1 A GROWING BODY OF LITERATURE suggests that supportive social relationships with family and friends have a positive effect on health (Badr, Acitelli, Duck and Carl 2001; Berkman and Breslow 1983; Hobfoll and De Vries 1995; Ryff and Singer 2000; Springer, Parcel, Baumler, and Ross 2006). Researchers have also linked strong social supports to reduced mortality rates (Repetti, Taylor, and Seeman 2002), improved self-rated health, and increased self-esteem (Ryff and Singer 2000; McNicholas 2002; Springer et al. 2006). Lohman and Jarvis have argued that social supports provide individuals with the resources they need to cope with stress, thereby preventing illnesses such as heart disease and depression (Lohman and Jarvis 2000). A number of studies have noted that women in particular rely on supportive relationships, and as a result, they experience more negative health effects in the absence of social supports than do their male counterparts (Berkman 1995; Hurdle 2001; Letvak 2002; Springer et al. 2006).
2 This qualitative project explored how women perceived their social relationships, and how they thought about the connection between those relationships and their health and well-being. Following the World Health Organization (2004), we conceptualized "health" not simply as the absence of disease. Instead, we viewed it as a multi-dimensional concept involving the physical, social, and emotional well-being of individuals which is influenced by social, economic, and political structures and resources within society (Raphael 2003). We were not attempting to establish a link between social relationships and specific health outcomes, but, rather, to gain an understanding of how social relationships are influenced by a changing environment, and how such relationships are viewed as affecting young women’s health and well-being. To establish these relationships we conducted interviews in three coastal communities — one on the Great Northern Peninsula of Newfoundland, and two in south-eastern Labrador. Each of these communities has undergone numerous social, economic, political, industrial, and environmental changes since the closure of the cod fishery in 1992 (Ommer 2002; MacDonald, Neis and Grzetic 2005; Sinclair and Ommer 2006). We wanted to explore how young women perceive their social relationships in the context of community "restructuring," and to consider their thoughts on the implications of potentially changing social relationships for their health.
COMMUNITY RESTRUCTURING AND OUT-MIGRATION
3 Out-migration from the province of Newfoundland and Labrador began well before the closure of the cod fishery. Indeed, for decades, even centuries, Newfoundlanders and Labradorians have moved from place to place to find work. Although the decision to migrate is most often employment related, a desire to re-establish strong family, kinship, and friendship ties often motivates those who either do not leave, or who return home (House et al. 1989). The cod moratorium, however, prompted a larger portion of people to leave home to find employment, and has diminished the ability for many to stay. MacDonald, Neis, and Grzetic (2006) suggest that the determination displayed by some outport community residents to remain in their home communities despite economic instability and environmental degradation represents an act of resilience. They also suggest that this resilience may affect the health of those who stay, because remaining socially integrated within their home communities can act as a protective factor against illness. However, the stress that accompanies employment uncertainty, as well as staying behind while friends and family move away, can also have negative effects on one’s health. Out-migration, therefore, can influence health. This study considers how people, in this case, young women, perceive their social relationships in a context of significant community changes, and how they view these changing relationships influencing their health and well-being.
INFORMAL SUPPORT IN OUT-PORT COMMUNITIES
4 Schwartz’s 1974 study of a Newfoundland outport found that specific cultural and economic processes strongly influenced all of the "dimensions" surrounding the friendship of local people. For example, as a fishing community, the dynamics of friend relations often centered on the family and crew with whom one fished. This included immediate family members and friends of the family who, while fishing for extended periods of time on a small fishing boat, become like one’s immediate family. In essence, the relationships that one developed with one’s neighbours in a small close-knit community often resulted in relations and non-relations becoming quite interconnected. Given that there is an economic need to work together, these relationships were important to one’s social well-being.
5 Since the moratorium, a number of studies of coastal Newfoundland and Labrador have emphasized that the strong social ties characteristic of small outport communities continue to play an important role (Hamilton and Seyfrit 1994; Ommer and Turner 2004; MacDonald, Neis, and Grzetic 2005, Sinclair 2002). Ommer and Turner (2004) highlight the importance of having informal supports during periods of significant economic hardship. In their historical overview of informal economies in rural communities, they note that the reciprocity and exchange of goods and resources among family and community members during "hard times" reinforced a feeling of camaraderie and solidarity, which made it easier to deal with the uncertainty brought about by economic change.
6 The strong social ties within a community appear to provide residents with instrumental, or practical, support when families might be struggling economically. Sinclair (2002) uses the term "embeddedness" to describe the degree to which individuals from the east coast community of Bonavista are socially integrated. He notes that embeddedness seems to be closely linked to the informal sector because that allows people in the community to share resources and skills with one another without having to pay for their services. This type of informal trading of goods and services has the advantage of providing even the poorest people in the community with opportunities to avail of services which they would otherwise be unable to afford. They are also able to offer their own services to others and thereby reinforce and reaffirm their connectedness to the community.
7 Social ties are also an important influence on young peoples’ decisions about whether to leave coastal Newfoundland and Labrador communities that are going through economic uncertainty. Hamilton and Seyfrit (1994) studied the migration patterns of high school students in two rural communities in Newfoundland, noting that youth with strong social ties are more likely to want to stay in their community. Although socio-economic uncertainties make it difficult for many to stay, the significance of having strong social relationships appears to create a desire to remain "at home."
8 The cod moratorium has led to many adults and youth leaving their communities for higher education or employment (Jackson, Marshall, Tirone, Donovan, and Shepard 2006; Ommer and Sinclair 1994), and research points to the changing nature of social relationships within many communities. Ommer and Sinclair (1994) studied the future plans of residents in a fishing community on the west coast of Newfoundland immediately following the cod moratorium, finding that just over 79 per cent of those under age 25 planned to leave the area within 5 years. A more recent study of the migration intentions of young people in Newfoundland suggests that economic opportunities are the primary reason youth want to leave their community (Palmer and Sinclair 2000), and the authors note that if all of the youth who expect to leave in fact do leave, some fishing communities in Newfoundland will not be viable. Aside from the devastating economic impact this would have, its effect on the configuration of social relationships within coastal communities may be dramatic. In this context of significant community change and out-migration, we undertook to explore young women’s perceptions of the social relationships in their lives, and the implications of such relationships for their health and well-being.
9 We conducted this study in one coastal community on the Great Northern Peninsula and two coastal communities in southeastern Labrador, the names of which are withheld to protect the anonymity of the participants. Each of these communities relied on the fishing industry, but changed dramatically after the 1992 moratorium. In all three cases, the population declined by 14.7 per cent to 19.7 per cent from 1986 to 2001(Government of Newfoundland and Labrador 2006). We chose these two Labrador communities in particular because there was a large population of Labrador Metis in this area, and we wanted to include Metis women in the sample to ensure a diversity of perspectives. We selected the community on the Great Northern Peninsula because it is a fishing community that has been significantly affected by the closure of the fishery and is close to the communities in south-eastern Labrador.
Study Participants and the Interview Process
10 We used two strategies to recruit young women: we placed posters in various stores and schools throughout the communities, and asked key informants throughout the community to refer young women. In both instances, we emphasized that we wanted to interview women between the ages of 18 and 24, who self-identified as either non-Aboriginal or Aboriginal, and who had been a resident of the community or surrounding area for at least two consecutive years. This residency requirement ensured both that participants had experienced some of the recent community changes, and that they could comment on the potential impact of changes on their relationships. Eleven young women volunteered. Five of them were Labrador Metis and six were non-Aboriginal. All of them had lived their entire lives in rural Newfoundland or Labrador, although three had lived for a period of time in larger cities to attend post-secondary institutions or for employment. Three of the women were living with male partners and young children.
11 We engaged the women in one-on-one, face-to-face interviews either in a classroom of a local school, in a private room at a youth centre, or in their homes. We used a semi-structured interview guide, and aimed our questions at exploring how the young women perceived recent community changes as influencing, if at all, their social relationships and in turn their general health and well-being. We pretested the interview guide with two young women who had grown up in single-resource based communities in coastal areas of Atlantic Canada. These communities bear some resemblance to the communities included in this study in that they have also been affected by the cod moratorium. A sample of some of the interview questions is included in Appendix A. We revised the interview guide based on the interviews with these two women. The principal author, who conducted all of the interviews, grew up in a small coastal community and is also a member of the Labrador Metis Nation. She was, therefore, familiar with the area and cultural context, and her cultural background and expertise further assisted in the development of the interview guide. We obtained ethics approval for the study through Dalhousie University where the first author is a student and the second author is a faculty member.
12 Before beginning the interviews, each young woman provided written, informed consent. We audiotaped and later transcribed the interviews verbatim. All transcripts were read and re-read, and a preliminary coding structure was developed from the reading of the transcripts. The authors of this article discussed the codes and related parts of the transcripts to ensure that they captured the essence of the interviews. Following these discussions, the coding structure was revised, and all of the transcripts were coded using the software programme Atlas.ti. "Reports" of the coded transcripts were read and re-read for emerging themes and sub-themes. For example, a code labelled "extended family" (which included discussions of parents, grandparents, etc.) was examined for sub-themes, and during this process the sub-theme of "sense of security and safety" emerged from the data. This sub-theme also emerged under the code "community" so the sub-theme "sense of security and safety" was linked to both extended family and community. Through this process of examining and linking sub-themes, it became clear that a theme that united the sub-themes was the dominant theme of "Family and Friends as Community." We developed additional themes using the same process, and used an iterative process of comparing and contrasting all key themes and related sub-themes out until conceptual integration was obtained, as outlined by Strauss and Corbin (1998). Conceptual integration is achieved when all themes and sub-themes are linked into a cohesive understanding of the issue, and no new themes emerge from a reading of the transcripts.
13 Three dominant themes emerged from the analysis. The first speaks to the importance that the young women placed on their relationships with family and friends, and their perceptions of the healthy aspects of these relationships. The second points to the women’s sense that they had lost some of their key social relations with both friends and family who either moved away permanently, or who came and went from the community for shorter periods of time. These losses appear to have a negative effect on the women’s social support systems and their sense of well-being. The third includes the young women’s discussions of key tensions between social supports within their home community and relationships "away." Such tensions direct our attention to the need to understand the complexity of people’s relationships and social support systems, and the ways in which competing social support systems may have negative implications for one’s health.
THEME 1: FAMILY AND FRIENDS AS COMMUNITY
a) Informal Supports
14 The respondents viewed spending time with extended family as an essential part, and perhaps even the core, of their lives.We’ve never had a Christmas just the four of us. It’s either been with my grandparents or… here for Christmas dinner it’ll be like twenty people … family is a big thing for them and therefore a big thing for me. Even though I only have one sibling, I still love to be with my extended family (Labrador Metis woman).I find that families are close around here, you know what I mean? Like a lot of brothers and sisters and everything, like they’re a lot closer and they’re there for one another (Newfoundland woman).
15 The women spoke of experiencing social supports not just in the context of their family activities and relationships with extended kin, but through day-to-day activities in the community. Indeed, they spoke of the "whole" community as being like one’s family — providing a constant form of support by acknowledging the women and the important contributions they make to the community. The community as "family" is composed of individuals who trust and respect one another, and who, according to the women, create a climate of safety.like the kids or the young people don’t realize how much they do have here. The safety I had growing up, you know everybody, you didn’t always have to lock your door, you know that sort of thing. You don’t realize how precious that is until you go to St. John’s or you go to London somewhere and nobody smiles and you don’t make eye contact and stuff like that right (Labrador Metis woman).
b) The Convergence of Informal and Formal Supports
16 Not only did many women describe "knowing everyone" in the community, but they noted that immediate and extended relatives, as well as friends, comprised a large portion of the community’s population. As a result, family or friends are sometimes part of professional social service or health care networks. One respondent noted that a family member acts as both a key source of informal social support, and is also the local guidance counselor. Two of the women interviewed felt that it was beneficial to have one’s friend or relative providing formal care and support because the professional care becomes informed by knowledge of the whole person rather than based on only viewing the woman as a patient or as a client stripped of her background and individual history.In a way it’s better here than when I was going to university because I’d go [to the health care clinic] and you’re more of a number … they don’t know who you are. They can’t remember seeing you, you know, but here, you do have that … a nurse that kinda watched me grow up … she knew who I was my whole life …and she knows my health problems …if I’m there she’s like ‘oh, are you here for such and such a thing?’ or ‘how are you feeling today?’ … it makes people feel … more comfortable and it makes you feel like they do care (Labrador Metis woman).
THEME 2: LOSS OF FRIENDS AND FAMILY
a) Permanent and Temporary Losses
17 The women in this study spoke passionately about their strong relationships with family and friends, and the "whole" community, yet many also talked of the recent losses of social relationships as a result of the cod moratorium and out-migration. They reported that losing members of their social support network was particularly stressful because it caused loneliness.I think my biggest thing here that would have a negative impact on my mental health is just, you know, even though I have a lot of girlfriends, there’s not a lot of us around, and like sometimes you do get lonesome … (Newfoundland woman).
18 The women also reported that they tried to stay in touch and remain emotionally close with friends and family who had moved away, but the physical separation affects the quality of the support because it is very sporadic, and they lost the day-to-day informal supports. Still, remaining in touch does appear to be very important to the women, and they reported it contributes to their well-being.Friends I’ve had growing up are in St. John’s, and friends I’ve made in university are in St. John’s, so I’ll call [them] on the phone. It’s worth coming to work if I’ll write a big e-mail or something like that (Labrador Metis woman).
19 Another woman spoke about the loss of many of her close friends in the last two years. She has stayed home to attend the local community college but many of her friends left to attend school or work elsewhere. Although she keeps in touch with them by telephone or email, she feels it is not the same as having them present all the time.For me now, it’s harder for me to see my close friends … but I keep in contact with them a nice bit, but it was hard at first, because not having them actually there makes a difference too sometimes (Newfoundland woman).
20 As a result of the closure of the cod fishery, many individuals and families leave their communities to work seasonally, but return in their "off-season." This means that the loss of relationships not only results from out-migration, but also temporary losses for weeks or months at a time as people leave for seasonal work. Several women commented on the "temporary" absence of individuals, particularly spouses or partners who are away for extended periods of time because of the nature of their employment. The temporary absence of a male partner is especially stressful for young women who have small children. Four of the young women interviewed had children, and of these women, three had partners who worked seasonal jobs that required them to leave the community for months at a time. As one woman explains, when her partner is away she loses the "day-to-day" support that she is accustomed to having, and she is transformed into a single parent which makes her life particularly stressful.I feels a lot better when he is around, and, I likes having a lot of people around. I don’t like being by myself, because, I don’t know, its too boring just sitting there – you’ve got nobody to talk to, and when [partner] is here, we might be just down on the couch just watching TV and say a scattered word here and there but at least I knows he’s there if I wants someone to talk to right? (Labrador Metis woman)‘Cause I mean, when you’re both mom and dad, I notice … she [her daughter] gets hard. Harder to handle … I couldn’t get her to listen well and stuff right? Cause she’s perfect, right? You couldn’t ask for a kid to listen any better. But when [her Dad] goes away to go to work in summer … she’s going out of herself. I’m, like, ‘Stop!’ But we figured that’s what it is (Labrador Metis woman).
b) Loss of Supports Obtained Through Leisure and Recreation
21 Several of the women noted that prior to the cod moratorium they had engaged in many structured leisure activities with family and friends, but now there were few of these and this is affecting their support systems. In Sinclair’s (2002) study of young people’s decision to migrate from Newfoundland and Labrador, he notes that despite having an overall perception of their home community as a great place to live, young people had negative perceptions of their community because of the lack of employment and recreation facilities. In our study, the young women argued that the relative lack of entertainment and recreation goes beyond the reduction in structured activities, it also affects informal gatherings. As one woman commented, people who remain in the community are less interested in social gatherings because their whole family is not present and this contributes to a decline in the social life and social support.And it seems like everybody just up and leaves here, and then that affects a lot of families because families don’t want to do stuff without the whole family there. It’s hard to explain … they just give up or something. And if more people would get out and show some interest. Then it would be a lot better place to live that’s for sure (Newfoundland woman).
22 The women also reported that prior to the cod moratorium it was easier to organize all-female leisure activities that allowed women to interact with one another and gain support from other women. Our respondents indicated that there were too few women to organize all-female sports teams and as they sometimes needed men to "fill in." However, as one woman argued, this makes the sport less enjoyable as it becomes more of a competition and less of an opportunity to socialize. For her, the support obtained through women having fun together has been lost.The teacher that was here a couple of years ago, she tried to get volleyball on the go and the first night we had it there was eight of us out there, so we tried it the week after, four of us showed up. So you can’t play volleyball with four people. So at the end of it, we used to have the men to come out and help us, and its not so much fun with men ‘cause you don’t get a chance to have fun. ‘Cause they hogs the ball and you know (Labrador Metis woman).
THEME 3: TENSIONS BETWEEN SOCIAL SUPPORTS SYSTEMS AT "HOME" AND "AWAY"
23 A few of those interviewed described leaving their communities for a period of time either to attend school or seek employment. They returned to their home communities for a variety of reasons, and talked of the importance of being "home" and having the support of family and friends – support that is important to their well-being. At the same time, there was a feeling of loss of what they left behind. This suggests that the social supports within their community alone are not enough for them to feel complete just as living "away" without the supports of their home often leaves them feeling lonely.I’m jealous of my friends who work in Halifax who can go to courses on the weekends. Or my friends who are in New Brunswick who can go to Halifax or just drive down to the States or you know like, that opportunity. Like here, the nearest place is [name of town], five hours away, and still you feel like you want to drive that extra six hours to get to St. John’s. After you’ve been away there’s certain things that you do miss, as much as you love home. And sometimes I find that … I guess that’s one of the things that I find mentally exhausting.... I’ve got a good job, I was able to come home and have a good job.... I’m living with my parents.... they’re here ... you’ve got a good family and good friends, really what are you complaining about? (Newfoundland woman)
24 Another woman spoke of the friendships she made while she was "away" as being particularly valuable to her because she was able to meet people that shared similar interests.When you go away to university you actually get to go away and meet so many different types of people and they get to … see who you probably actually are, and you change a bit yourself. And you find you’re closer with friends in university, maybe because they have more similarities, you know, you always find the ones that are more like you and then when I came back … well still now, I still really miss my university friends because its just not the same. It’s a different level, it’s a mature level of friendship (Newfoundland woman).
25 In one instance, a woman spoke of how her social support network "away," along with the recreation facilities available in larger places, helped to keep her involved in physical activities.Like a disadvantage to here for me is, I like to go to the gym, like with weights and stuff like that, and when I was going to university myself and my buddies would go to the gym or whatever … but I’ve gained weight since I came home because all you can basically do is walk (Labrador Metis woman).
26 Yet another woman indicated that she wanted a job that matched her education, which was unavailable in her community, and she experienced a tension between the social supports of home and the limits of what the community provided from an intellectual point of view.I went to university, I have an honours degree, and coming home and that’s all I’m getting and that can be somewhat depressing.... I was going through a phase of ‘I feel like a loser, my BA is not going to get me anywhere, you can’t stay here’ and you know whatever, … but for me I’m like, I work so hard I want something more or deserve something more, you know what I mean? (Labrador Metis woman)
27 As Popay, Thomas, and Williams (2003) suggest, one’s community may have a profound impact on the type and nature of one’s social relationships, and in turn the support gained from these relationships. Our respondents suggest that the supports that they experience within their communities are important to their health and well-being. They talked of growing up within a tight-knit community where one constantly experiences informal supports through family events, and "just by walking down the road." Unlike urban centres where one is often "faceless," the women spoke of feelings constant support. Although many studies have reported the difficulties associated with living in small places, such as gossip or "everyone knowing everyone else’s business" (Glendinning et al. 2003; Hendry and Reid 2000), as well as the limited structured recreation and educational opportunities (Sinclair 2002), our research suggests that "knowing everyone" has some benefits in emotional health and well-being.
28 We focused on young women because research suggests that they may be particularly vulnerable to a loss or change of their key relationships (Adams, Bowden, Humphrey, and MacAdams 2001; Berkman 1995; Glendinning, Nuttall, Hendry, Kloep, and Wood 2003). While the literature concludes that a firm social network benefits women’s health and well being, it says little about men. This tendency may be more a reflection of men’s hesitancy to talk about social relationships than an indication that such relationships are unimportant to them or their health. The dominant discourse on masculinity may not only affect researchers’ questions, thus creating a bias towards research on women and social relationships, but also discourage men from talking about their relationships. We need more research on men’s social relationships, as well as linkages between their social relationships and health, especially given that community restructuring has significantly affected men’s economic and job opportunities and has encouraged them to move away.
29 In our study, all of the young women described their family and friends as of central importance to their lives, and as contributing to their happiness and sense of well-being. As was the case in Schwartz’s (1974) study where he describes family members and community members all forming an important part of one’s social support network, the young women in our research also spoke of "family" as a large extended group of people and not merely one’s nuclear family. As a result of the dramatic economic changes in the communities we studied, many family members and friends have moved away either temporarily or permanently and this has affected the women’s social support systems. Although the young women have different experiences, some are married with children, others are living at home with their parents, and still others have returned after a period of time away for school or work, there are similarities. Each of them place importance on having "enough" support (qualitatively speaking) from friends and family.
30 Whether they moved to the community to live with their partners, or are living at home with parents, each woman has coped with a loss of day-to-day, face-to-face friendships and of people with whom she can enjoy various activities that contribute to her overall sense of well-being. For some women, the absence of a significant other for extended periods appears to take a toll, not only because it means added responsibilities within the household, but also because of the loss of the day-to-day informal supports.
31 Many women described "knowing everyone" in the community, but they noted that immediate and extended relatives, and friends, sometimes provided professional social service or health care. Some spoke about the value of this personalized, one-on-one healthcare and counselling from individuals they know. However, other studies have found that in rural areas where one knows professional social service and health care providers there are worries about confidentiality and lack of anonymity (Hendry and Reid 2001; Letvak 2002). In our study, women did not raise these concerns, instead, they indicated that they preferred this type of care to situations where one is simply a "number." Such differences across studies may be a product of variations in people’s comfort level in accessing services, as well as differences in the types of services sought. In some instances (for example, seeking mental health care services or other services that have the potential to greatly stigmatize an individual), there may be a greater need to access services from professionals with whom one does not have a social connection. Future research is also needed to examine whether or not professional care delivered by someone a person knows well affects the likelihood of following professional recommendations as this may have important implications for improving health outcomes.
32 A few of those we interviewed had lived away and reported being very happy and lucky to be home, mainly because they were able to live close to family and friends, and a large social network. As Marshall (2001) suggests, women who have left their communities may feel a greater "connectivity" upon their return. In our study, a greater sense of connectivity to family, friends, and to the community as a whole was often tempered by the new relationships many women reported that they made while living in other places. The women argued that they felt a tension between the loss of social supports and friendships developed when "away" and the current supports within their home community. Returning contributed to their sense of well-being despite their being losses associated with the move.
33 The women in this study clearly articulated the importance of positive social relationships for their lives and their happiness. Absent from our conversation were discussions about "negative" relationships, although they did talk about the absence of support, which may have harmful implications for health. Further research is needed to explore some of the health effects that caused by "negative" social supports such as unwanted or unsolicited support.
34 Frequently the young women reported that their key social supports came from people who were living some distance "away" from home, either temporarily or permanently. Long distance relationships maintained over the phone or through email were common, and seemed to be an accepted part of living in these relatively isolated communities. Although those who participated in this study feel that they have "enough" support, we wonder the extent to which the lack of "quality time" with a close friend or relative might harm their health and well-being. If, as the literature suggests, social supports are critical in preventing stress-related illnesses and promoting longevity, to what extent can one receive these same health benefits when one’s key sources of social support live temporarily or permanently at a distance? We feel that it is possible that the relative absence of day-to-day, face-to-face positive social supports might foster negative health outcomes, particularly when the absence of friends and family is accompanied by the added stress and uncertainty of community changes. Although strong, supportive relationships seem to be fostered within small, close-knit communities, the ability to create and maintain multiple positive supports is being severely challenged by the changes brought on by community restructuring. Future research is needed to examine how "virtual" supports are influencing health, and to determine the health implications for different groups of individuals (for example, men and older adults).
35 Understanding the nature of social relations within the uncertain context created by community restructuring, will help to highlight the community level forces (such as out-migration) that affect social relations, and in turn, health. To date, many of the interventions aimed at influencing positive health choices target a more "individual" level (for instance, behavioural change programmes such as smoking cessation or drug awareness campaigns) failing to account for the fact that social support systems, which play a significant role in the individual-level choices people make about their health every day, may be hampered by existing community-level conditions. Although it seems that positive social relationships can offer protective health benefits in the form of emotional and social support, we feel that these protective benefits cannot be simply labelled as "direct health outcomes" of positive social support. Turning our attention to the forces within communities that shape the type of social relationships available to community members will help to direct programmes and policies to that level, and potentially serve to improve the overall health and well-being of community members.
APPENDIX A - ENTRY QUESTIONS
Personal Definition of Health
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