“Looking back to look forward”: evaluation of a leadership program for prison staff designed to promote public health-focused culture change in US prisons Open Access

Prisons are associated with poor health outcomes for people who are incarcerated and for prison staff (Cloud et al., 2023a; Favril et al., 2024; Ferdik and Smith, 2017; Miller et al., 2022). Studies suggest that the life expectancy of correctional officers in the USA is nearly two decades lower than the national average (Cheek and Miller, 1983; Kochanek et al., 2024). The rates of heart disease, diabetes, hypertension, depression, posttraumatic stress disorder, alcohol use disorder and suicide among this workforce exceed those in the public (Miller et al., 2022; Bezerra et al., 2016; Bourbonnais et al., 2007; Brower, 2013; Obidoa et al., 2011; Regehr et al., 2021). Correctional officers also report high rates of divorce, family conflict and other social adversities. Job-related stress and burnout are major drivers of the poor health among correctional officers (Obidoa et al., 2011; Valentine et al., 2012). Prison staff consistently report organizational and occupational stressors that contribute to low job satisfaction, burnout, moral and physical injuries and other adverse health outcomes (Bezerra et al., 2016; Bourbonnais et al., 2007; Brower, 2013; Obidoa et al., 2011; Regehr et al., 2021; Denhof et al., 2014; Finney et al., 2013; Lerman et al., 2022; Reiter and Chesnut, 2018; Trounson and Pfeifer, 2017; Flanagan, 2006; Gallavan and Newman, 2013). Examples of organizational stressors include having diminished autonomy, feeling unsupported by agency leadership and finding little purpose or meaning in their professional responsibilities (Bezerra et al., 2016; Bourbonnais et al., 2007, Lerman et al., 2022, Trounson and Pfeifer, 2017, Schaufeli and Peeters, 2000, Senter et al., 2010). Occupational stressors include responding to traumatic or violent incidents that result in physical or psychological injuries (Konda et al., 2012, Steiner and Wooldredge, 2017), and antagonistic dynamics with supervisors, colleagues and incarcerated people (Bezerra et al., 2016; Brower, 2013, Denhof et al., 2014). Pervasive occupational health hazards and stress-related ailments are also contributing to high rates of absenteeism, turnover and vacancies in correctional agencies nationwide (Lambert et al., 2005). Indeed, in 2024, the US Senate held a hearing calling attention to how this public health crisis imperils the health and safety of people living and working in carceral institutions.

Historically, efforts to improve public health by changing the toxic culture of prisons typically focus on litigation, legislation and on changing prison policies. Yet, implementation of these top-down approaches to change is often hampered, and even undermined, by prison staff who have countervailing attitudes and beliefs and/or deficits in the knowledge and skills needed to enact the mandated changes (Lerman and Harney, 2019; Reiter, 2015). Evidence suggests that these “top-down” approaches to prison reform efforts can fall short if they fail to consider the implications for staff health and safety (Keramet Reiter et al., 2025). Indeed, the culture of prison staff who respond negatively to external legal mandates or agency directives compelling change is a formidable impediment to implementing policy and cultural change initiatives. Conversely, studies in organizational behavior and management scholarship, suggest that “bottom-up” strategies that engage frontline staff and provide them with education and support from leadership are essential to policy change initiatives. Yet, in a prison context, few efforts have been made to foster “ground-up” changes in prison culture and practices by educating and mobilizing prison staff to envision, invest in and drive the creation of healthier prison environments to reduce institutional harm. In 2015, we launched a partnership with the Norwegian Correctional Service to train US prison staff in international approaches to prison work that focus on rehabilitation and health, rather than punishment (Ahalt et al., 2020).

The National Correctional Service of Norway is considered an international gold standard in public health-focused prison practices and boasts among the world’s lowest rates of incarceration, recidivism and prison violence. It maintains that “people go to court to get punished and go to prison to become better neighbors.” (Benko, 2018; Hyatt and Andersen, 2018; Norwegian Ministry of Justice and the Police, 2018; Labutta, 2016). This rehabilitation-focused orientation means that Norway’s prison officers are trained to play an active role in prison residents’ rehabilitation by using positive incentives and motivational interviewing, engaging and connecting residents to health-focused programming, and providing intensive mentorship, programming and positive interactions to support them to change their lives for the better and return to the community as “better neighbors.” (Labutta, 2016; Abdel-Salam and Myhre Sunde, 2018). Our programming includes leading immersion courses in Norway for US prison and policy leaders to better understand this approach, providing technical assistance for US prison leaders to pilot new humanity-centered, dignity-driven, public health models that reduce prison harm, and delivering intensive trainings for US prison officers to operationalize these new models in the USA (Ahalt et al., 2020).

In 2021, we developed an “Ambassadors Program” for prison staff to inspire and train their colleagues to lead and drive change within US prisons. The aims of the program are to teach participants about the history of the US criminal legal system and its impact on the health and wellbeing of people who are incarcerated and prison staff; educate participants about public health approaches to criminal justice reform from Norway and beyond; and empower participants to drive dignity-driven, humanity-focused change in US prisons. The long-term goal of the Ambassadors program is to develop a cadre of change agents who have the leadership skills needed to inspire, motivate and educate other prison staff, correctional leaders and policymakers to change conditions in US prisons that harm residents and staff.

This manuscript describes a formative evaluation of the Ambassadors program. The evaluation was designed to assess whether this immersive, educational intervention could inspire public-health-focused leadership among prison professionals to lead changes in prison culture. We use the Proctor Model, a widely used implementation science framework, described in the next section, to evaluate the early implementation of this program, report its impact on participants and set the stage for future research (Proctor et al., 2013).

We enrolled three cohorts of participants in the Ambassadors training program between 2021 and 2023. The program included a seven-unit, synchronous, interactive, online course followed by an immersion program in the Norwegian Correctional Service. US participants included security and healthcare staff from US prisons who were recruited from four states that previously received our educational interventions (Washington, Oregon, North Dakota and California). Nominees were chosen by their supervisors for leading or expressing interest in being leaders in prison reform; all nominees were enrolled in the program. Although US prison staff were the main participants, we also enrolled two Norwegian prison officers in each cohort to share their perspectives and experiences, and to facilitate their understanding about the history of US prisons to enhance their ability to support our future training and technical assistance in the US. All participants elected to participate in an optional program evaluation.

The goals of the Ambassadors program were to:

• Teach participants about the history and current state of the US prison system and its roots in slavery, subjugation and racial violence.

• Educate Ambassadors about public health approaches to prison reform, including Norway’s innovative approaches to prison work.

• Empower Ambassadors to lead dignity-driven, humanity-focused change in US prisons.

The Ambassadors program drew on successful practices from adult education, including experiential, transformative and reflective learning (Mezirow, 2018). The online portion of the program used a “flipped classroom” approach, including asynchronous readings and viewings of videos developed for the course, followed by synchronous online group discussions with other participants and formerly incarcerated community leaders (“community partners”).

The course was comprised of two parts: “Looking Back” and “Looking Forward,” Figure 1. In the first, “Looking Back” portion of the course, participants learned how legacies of slavery and convict leasing, and the impacts of the war on drugs and deinstitutionalization of the mentally ill have led to mass incarceration and the unhealthy culture present in most US prisons today. The “Looking Forward” part of the course introduced ways that prisons can change, including the humanizing power of changing language (Tran et al., 2018) and respectful staff-resident interactions (Chanenson et al., 2024), the positive role that prison staff can play in helping someone change their life for the better, and the promise of rehabilitative programming for community safety, Table 1. Each of these sessions were conducted via zoom and lasted approximately 90 min. Participants were invited to submit requests for additional technical assistance from Amend staff and Norwegian collaborators throughout their participation in the program.

Participants were also asked to develop a “Legacy Project” that draws on the foundational correctional principles of Norway’s prison service (e.g., dynamic security, normalization, progression, humanization and a professionalized workforce).

The Ambassadors course culminated in a week-long immersion program in the Norwegian Correctional Service. Norwegian course participants joined the immersion activities, led group site visits at their home prisons and joined group events. The week-long immersion program included site visits to Norwegian prisons, Norway’s Prison Staff Academy and a series of lectures and workshops on prison reform and leadership development. Prison visits included a high-security prison (Halden Prison), low security “open” prison (Bastøy Prison) and a reentry/halfway house (Oslo Halfway House). Other site visits were customized to each participant’s professional duties, and included a women’s prison, and additional high-security prisons (Oslo Prison, Ila Prison, Romerike Prison).

All site visits included job shadowing opportunities for participants to interact with staff and incarcerated people and to highlight the ways in which Norwegian prisons of all security levels embody key principles such as normalization (life inside prison should resemble life outside as much as possible), progression (prison residents should have opportunities to earn increased freedom alongside increased responsibility throughout their sentence) and dynamic security (that respectful professional relationships between staff and incarcerated people are a critical facet of prison security) (Cloud et al., 2021; Høidal, 2018). Participants also attended a series of lectures about prison reform in Norway, guided reflection activities and a narrative workshop by a US professor of English Literature.

Following completion of the formal Ambassadors course, participants were encouraged to continue implementing their Legacy Projects or lead other projects at their home institutions. We hosted quarterly online check-ins to allow participants to share updates and continue learning from each other. We also offered Ambassadors a variety of leadership opportunities, including local, regional or national speaking engagements; presenting their Legacy Projects to elected officials; and leading trainings at other carceral facilities with our training staff.

All participants were asked to complete optional surveys before and after the online course and following the Norway immersion program. Baseline surveys assessed participant sociodemographics and professional experiences. We used a pre/post survey design using five-point Likert scales to assess attitudes and perspectives about the optimal role of prison staff, prison conditions, the presence of racial discrimination in prisons, well-being and burnout, historical knowledge about US prisons and key public health correctional principles such as dynamic security, normalization and progression.

After the course, all participants were invited to complete voluntary 30-to-60-minute semi-structured interviews about their experiences in and perspectives about the course. Interviews were conducted in person or via a videoconferencing call with one of the authors (I.G.-G., D.H.C.) and were audio-recorded and transcribed.

Our program evaluation was guided by Proctor’s Model of Implementation Research. Implementation science approaches are increasingly used to study health-focused interventions in carceral settings (Proctor et al., 2011; Proctor et al., 2013; Van Deinse et al., 2023). The Proctor Model provides a framework for understanding the process and success of the implementation of an intervention, including evaluation of implementation outcomes, service outcomes and client outcomes (Proctor et al., 2011, Proctor et al., 2013). We evaluated relevant outcome categories, including implementation outcomes (acceptability, appropriateness, adoption, feasibility, penetration), service outcomes (effectiveness) and client outcomes (satisfaction and function). The Proctor Model provides measurable constructs and a practical framework of conducting formative evaluations to describe the process of implementing novel health promotion interventions, assessing their impacts on participants and exploring the feasibility of adapting the program to diverse settings. Definitions of the relevant implementation domains from the Proctor Model and their application to the Ambassador program evaluation are outlined in Table 2.

Our mixed methods evaluation of the Ambassadors program used survey and interview data from our first three participant cohorts. We summarized participant characteristics using descriptive statistics. We used McNemar’s test to analyze dichotomous responses and Wilcoxon signed rank test for categorical variables (Adedokun and Burgess, 2012; Cummings and McKnight, 2004). We conducted a thematic analysis of participant interviews. Two authors (I.G.-G., D.H.C.) participated in an iterative process of coding themes from interview transcripts (Braun and Clarke, 2006; Braun and Clarke, 2014). This research was approved by the University of California, San Francisco Institutional Review Board. STATA version 17 and NVIVO software were used for all analyses.

Three cohorts of participants completed the Ambassadors program between September 2021 and May 2023. Research participants included 37 prison staff; 28 staff from 10 different US prisons across four states (Oregon, California, North Dakota and Washington) and 9 prison staff from 3 Norwegian prisons, Table 3. Of our 37 participants, 59% were male, 80% were younger than 50 years old and 68% identified as white. On average, participants had worked in corrections for 15 years and the majority were security staff (83%).

Adoption refers to the intention, initial decision or action to adopt an innovative program, while acceptability considers the extent to which stakeholders perceive a program and its implementation as suitable and beneficial to their interests (Proctor et al., 2011). All participants completed the full program and as of January 2024, 32 (86%) had participated in or led a training with our program. Overall, 100% of participants agreed or strongly agreed that they learned something valuable and 100% strongly agreed that their colleagues would benefit from participating in the program.

On average, participants agreed strongly that group discussions (78%) and films (64%) were effective teaching methods; fewer agreed strongly that online reflections (28%) and reading assignments (33%) were effective learning tools. Most participants agreed strongly that it was beneficial to discuss program materials with prison staff from other states (86%), with previously incarcerated people (86%), with prison staff from Norway (75%), and with prison-based healthcare professionals (64%). During interviews, most participants described the program’s experiential components as having the greatest educational impact, including the narrative workshop. As one participant explained:

Others found having formerly incarcerated community partners participating in the program and taking a leadership role in some sessions to be among the most impactful elements of the program. Many described that having a professional relationship with a formerly incarcerated person was a new experience for them. Others noted finding common ground with community partners: “I now have friends for life and truly believe we all suffered in silence and can relate to a lot of the same things while we all did time [in prison]”. Others highlighted the important perspective community partners brought to the program: “their perspective is invaluable for my development and for the future of prisons”.

The Proctor Model defines the domain of appropriateness based on a program’s “fit, relevance, or compatibility” within a practice settin (Proctor et al., 2011). Participants described the educational content and experiential components of the Ambassadors program as being highly relevant to their workplaces. One participant shared their perspective on the applicability of the program:

Another participant stated that “[This program] has provided opportunities for me to be inspired and to get a different perspective.” Several people explained that the program helped them understand pathways to making culture change within their workplaces, including that change can occur from the ground up, rather than top down. As one participant stated, “what I learned in the course about culture change is you really have to make a decision to be the culture change”.

Others reported that the Ambassadors program provided valuable knowledge and created new opportunities for connecting with others who share an interest in prison reform. When asked for the most important takeaways from the program, many commented on the power of social networking and connection “beyond the ocean and state borders” to cultivate group learning and to nurture support for advancing reform initiatives in their work environments. In addition, 97% agreed or strongly agreed it was helpful that the course incorporated prison staff from multiple states and facilities. One participant described that the most important lesson was “I am not alone – there are people who feel the same way I do and have the same or similar struggles.” Many participants described a feeling that the course had created a new community that decreased work isolation, increased individual confidence, and provided opportunities to learn from and support others engaged in similar work.

Following the immersion program in Norway, participants explained that seeing the Norwegian system allowed them to envision changes in US prisons. After the immersion experience, 95% of participants agreed or strongly agreed that their prison can become more like the ones in Norway. One said that “by physically seeing the Norway Prison system, I know it can be done in California.” In interviews, when asked what they liked the most about the trip, many described the power of seeing another system firsthand. “[I liked] experiencing the facilities with all your senses. It is one thing to see a video, but [another] to see, hear, feel the places and teamwork”.

Penetration is a domain for assessing whether and how an intervention is integrated within a real-world setting (Proctor et al., 2011). Here, this was operationalized by examining whether and how program participants leveraged newly acquired knowledge to initiate changes in practice or policy in their own work environment. Overall, 84% of participants implemented a Legacy Project in their workplace focused on creating public health-informed changes. Examples included creation of a Contact Officer program, inspired by the Norwegian model where officers provide one-on-one mentorship to incarcerated people; the development of Resource Teams, also inspired by the Norwegian model, in which trained teams of prison staff work to increase time out of cell for people in solitary confinement (Lerman et al., 2022).

Following completion of the course, 86% of participants continued to be closely involved in leadership opportunities within our training program. These opportunities have included co-facilitating trainings with program staff, joining academic conference presentations to present projects from their institutions, and developing their Legacy Projects into programs that are replicable models for other facilities.

Feasibility refers to whether a program can be successfully introduced to a group of practitioners or within a distinct organizational context (Proctor et al., 2011). This evaluation assessed the barriers and facilitators to implementing the Ambassador’s educational curriculum among three cohorts of prison staff. The 100% completion rate among participants, and high rate of engagement after the program (86%) demonstrates it is feasible to engage prison staff in reflecting on historical and institutional forces shaping culture in US prisons and investing in its change. One logistical barrier to implementation was the COVID-19 pandemic, which resulted in travel restrictions and delays in the first immersion program in Norway for Cohort 1 (which is why they joined Cohort 2’s immersion program). Another barrier in one state prison system included profound understaffing which limited opportunities to their staff to participate in program trainings beyond their own prison.

The Proctor Model simply defines the effectiveness of program implementation as extent to which a program meets its stated objectives (Proctor et al., 2011). Here, we assessed whether participants in the Amend Ambassador’s program experienced an increase in their knowledge of topics in the course curriculum, changes in their views of correctional practice, confidence and skills in leadership and positive impact on their overall well-being.

The Ambassadors program increased knowledge about US prison history and prison reform initiatives including an increase in self-reported knowledge across all 13 core topics after the course, Table 4. In interviews, most participants described having had no education about the history of US prisons and their relationship to slavery and emphasized that this history should be included in their basic training. “Everybody in our ambassador group is saying we need this to be part of correctional officer basic training. We have to understand the history”. Another participant shared, “It is important to know our history to know where and how to move forward. A lot of the content in the Ambassadors program should be made available to more staff.” One participant viewed learning about structural racism and history of corrections as important for driving culture change:

Norwegian participants also found the course helpful and that learning more about the US historical context of prisons would help them to be more effective when educating US prison staff.

We found that some attitudes about the role of prisons in the USA differed after completion of the course. At the end of the program, fewer participants believed that the purpose of a prison sentence should be punishment, fewer believed that people were incarcerated in prisons solely because of their personal failures, and fewer thought that living conditions should be as uncomfortable as possible as a deterrent to crime, Table 5.

Following the program, 97% of participants reported that they felt more inspired to lead culture change in prisons. One participant stated:

This inspiration appeared to be tied to participants’ confidence in becoming leaders in their work communities. One participant shared, “[This program] has made me a more confident and driven leader, [I believe] that this work must be done and that it is my responsibility to drive it forward and be the role model at my prison”. Another attributed this feeling to the content covered in the Ambassadors course: “The passion has been there since my first time [interacting with] this program, but now I feel like I can ‘talk the talk’ because I am better educated on our own history, the ‘how’ and the ‘why’.”

All participants agreed or strongly agreed they had learned something valuable in the Ambassador program. Participants were impressed by the humanity they observed in the Norwegian prison service which helped them to reflect on how to improve their own work practices. Participants identified many ways that they planned to apply what they learned, including designing interventions targeting prison staff wellness; promoting the Norwegian concept of “normalization” by creating gardens or grocery stores in their prisons; and finding ways to promote humanity and dignity in staff and resident relationships. Others planned to use their new leadership skills upon their return, “[I plan on] helping my prison identify what their most important value(s) are first and then planning as a team what our next important steps are.” All participants strongly agreed that their colleagues would benefit from this program, pointing to the power and impact of the program and suggesting the need to continue these types of training and immersive experiences.

Overall, 77% of participants reported the course had a positive impact on their health and 58% reported feeling that their burnout was improved. One shared, “my health was positively impacted by the Ambassadors course by giving me a more open mindset, hope for the future, and helpful tools to make a change.” Another stated, “the way I think about my job has shifted due to the Ambassadors program – from housing inmates and processing paperwork to reimagining our communities filled with re-integrated, thriving individuals who were formerly incarcerated”. Some participants expressed appreciation that the program prioritizes staff wellness and emphasizes that prison reform work can lead to better staff outcomes:

Another participant wrote that the program, “gave me the strength to return [to work] as an advocate for what would give me job satisfaction, for a role and responsibilities that would bring me happiness and fulfillment at work […] things that will have an immense impact on my burnout and wellness”. Although 63% reported a sense of improvement in burnout at work, there were no statistically significant changes found in the individual burnout measures we collected (Table 6).

Prison conditions are hazardous to the health of people who are incarcerated in them and for staff who work in them (Cloud et al., 2023a; Favril et al., 2024; Ferdik and Smith, 2017; Miller et al., 2022; Cheek and Miller, 1983). Yet, policy mandates to improve prison conditions are often adopted with minimal (if any) resources or strategies for encouraging, educating, or training line-level prison staff on why or how to implement them. We developed the Ambassadors program which was designed to help prison staff understand the potential positive impact of prison culture change on their own lives, to develop leadership skills to drive “ground up” health-focused changes in carceral facilities. and to give them training skills to train their colleagues in humanistic, public-health-focused correctional principles.

Participants from multiple US states and institutions gave the Ambassadors program high acceptability ratings. The educational methods rated as most effective included having trainers from institutions that have already initiated public-health-focused reform and trainers who are formerly incarcerated who can share their lived experiences in US prisons. The immersion experience in the Norwegian Correctional Service was also considered particularly impactful for participants to see the staff culture and interventions used in a prison system considered an international model for best practice. Following completion of the course, participants reported increased knowledge of the history of US prisons and prison reform initiatives. Participants also reported feeling engaged in the material, inspired to lead transformative efforts in their institutions and committed to bringing along more colleagues in culture change efforts.

Participants found the Ambassadors program to be effective in providing them with the knowledge, skills and motivation to make “ground-up” changes to address problems in their facilities. Following participation in the program, nearly all participants reported increased confidence in their leadership capabilities and felt that they were empowered to lead changes in their workplaces. Following completion of the training course, 4 out of 5 participants took on a range of leadership roles and projects from local to national settings. However, further research is needed to assess whether these participants continue to play a role as change leaders in future years and what factors promote ongoing leadership engagement and help Ambassors scale and sustain of culture change initiatives in their workplace.

Several limitations should be considered when interpreting the results of this evaluation. First, most of our participants described improvements in their wellness because of their participation in the Ambassadors program. However, we did not observe statistical differences in burnout measures before and after the course. Possible explanations include an overall low level of burnout reported in this cohort and small sample sizes. However, given the novelty and potential impact of this program we believe an early evaluation is still informative. There may be variability in participant experiences based on their sociodemographics, locations or prior work experiences, but small sample sizes prevented us from evaluating these factors. In addition, it is important to note that Ambassadors program participants were selected for their demonstrated interest in making reform, as a result, these findings may not be generalizable to all prison staff. Finally, while these initial findings suggest this is a feasible and beneficial program for reducing harm and promoting rehabilitative values in prison environments shaped by decades of punitive ideological principles, it is important to underscore the vulnerability of such a program to the perpetual threat of “carceral clawback” – which is a concept that recognizes “the power of the prison constantly to deconstruct and successfully reconstruct the ideological conditions for its own existence”. Teaching frontline correctional staff about the ways through which mass incarceration is rooted in and shaped by the legacies of enslavement, racial oppression, and social inequality and teaching them new skills grounded in human dignity are essential for helping them reckon with the detrimental consequences that their profession often inflicts and give them tools to embrace calls for transformative change. At the same time, however, there is some risk that programs that professionalize prison staff run the risk of emboldening the power and legitimacy of prison officer unions and other influential stakeholders that have tenaciously opposed decarceration and radical reform initiatives because they have social, economic and political interest in sustaining, instead of shrinking the size of the carceral state. Our hope is that continuing to cast a light on the damage that prisons often inflict on the health of people who live and work within them will broaden the coalitions of stakeholders calling for both urgent, practical reforms to reduce harm and structural changes focused on decarceration and addressing social determinants of health.

This evaluation suggests that training prison staff in international approaches to humane, dignity-driven prison policies, educating prison staff about how to train other staff, and introducing them to the history of US prisons, including the legacies of enslavement and racial violence in shaping modern penal practices, can help to inspire efforts for reform of prison culture. In addition, because the US prison workforce experiences among the lowest occupational life expectancies and highest rates of morbidity (Ferdik and Smith, 2017; Butler et al., 2019), incorporating a focus on occupational health into prison staff-led culture change efforts is an important, yet often overlooked component of policy interventions seeking to undo harmful carceral practices and create organizational cultures receptive to transformative change (Ahalt et al., 2020; Cloud et al., 2023b, Santora et al., 2014).

Litigation, legislation and regulation are essential tools for undoing carceral policies and addressing institutional conditions that imperil the health, safety and rights of incarcerated people. However, efforts to change the policies and practices of carceral institutions through legal mandates often unfold within social, political and cultural contexts enmeshed in adversarial tensions. Implementation of these top-down approaches is often hampered and even undermined by prison staff resistant to change (Reiter and Chesnut, 2018). To our knowledge, this among the first programs designed to create leaders for prison reform by teaching frontline prison staff about the historical context of the US carceral system and drawing on best practices from international systems, including Norway. We found that this experiential learning approach that trains prison staff to become change makers in the quest to address inhumane conditions in the prisons in which they work is a feasible model for promoting public-health-focused culture change in prisons.

Funding: This research was supported by Arnold Ventures, the Jacob and Valeria Langeloth Foundation, the Charles and Lynn Schusterman Family Philanthropies and other private donors. The funders had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript.