections across units among all entities working on initiatives in any of these three areas. Whether initiatives are led by administrative staff and/or student-run, large or small, or single-issue-focused (e.g., consent education, suicide prevention, student retention) or broader (e.g., campus climate, mental health, belonging), the potential for synergy and reinforcement is critical, as is making it explicit how all relate to the shared outcomes of sexual violence and misconduct, student connectedness, and depression/mental health.
Student connectedness can be cultivated and reinforced as an asset in a way that emphasizes positive messages and outcomes. Because it is universally beneficial across the student body, it can be infused into nearly all student-focused activities, and as a proactive way to potentially protect students from some negative consequences if they do experience sexual violence or misconduct (which we know will happen based on incidence and prevalence data). Focusing on student connectedness as an asset can also be a valuable way to encourage strengths-based, trauma-focused responses to incidents of sexual violence and misconduct that do occur (Firkey et al., 2023).

Author Contributions

Conceptualization, S.A.N.S., E.S.G., A.S.B. and L.D.L.; Methodology, S.A.N.S., E.S.G., A.S.B. and L.D.L.; Formal Analysis, S.A.N.S. and A.S.B.; Investigation, S.A.N.S., E.S.G., A.S.B. and L.D.L.; Data Curation, S.A.N.S. and A.S.B.; Writing—Original Draft Preparation, A.S.B., S.A.N.S., L.D.L. and R.M.; Writing—Review and Editing, S.A.N.S., E.S.G., A.S.B. and L.D.L. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

The study was conducted in accordance with the Declaration of Helsinki and approved by the Institutional Review Board of Montclair State University (protocol code IRB-15-16-245 and date of approval 19 December 2016).

Data Availability Statement

The original contributions of this study are included in the article. Further inquiries can be directed to the corresponding author.

Acknowledgments

The authors wish to acknowledge the assistance of Cindy Meneghin, Hila Berger, and Kim O’Halloran, who assisted in navigating the challenges of university hesitancy to embark on this study.

Conflicts of Interest

The authors have no conflicts of interest to disclose.

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