Michelle Nwufo
Adaeze Onuoha
Cori Mallory
Joy Stradford4
Vickie M. Mays- 1Los Angeles (UCLA) BRITE Center for Science, Research, and Policy Development, University of California, Los Angeles, Los Angeles, CA, United States
- 2Los Angeles (UCLA) David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
- 3Los Angeles (UCLA) School of Nursing, University of California, Los Angeles, Los Angeles, CA, United States
- 4San Diego State University (SDSU)/UC San Diego Joint Doctoral Program in Clinical Psychology, La Jolla, CA, United States
- 5Los Angeles (UCLA) Department of Psychology, University of California, Los Angeles, Los Angeles, CA, United States
- 6Los Angeles (UCLA) Department of Health Policy and Management, University of California, Los Angeles, Los Angeles, CA, United States
Introduction
There is growing evidence to suggest cognitive impairment and adverse brain health outcomes are associated with chronic health conditions such as diabetes, hypertension, and cardiovascular disease (Barnes and Bennett, 2014; Lock et al., 2023; National Academies of Sciences et al., 2023). These conditions can contribute to cognitive dysfunction by disrupting physiological feedback mechanisms that regulate oxidative stress (Pugazhenthi et al., 2017), causing fluctuations in systemic blood pressure (Wanleenuwat et al., 2019), or promoting vasoconstriction that impairs cerebral perfusion (Stephan et al., 2017). The higher prevalence of these conditions in the Black population (Ajuwon and Love, 2020; Musemwa and Gadegbeku, 2017; Wang et al., 2021) may be associated with an increased risk of dementias, such as Alzheimer's disease, increasingly seen in Black Americans (Basu and Gujral, 2020; Rajan et al., 2019).
While the compelling scientific need for further evaluation of these connections may be helpful in addressing Black health disparities, neuroscience studies have often been slow to advance such contributions in the United States (U.S.) Black population (Burke et al., 2017; Zuelsdorff et al., 2020). This may stem from underpowered Black participation in neuroscience research (Rutten-Jacobs et al., 2024), which is commonly attributed to historically rooted mistrust in medical research (Otado et al., 2015; Scharff et al., 2010; Webb et al., 2022) or ineffective sampling (Abiodun, 2019; Awidi and Hadidi, 2021). An often-overlooked factor that may further impact the inclusion of Black participants in neuroscience studies is researchers' decision-making processes for participants who report forced hand use on screening assessments.
Handedness screening assessments are a common method for establishing hand dominance in neuroscience studies (Scharoun and Bryden, 2014). Hand “dominance” is characterized by a distinct affinity for the hand that demonstrates the highest proficiency when performing manual tasks (Serrien et al., 2006), while hand “preference” is defined by the hand an individual habitually selects for task performance, independent of proficiency (Chatagny et al., 2013). Handedness is believed to influence an individual's mental and neuropsychological abilities (Johncy et al., 2021). Researchers, particularly in human neuroscience, may selectively analyze the data of right-handed individuals to minimize variance in datasets (Bailey et al., 2019; Willems et al., 2014). Unrealized biases embedded in handedness screening tools may unknowingly facilitate misclassification error for Black participants with a history of culturally influenced handedness practices.
Researchers' understanding of how cultural and religious practices shape handedness in diverse Black communities could affect the internal validity of handedness assessment tools that assess forced hand use. We encountered this issue in a preliminary study on racism and cognitive processing, where assumptions about responses to forced hand use, and its potential link to hand dominance, were susceptible to misunderstandings of the cultural and religious factors influencing forced use. Given the need for greater inclusion in neuroscience research, an examination of the decision-making methods surrounding Black participants' employment of handedness warrants further investigation. Examining how cultural and religious practices are established within the Black population and their relationship to handedness could serve as one intervention to increase researchers' acceptance of Black participants who report a history of forced hand use.
Understanding cultural/religious right-hand practices of African immigrant populations and their descendants
When assessing handedness in culturally diverse populations, it is useful to establish criteria for including or excluding individuals based on the forced use of the right hand, given the historical preference for right-handedness in formal and functional tasks (De Kovel et al., 2019; Galobardes et al., 1999; Klöppel et al., 2010). In some West African countries like Ghana, Nigeria, and Senegal individuals can display a preference for the right hand when performing tasks that require direct contact with others (Alhassan, 2018). Conversely, in these same regions, the left hand is perceived as dirty or intolerable (Awidi and Hadidi, 2021) and relegated to private tasks such as washing one's body or using the bathroom. In particular, the rare hereditary pattern of left handedness may contribute to its cultural perception as an unlucky trait, leading to public avoidance of left-hand use (Jing, 2020). In other words, the use of the right or left hand for a particular activity may not be a matter of dominance nor preference but an enforced practice honored by one's culture.
The left hand is also subject to stigmatization within the religious teachings of Christianity and Islam, commonly practiced among African and African American communities (Agbiji and Swart, 2015; Park et al., 2020; Simmons, 2008). Christian doctrines have historically associated left handedness with the devil (Hertz, 2013), while Islamic scriptures have regarded the left hand as a symbol of uncleanliness or impurity (Fagard and Dahmen, 2004; Singh and Kundu, 1994). Devoutly religious individuals may therefore refrain from using their left hand during social activities, even for simple gestures like handing over an object or receiving money, as they can have significant social repercussions (Alhassan, 2018). To avoid ostracism, adherents to religious customs must often consciously use the right or left hand in a socially cued manner. Consideration of such practices in the Black diaspora may enhance the efficacy of screening protocols while allowing for the appropriate determination of handedness (Shanunu et al., 2022; Zverev, 2006).
This is important knowledge to incorporate in handedness assessments as a longitudinal analysis of U.S. migration trends revealed that the Black population grew by 20 million over the last four decades (Tamir and Anderson, 2022). Additionally, Tamir (2022) reported that the number of Black immigrants living in the U.S. reached 4.6 million in 2019, a substantial increase from the documented 800,000 in 1980. This growth represents nearly a fifth of the total Black population and it is projected that Black immigrants will contribute to approximately one-third of the overall increase in the U.S. Black population's growth by 2060 (Tamir, 2022). Presently, one in every ten Black Americans is foreign-born and these immigrants often maintain strong religious affiliations that underpin their handedness practices (Mohamed et al., 2021; Shanunu et al., 2022). While such ideologies may originate in Africa, cultural socialization plays a significant role in defining the identity of ethnic-racial populations (Wang et al., 2023). Individuals of African ancestry may retain handedness habits passed down from previous familial generations. With the growing influx of African immigrants to the U.S. (Corra, 2023), an effort to recognize their cultural handedness behaviors is essential to effectively refining research screening tools to ensure the integrity of scientific practices in neuroscience research. Further, it would be worth investigating whether these socialized hand preferences correlate to shifts in brain laterality.
Integration of cultural competencies in handedness assessments
A primary goal of handedness screening assessments is to determine an individual's hand dominance based on their reported hand preference across a variety of tasks. These assessments draw from a basic inventory to evaluate hand dominance, with some screening tools incorporating additional survey questions that examine the influence of familial factors on handedness (Klöppel et al., 2010). Inventories typically include questions about the direction and degree of hand use for routine activities, such as writing, eating, and throwing, while concurrently assessing how frequently one hand is favored over the other (Oldfield, 1971). While handedness inventories are generally regarded as a reliable instrument for evaluating hand dominance, it is important to heed the caution given by psychologist Richard Charles Oldfield, inventor of the Edinburgh Handedness Inventory (EHI). Oldfield acknowledged that the selection of tasks in such inventories requires greater cultural sensitivity to be universally applicable to participants of differing social groups, including variations in sex, culture, nationality, and socioeconomic status (Oldfield, 1971). For example, researchers translating an English version of the EHI within a Chinese validity study identified tasks in the questionnaire that could be revised to better model Chinese practices. Altering a task description from “knife without a fork” to “knife to cut meat or vegetables,” and replacing “spoon” with “chopsticks” ensured that the language used in the EHI was more aligned with Chinese culture (Yang et al., 2018).
Our team's experimental study on racism and cognitive function among Black males revealed the potential for cultural perspectives to influence handedness assessment responses. Participants born to West African immigrants were more likely to report mixed hand use or forced hand conversion. These individuals were initially excluded from the study by us, resulting in an overall decline in the number of eligible participants. To better understand this occurrence, we asked participants to provide more details about their responses to the questionnaire. We discovered that our handedness assessment may not have accounted for African cultural and religious practices where the right hand is traditionally reserved for formal tasks and the left hand for chores (Alhassan, 2018; Awidi and Hadidi, 2021).
Participants in our study frequently sought clarification on a particular survey question about forced right-hand conversion (see Supplementary material). Our team later identified two distinct interpretations of this question by participants. The first interpretation was perceived as whether a parent ever attempted to convert the participant's true handedness from left to right. Meanwhile, the second interpretation was perceived as whether a parent required the participant to temporarily use a preferred hand during task performance. As a result, responses could have different implications depending on participants' comprehension of the question. For example, marking “yes” to the latter interpretation might indicate that the use of the right hand was enforced short-term for specific tasks rather than as a permanent change in handedness.
On the contrary, marking “yes” may lead researchers to conclude that a participant has spent significant effort in converting their handedness to the right side. This is a critical inference because, if a serious attempt at hand conversion is assumed, scientists may believe that permanent changes to brain laterality have occurred (Siebner et al., 2002). Such an assumption could lead to the potential dismissal of participants from a study. Given this implication, further research is needed to examine how cultural practices influence assessment responses across the broader Black community and whether they impact hand dominance, leading to long-term brain changes.
Potential culturally sensitive modifications to handedness screening assessments
To improve the internal validity of screening tools, adding questions that address the role of culture and religion could provide a more holistic understanding of handedness in ethnically diverse populations. We suggest incorporating questions designed to determine if a cultural or religious practice might account for a dextral response. We recommend including questions that examine whether:
• Participants experience forced changes in handedness based on cultural or religious beliefs (i.e., were you forced to use your preferred hand for this task due to a cultural or religious belief?).
• Hand preference deviates from hand dominance (i.e., is your preferred hand for this task different from your dominant hand?).
• Frequency of the hand used in tasks is equivalent to the assumption of handedness (i.e., how often do you utilize this task in your daily routine?).
Adopting such changes may enlighten neuroscience researchers about the sociocultural dimensions of handedness. A related concern beyond the screening itself is the unavailability of a scientific workforce that can and will drive a research agenda inclusive of racial/ethnic/religious factors that may matter in neuroscience research. Addressing this requires continued efforts to diversify the workforce and incorporate varied perspectives throughout the research process. One effective approach would be for research teams studying culturally diverse populations to enlist community advisory boards (La Scala et al., 2023). These boards, composed of members representative of the study population, can critically review screening tools, and determine whether tasks and associated survey questions are culturally appropriate.
Conclusion
To advance our knowledge of how cultural and religious differences impact handedness screening tools, careful assessment of handedness research protocols is needed. In the face of improved tools for determining lateralization, neuroscience researchers should consider including left-handed individuals as stratified samples in cognitive studies, as this may help reveal the impact of handedness on cognitive function. To improve the internal validity of handedness research, future studies should examine the effects of culture and religion on hand dominance and its relationship to structure and function in the brain. Researchers can help mitigate disparities in neuroscience research by carefully evaluating tools for potential bias, and thoroughly assessing study inclusion/exclusion criteria that may unknowingly exclude those who bear a greater burden of health disparities. Neuroscience research stands to benefit from reducing brain health disparities in Black populations by driving research agendas whose criteria and knowledge of diversity is based on inclusive science.
Author contributions
MN: Conceptualization, Project administration, Supervision, Writing – original draft, Writing – review & editing. AO: Conceptualization, Methodology, Writing – original draft, Writing – review & editing. CM: Investigation, Writing – original draft, Writing – review & editing. JS: Conceptualization, Project administration, Supervision, Writing – review & editing. EZ: Conceptualization, Project administration, Supervision, Writing – original draft. VM: Conceptualization, Funding acquisition, Project administration, Supervision, Writing – original draft, Writing – review & editing.
Funding
The author(s) declare financial support was received for the research, authorship, and/or publication of this article. Funding for this article was provided by MD006923 National Institute of Minority Health and Heath Disparities MH115344 National Institute of Mental Health.
Acknowledgments
We thank Esther Emanelom, Raneem Mokatrin, and Ann Pham for their early work in recruiting participants and contribution to the initial work in the African American Male Racism Interview (AAMRI) study, Kosi Ogbuli and Kelechi Iheancho for their assistance in recruiting and commenting on the cultural aspects of handedness, and Xingrou Zhang for her assistance in AAMRI data input and analyses.
Conflict of interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Publisher's note
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.
Supplementary material
The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fnhum.2024.1390881/full#supplementary-material
References
Abiodun, S. J. (2019). “Seeing Color,” a discussion of the implications and applications of race in the field of neuroscience. Front. Hum. Neurosci. 13:280. doi: 10.3389/fnhum.2019.00280
Agbiji, O. M., and Swart, I. (2015). Religion and social transformation in Africa: a critical and appreciative perspective. Scriptura 114, 1–20. doi: 10.7833/114-0-1115
Ajuwon, A. M., and Love, R. (2020). Type 2 diabetes and depression in the African American population. J. Am. Assoc. Nurse Pract. 32, 120–127. doi: 10.1097/JXX.0000000000000240
Alhassan, A. B. (2018). Left-handedness and stigmatization in Africa: implications for parents and teachers. Global J. Archaeol. Anthropol. 7, 1–5. doi: 10.19080/GJAA.2018.07.555713
Awidi, M., and Hadidi, S. (2021). Participation of Black Americans in cancer clinical trials: current challenges and proposed solutions. JCO Oncol. Pract. 17, 265–271. doi: 10.1200/OP.21.00001
Bailey, L. M., McMillan, L. E., and Newman, A. J. (2019). A sinister subject: quantifying handedness-based recruitment biases in current neuroimaging research. Eur. J. Neurosci. 51, 1642–1656. doi: 10.1111/ejn.14542
Barnes, L. L., and Bennett, D. A. (2014). Alzheimer's disease in African Americans: risk factors and challenges for the future. Health Affairs 33, 530–536. doi: 10.1377/hlthaff.2013.1353
Basu, A., and Gujral, K. (2020). Evidence generation, decision making, and consequent growth in health disparities. Proc. Natl. Acad. Sci. USA. 117, 14042–14051. doi: 10.1073/pnas.1920197117
Burke, S. L., Cadet, T., and Maddux, M. (2017). Chronic health illnesses as predictors of mild cognitive impairment among African American older adults. J. Natl. Med. Assoc. 110, 314–325. doi: 10.1016/j.jnma.2017.06.007
Chatagny, P., Badoud, S., Kaeser, M., Gindrat, A., Savidan, J., Fregosi, M., et al. (2013). Distinction between hand dominance and hand preference in primates: a behavioral investigation of manual dexterity in nonhuman primates (macaques) and human subjects. Brain Behav. 3, 575–595. doi: 10.1002/brb3.160
Corra, M. (2023). Immigration from Africa to the United States: key insights from recent research. Front. Sociol. 8:1171818. doi: 10.3389/fsoc.2023.1171818
De Kovel, C. G., Carrión-Castillo, A., and Francks, C. (2019). A large-scale population study of early life factors influencing left-handedness. Sci. Rep. 9:584. doi: 10.1038/s41598-018-37423-8
Fagard, J., and Dahmen, R. (2004). Cultural influences on the development of lateral preferences: a comparison between French and Tunisian children. Laterality 9, 67–78. doi: 10.1080/13576500342000167
Galobardes, B., Bernstein, M. S., and Morabia, A. (1999). The association between switching hand preference and the declining prevalence of left-handedness with age. Am. J. Public Health 89, 1873–1875. doi: 10.2105/AJPH.89.12.1873
Jing, S. S. (2020). Hand dominance: nature, nurture, and relevance for hand surgeons. J. Hand Microsurg. 14, 111–112. doi: 10.1055/s-0040-1713557
Johncy, S. S., Sau, M. T, and Samuel, T. V. (2021). Impact of handedness on mental and neuropsychological performance in young adults. Natl. J. Physiol. Phar. Pharmacol. 11, 51–55. doi: 10.5455/njppp.2021.10.08213202003092020
Klöppel, S., Mangin, J., Vongerichten, A., Frackowiak, R. S., and Siebner, H. R. (2010). Nurture versus nature: long-term impact of forced right-handedness on structure of pericentral cortex and basal ganglia. J. Neurosci. 30, 3271–3275. doi: 10.1523/JNEUROSCI.4394-09.2010
La Scala, S., Mullins, J. L., Firat, R. B., Emotional Learning Research Community Advisory B.oard,, and Michalska, K. J. (2023). Equity, diversity, and inclusion in developmental neuroscience: practical lessons from community-based participatory research. Front. Integr. Neurosci. 16:1007249. doi: 10.3389/fnint.2022.1007249
Lock, S. L., Chura, L. R., Dilworth-Anderson, P., and Peterson, J. (2023). Equity across the life course matters for brain health. Nat. Aging 3, 466–468. doi: 10.1038/s43587-023-00413-1
Mohamed, B., Cox, K., Diamant, J., and Gecewicz, C. (2021). Faith among Black Americans. Pew Research Center. Available at: https://www.pewresearch.org/religion/2021/02/16/faith-among-black-americans/ (accessed September 18, 2024).
Musemwa, N., and Gadegbeku, C. A. (2017). Hypertension in African Americans. Curr. Cardiol. Rep. 19:129. doi: 10.1007/s11886-017-0933-z
National Academies of Sciences Engineering, Medicine; Health Medicine Division; Board on Health Sciences Policy; Forum on Neuroscience Nervous System Disorders, Posey Norris, S. M. Childers E. Brookshire B. (2023). Health Disparities in Central Nervous System Disorders: Access to Care: Proceedings of a Workshop—in Brief. New York: National Academies Press (US).
Oldfield, R. C. (1971). The assessment and analysis of handedness: the Edinburgh inventory. Neuropsychologia 9, 97–113. doi: 10.1016/0028-3932(71)90067-4
Otado, J., Kwagyan, J., Edwards, D., Ukaegbu, A., Rockcliffe, F., and Osafo, N. (2015). Culturally competent strategies for recruitment and retention of african american populations into clinical trials. Clin. Transl. Sci. 8, 460–466. doi: 10.1111/cts.12285
Park, J., Chang, J., and Davidson, J. (2020). Equal opportunity beliefs beyond black and white American Christianity. Religions 11:348. doi: 10.3390/rel11070348
Pugazhenthi, S., Qin, L., and Reddy, P. H. (2017). Common neurodegenerative pathways in obesity, diabetes, and Alzheimer's disease. Biochim. Biophys. Acta Mol. Basis Dis. 1863, 1037–1045. doi: 10.1016/j.bbadis.2016.04.017
Rajan, K. B., Weuve, J., Barnes, L. L., Wilson, R. S., and Evans, D. A. (2019). Prevalence and incidence of clinically diagnosed Alzheimer's disease dementia from 1994 to 2012 in a population study. Alzheimer's Demen. 15, 1–7. doi: 10.1016/j.jalz.2018.07.216
Rutten-Jacobs, L., McIver, T., Reyes, A., Pereira, M., Rosenthal, R., Parusel, C. T., et al. (2024). Racial and ethnic diversity in global neuroscience clinical trials. Contempor. Clin. Trials Commun. 37:101255. doi: 10.1016/j.conctc.2024.101255
Scharff, D., Mathews, K., Jackson, P., Hoffsuemmer, J., Martin, E., and Edwards, D. (2010). More than tuskegee: understanding mistrust about research participation. J. Health Care Poor Underser. 21, 879–897. doi: 10.1353/hpu.0.0323
Scharoun, S. M., and Bryden, P. J. (2014). Hand preference, performance abilities, and hand selection in children. Front. Psychol. 5:82. doi: 10.3389/fpsyg.2014.00082
Serrien, D. J., Ivry, R. B., and Swinnen, S. P. (2006). Dynamics of hemispheric specialization and integration in the context of motor control. Nat. Rev. Neurosci. 7, 160–166. doi: 10.1038/nrn1849
Shanunu, Z., Ibrahim, M. G., and Alhassan, E. (2022). Cultural underpinnings on the use of left-hand in Gbanjong community of the Tolon district of Ghana. J. Educ. Lear. Technol. 3, 13–27. doi: 10.38159/jelt.2022321
Siebner, H. R., Limmer, C., Peinemann, A., Drzezga, A., Bloem, B. R., Schwaiger, M., et al. (2002). Long-term consequences of switching handedness: a positron emission tomography study on handwriting in “converted” left-handers. J. Neurosci. 22, 2816–2825. doi: 10.1523/JNEUROSCI.22-07-02816.2002
Simmons, G. (2008). From Muslims in America to American Muslims. J. Islamic Law Cult. 10, 254–280. doi: 10.1080/15288170802481145
Singh, M., and Kundu, A. (1994). Hand preference and approval among Hindus and Muslims in India. Int. J. Neurosci. 75, 19–29. doi: 10.3109/00207459408986285
Stephan, B., Harrison, S. L., Keage, H., Babateen, A., Robinson, L., and Siervo, M. (2017). Cardiovascular disease, the nitric oxide pathway and risk of cognitive impairment and dementia. Curr. Cardiol. Rep. 19:87. doi: 10.1007/s11886-017-0898-y
Tamir, C. (2022). Key findings about Black immigrants in the U.S. Pew Research Center. Available at: https://www.pewresearch.org/short-reads/2022/01/27/key-findings-about-black-immigrants-in-the-u-s/#:~:text=One%2Din%2Dten%20Black%20people,million%20during%20the%20same%20period (accessed September 14, 2024).
Tamir, C., and Anderson, M. (2022). One-in-Ten Black People Living in the U.S. are Immigrants. Pew Research Center. Available at: https://www.pewresearch.org/race-ethnicity/2022/01/20/one-in-ten-black-people-living-in-the-u-s-are-immigrants/ (accessed September 17, 2024).
Wang, Q., Davis, P. B., Gurney, M. E., and Xu, R. (2021). COVID-19 and dementia: Analyses of risk, disparity, and outcomes from electronic health records in the US. Alzheimer's Dement. 17, 1297–1306. doi: 10.1002/alz.12296
Wang, Y., Zhang, Y., and Wadsworth, H. (2023). Family and peer ethnic-racial socialization in adolescents' everyday life: a daily transactional model with ethnic-racial identity and discrimination. Child Dev. 94, 1566–1580. doi: 10.1111/cdev.13937
Wanleenuwat, P., Iwanowski, P., and Kozubski, W. (2019). Alzheimer's dementia: pathogenesis and impact of cardiovascular risk factors on cognitive decline. Postgrad. Med. 131, 415–422. doi: 10.1080/00325481.2019.1657776
Webb, E., Etter, J., and Kwasa, J. (2022). Addressing racial and phenotypic bias in human neuroscience methods. Nat. Neurosci. 25, 410–414. doi: 10.1038/s41593-022-01046-0
Willems, R. M., Van der Haegen, L., Fisher, S. E., and Francks, C. (2014). On the other hand: including left-handers in cognitive neuroscience and neurogenetics. Nat. Rev. Neurosci. 15, 193–201. doi: 10.1038/nrn3679
Yang, N., Waddington, G., Adams, R., and Han, J. (2018). Translation, cultural adaptation, and test-retest reliability of Chinese versions of the edinburgh handedness inventory and waterloo footedness questionnaire. Laterality 23, 255–273. doi: 10.1080/1357650X.2017.1357728
Zuelsdorff, M., Okonkwo, O. C., Norton, D., Barnes, L. L., Graham, K. L., Clark, L. R., et al. (2020). Stressful life events and racial disparities in cognition among middle-aged and older adults. JAD 73, 671–682. doi: 10.3233/JAD-190439
Keywords: black, culture, diversity, neuroscience, hand dominance, handedness screening assessments
Citation: Nwufo M, Onuoha A, Mallory C, Stradford J, Zaidel E and Mays VM (2024) Might culture impact the assessment of handedness in Black participants in neuroscience research? Front. Hum. Neurosci. 18:1390881. doi: 10.3389/fnhum.2024.1390881
Received: 24 February 2024; Accepted: 14 October 2024;
Published: 06 November 2024.
Edited by:
Stefanie Bodison, University of Florida, United StatesReviewed by:
Melissa A. Harrington, Delaware State University, United StatesVoyko Kavcic, Wayne State University, United States
Copyright © 2024 Nwufo, Onuoha, Mallory, Stradford, Zaidel and Mays. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Vickie M. Mays, mays@ucla.edu
†Deceased