Medicine and Health Sciences Commons^™

Community Paramedicine In Central Oregon: A Promising Model To Reduce Non-Urgent Emergency Department Utilization Among Medically Complexmedicaid Beneficiaries, Jessica Currier, Neal Wallace, Keshia Bigler, Maggie O’Connor, Paige E. Farris, Jackilen Shannon

OHSU-PSU School of Public Health Faculty Publications and Presentations

Background

Community paramedicine has emerged as a promising model to redirect persons with nonmedically emergent conditions to more appropriate and less expensive community-based health care settings. Outreach through community paramedicine to patients with a history of high hospital emergency department (ED) use and chronic health conditions has been found to reduce ED use. This study examined the effect of community paramedicine implemented in 2 rural counties in reducing nonemergent ED use among a sample of Medicaid beneficiaries with complex medical conditions and a history of high ED utilization.

Methods

A cluster randomized trial approach with a stepped wedge design was …

The Resident View In Community- Based Care Residential Settings, Diana L. White, Ozcan Tunalilar, Serena Hasworth, Jaclyn Winfree

Institute on Aging Publications

The Resident VIEW is a measure of person-centered care (PCC) from residents’ perspectives and was previously studied in nursing homes. The current study presents descriptive data for the Resident VIEW in community-based care settings including assisted living, residential care (AL/RC), and adult foster homes (AFH). Using a two-stage sampling design, we recruited 31 AL/RC and 119 AFH in Oregon and completed face-to-face structured interviews with 227 and 195 residents, respectively. Residents provided ratings for both the importance of and their experience with 66 items that tapped into PCC practices in eight domains. Results are provided for each item, many of …

Engaging Public Health Critical Race Praxis In Local Social Determinants Of Health Research: The Youth Health Equity And Action Research Training Program In Portland, Or—Yheartpdx, Ryan J. Petteway, Lourdes Gonzalez

OHSU-PSU School of Public Health Faculty Publications and Presentations

The social determinants of health (SDH) have long been considered a core mechanism through which racial health inequities are (re)produced and incubated in the U.S. Moreover, scholars have expressly—and appropriately—named structural racism as a precursor to inequities associated with SDH. However, while research on racial health inequities—SDH-related or otherwise—continues to grow, communities of color remain grossly underrepresented as public health researchers and practitioners. Additionally, although SDH are experienced in a very local sense, much research and practice fails to more deeply and thoroughly engage and center local community knowledges. Thus, much work around SDH and racial health inequities presents, ironically, …

2022 Community Needs Assessment Of Klamath County Residential Services And Housing Needs, Karen Cellarius, Aliza Tuttle, Jennifer Blakeslee

Regional Research Institute for Human Services

The PSU Regional Research Institute for Human Services (RRI) was asked by Klamath Basin Behavioral Health (KBBH) and the Oregon Health Authority (OHA) to conduct a community-wide needs assessment focusing on residential services and housing needs for populations that (1) Have behavioral health needs, and (2) Identify with a community experiencing inequities in access to health care resources.

The assessment was conducted in collaboration with KBBH and other community partners. Data sources included key informant interviews, written surveys of individuals impacted by mental health challenges and/or housing needs, and focus groups with representatives from underserved communities in Klamath County, Oregon. …

Tools For Addressing Intimate Partner Violence And Suicide Risk: Lessons Learned From Oha’S Covid-19 Emergency Response For Suicide Prevention Grant, Karen Cellarius, Aliza Tuttle, Lea Sevey

Regional Research Institute for Human Services

In August 2020, the Oregon Coalition Against Domestic and Sexual Violence (OCADSV), the Oregon Health Authority (OHA), and Portland State University’s Regional Research Institute for Human Services (PSU RRI) began an 18-month collaboration to strengthen support for domestic violence and mental health agencies during COVID-19. As part of this grant, six domestic violence advocacy organizations around Oregon were able to place co-located advocates with their mental health partner agencies for services and cross-training. The content of this booklet is another product of this collaboration.

Social Determinants Of Health And Care Outcomes Among People With Hiv In The United States, Timothy W. Menza, Lindsay K. Hixson, Lauren E. Lipira, Linda Drach

Regional Research Institute for Human Services

Fewer than 70% of people with HIV (PWH) in the United States have achieved durable viral suppression. To end the HIV epidemic in the United States, clinicians, researchers, and public health practitioners must devise ways to remove barriers to effective HIV treatment. To identify PWH who experience challenges to accessing health care, we created a simple assessment of social determinants of health (SDOH) among PWH and examined the impact of cumulative social and economic disadvantage on key HIV care outcomes.

Adverse Childhood Experiences, Adult Depression, And Suicidal Ideation In Rural Uganda: A Cross-Sectional, Population-Based Study, Emily N. Satinsky, Bernard Kakuhikire, Charles Baguma, Justin D. Rasmussen, Scholastic Ashaba, Christine E. Cooper-Vince, Jessica M. Perkins, Allen Kiconco, Elizabeth B. Namara, David R. Bangsberg, Multiple Additional Authors

OHSU-PSU School of Public Health Faculty Publications and Presentations

Background: Depression is recognized globally as a leading cause of disability. Early-life adverse childhood experiences (ACEs) have been shown to have robust associations with poor mental health during adulthood. These effects may be cumulative, whereby a greater number of ACEs are progressively associated with worse outcomes. This study aimed to estimate the associations between ACEs and adult depression and suicidal ideation in a cross-sectional, population-based study of adults in Uganda. Methods and findings: Between 2016 and 2018, research assistants visited the homes of 1,626 adult residents of Nyakabare Parish, a rural area in southwestern Uganda. ACEs were assessed using a …

Examination Of Orthodontic Expenditures And Trends In The United States From 1996 To 2016: Disparities Across Demographics And Insurance Payers, Man Hung, Sharon Su, Eric S. Hon, Edgar Tilly, Alex Macdonald, Evelyn Lauren, Glen Roberson, Martin S. Lipsky

Institute on Aging Publications

Background: Orthodontics prevent and treat facial, dental, and occlusal anomalies. Untreated orthodontic problems can lead to significant dental public health issues, making it important to understand expenditures for orthodontic treatment. This study examined orthodontic expenditures and trends in the United States over 2 decades. Methods: This study used data collected by the Medical Expenditure Panel Survey to examine orthodontic expenditures in the United States from 1996 to 2016. Descriptive statistics for orthodontic expenditures were computed and graphed across various groups. Trends in orthodontic expenditures were adjusted to the 2016 United States dollar to account for inflation and deflation over time. …

Facilitators And Barriers To Healthy Eating Among American Indian And Alaska Native Adults With Type 2 Diabetes: Stakeholder Perspectives, Sarah Stotz, Nertila Bregaj, Kelly Gonzales, Luciana E. Hebert, Kelly R. Moore

OHSU-PSU School of Public Health Faculty Publications and Presentations

Background: American Indian and Alaska Native (AI/AN) adults have a higher prevalence of type 2 diabetes (T2D) and related complications than non-AI/AN adults. As healthy eating is a cornerstone of diabetes self-management, nutrition education plays an important role in diabetes self-management education.

Objective: To understand stakeholder perspectives on facilitators and barriers to healthy eating for AI/AN adults with T2D in order to inform the cultural adaptation of an existing diabetes nutrition education curriculum.

Methods: Individual interviews were conducted with 9 national content experts in diabetes nutrition education (e.g. registered dietitians, diabetes educators, experts on AI/AN food insecurity) and 10 community-based …

Predictors Of Opioid And Alcohol Pharmacotherapy Initiation At Hospital Discharge Among Patients Seen By An Inpatient Addiction Consult Service, Honora Englander, Caroline King, Christina Nicolaidis, Devin Collins, Alisa Patten, Jessica Gregg, P. Todd Korthuis

School of Social Work Faculty Publications and Presentations

Background:

Medications for opioid use disorder (MOUD) and alcohol use disorder (MAUD) are effective and under-prescribed. Hospital-based addiction consult services can engage out-of-treatment adults in addictions care. Understanding which patients are most likely to initiate MOUD and MAUD can inform interventions and deepen understanding of hospitals’ role in addressing substance use disorders (SUD).

Objective:

Determine patient- and consult-service level characteristics associated with MOUD/MAUD initiation during hospitalization.

Methods:

We analyzed data from a study of the Improving Addiction Care Team (IMPACT), an interprofessional hospital-based addiction consult service at an academic medical center. Researchers collected patient surveys and clinical data from September …

Predicting The Efficacy Of Psilocybin In Treating Mental Health And Addiction, Courtney Ledford

altREU Projects

Machine Learning is used to predict the efficacy of psilocybin in treating mental health and addiction by using a random forest algorithm. Psilocybin is a chemical compound found in fungi. Following ingestion, it is converted to psilocin which acts as a serotonin agonist, producing altered states of consciousness and hallucinations. Research suggests the use of psilocybin as a potential treatment for mental health disorders and addiction. An analysis of thirty-one experiments from the Altered States Database was inputted into the model. Past meta-analysis performed on this experimental data focuses on healthy participants rather than participants diagnosed with a mental illness. …

Understanding Individual And Family Experiences Associated With Dup: Lessons From The Early Assessment And Support Alliance (Easa) Program In Oregon, Usa, Ryan P. Melton, Shannon Blajeski, Diana Glasser

Regional Research Institute for Human Services

Research shows that a longer duration of untreated psychosis (DUP) is associated with worse psychiatric outcomes, with average length of DUP of 73 weeks in the U.S. The aim was to examine the DUP period for first episode psychosis in Oregon, with a focus on the processes between the first positive symptoms and first treatment. To investigate DUP, researchers used methods consistent with grounded theory to collect data from 9 participants and their families about the process between onset of psychotic symptoms and entrance into treatment. Results suggest that recognition of symptoms was the primary driver of help-seeking in this …

A Systematic Literature Review Of Video-Based Interventions To Improve Integrated Competitive Employment Skills Among Youth And Adults With Autism Spectrum Disorder, Vidya D. Munandar, Mary E. Morningstar, Sarah R. Carlson

Special Education Faculty Publications and Presentations

BACKGROUND:

People with Autism Spectrum Disorder (ASD) have lower employment rates than their peers without disabilities or other disabilities. Clear evidence exists regarding video-based interventions (VBIs) for improving task performance and social communication skills for students with ASD. However, such interventions have rarely been applied in integrated employment settings.

OBJECTIVE:

This systematic literature review aims to examine the utilization and efficacy of video-based interventions in improving the skills required to secure and maintain a job for youth and adults with ASD.

METHODS:

A systematic literature review was conducted on peer-reviewed articles on VBIs and ASD from electronic databases (n.d. –2019), …

‘Presumptively Initiating Vaccines And Optimizing Talk With Motivational Interviewing’ (Pivot With Mi) Trial: A Protocol For A Luster Randomised Controlled Trial Of A Clinician Vaccine Communication Intervention, Douglas J. Opel, Jeffrey D. Robinson, Heather Spielvogle, Christine Spina, Kathleen Garrett, Amanda F. Dempsey, Cathryn Perreira, Miriam Dickinson, Chuan Zhou, Barbara Pahud, Multiple Additional Authors

Communication Faculty Publications and Presentations

Introduction A key contributor to under immunisation is parental refusal or delay of vaccines due to vaccine concerns. Many clinicians lack confidence in communicating with vaccine-hesitant parents (VHP) and perceive that their discussions will do little to change parents’ minds. Improving clinician communication with VHPs is critical to increasing childhood vaccine uptake.

Methods and analysis We describe the protocol for a cluster randomised controlled trial to test the impact of a novel, multifaceted clinician vaccine communication strategy on child immunisation status. The trial will be conducted in 24 primary care practices in two US states (Washington and Colorado). The strategy …

The Politics Of Caregiving: Taking Stock Of State-Level Policies To Support Family Caregivers, Walter D. Dawson, Lauren Bangerter, Micheal Splaine

Institute on Aging Publications

The U.S. population is aging rapidly. The changing demographics offer several benefits and opportunities at local, national, and global levels (Kluge, Zagheni, Loichinger, & Vogt, 2014). Yet, living to an advanced age remains a significant risk factor for the need of care and support during one’s lifetime. Half of all adults 65 years of age and older will reach a point where they require a high level of support due to either physical or cognitive challenges (Tumlinson, Juring, & Alkema, 2016). At the same time, the number of older adults living with chronic disease (e.g., diabetes, …

Gut Carriage Of Antimicrobial Resistance Genes In Women Exposed To Small-Scale Poultry Farms In Rural Uganda: A Feasibility Study, Ana A. Weil, Meti D. Debela, Daniel M. Muyanja, Bernard Kakuhikire, Charles Baguma, David Bangsberg, Alexander C. Tsai, Peggy S. Lai

OHSU-PSU School of Public Health Faculty Publications and Presentations

Background: Antibiotic use for livestock is presumed to be a contributor to the acquisition of antimicrobial resistance (AMR) genes in humans, yet studies do not capture AMR data before and after livestock introduction.

Methods: We performed a feasibility study by recruiting a subset of women in a delayed-start randomized controlled trial of small-scale chicken farming to examine the prevalence of clinically-relevant AMR genes. Stool samples were obtained at baseline and one year post-randomization from five intervention women who received chickens at the start of the study, six control women who did not receive chickens until the end of the study, …

Strong Men, Strong Communities: Design Of A Randomized Controlled Trial Of A Diabetes Prevention Intervention For American Indian And Alaska Native Men, Ka‘Imi Sinclair, Cara Carty, Kelly L. Gonzales, Cassandra Nikolaus, Lucas Gillespie, Dedra Buchwald

OHSU-PSU School of Public Health Faculty Publications and Presentations

Type 2 diabetes is a serious global epidemic that disproportionately affects disadvantaged populations. American Indians and Alaska Natives (AIs/ANs) have the highest rates of diabetes in the nation with a prevalence of 14.7% in 2018, more than twice that of non-Hispanic Whites. AI/AN men have the highest prevalence of diagnosed type 2 diabetes (14.5%) compared to non-Hispanic Black (11.4%), non-Hispanic Asian (10.0%), and non-Hispanic White (8.6%) men. Several landmark clinical trials have shown that lifestyle interventions can effectively prevent or delay the onset of diabetes among those at risk, including in AIs/ANs. Despite positive outcomes for AIs/ANs in these studies, …

Annual Wellness Visits And Influenza Vaccinations Among Older Adults In The Us, Terese Sara Hoj Jørgensen, Heather G. Allore, Miriam R. Elman, Corey L. Nagel, Mengran Zhang, Sheila Markwardt, Ana R. Quiñones

OHSU-PSU School of Public Health Faculty Publications and Presentations

Objectives

Investigate whether combinations of sociodemographic factors, chronic conditions, and other health indicators pose barriers for older adults to access Annual Wellness Visits (AWVs) and influenza vaccinations.

Methods

Data on 4999 individuals aged ≥65 years from the 2012 wave of the Health and Retirement Study linked with Medicare claims were analyzed. Conditional Inference Tree (CIT) and Random Forest (CIRF) analyses identified the most important predictors of AWVs and influenza vaccinations. Multivariable logistic regression (MLR) was used to quantify the associations.

Results

Two-year uptake was 22.8% for AWVs and 65.9% for influenza vaccinations. For AWVs, geographical region and wealth emerged as …

Forests And Mental Health In South Africa: Panel Data Evidence, Dambala Gelo

Forest Collaborative Research

Slides from a presentation that examines the linkages between the green environment (urban forests, green open urban space) and mental health in South Africa. The author used representative panel data from the National Income Dynamics Survey, including the Center for Epidemiological Studies Short Depression Scale, to uncover these links.

Using “Remote” Training And Coaching To Increase Providers’ Skills For Working Effectively With Older Youth And Young Adults With Serious Mental Health Conditions, Janet S. Walker, Caitlin Baird

School of Social Work Faculty Publications and Presentations

Since about the turn of the century, a growing awareness of the poor outcomes resulting from “as usual” community mental health care has led to increasing efforts to implement programs and interventions with empirical evidence of effectiveness. However, these efforts have encountered numerous barriers, in particular the high cost of implementation, which has severely limited uptake and sustainment of empiricallysupported programs and interventions. Typically, the largest contributor to cost is the training and coaching required to ensure provider competence and fidelity to the intervention or program model. This paper describes a social innovation that aims to provide high-quality training and …

“Little Tablets Of Gold”: An Examination Of The Psychological And Social Dimensions Of Prep Among Lgbtq Communities, Christina J. Sun, Kirsten M. Anderson, Kim Toevs, Dayna Morrison, Caitlin Wells, Christina Nicolaidis

OHSU-PSU School of Public Health Faculty Publications and Presentations

There are significant psychological, social, and cultural dimensions to the HIV epidemic in the United States, especially among lesbian, gay, bisexual, transgender, and queer (LGBTQ) communities. Biomedical HIV treatment has been shown to impact these dimensions. However, there is little understanding of the real-world psychosocial and sociocultural effects of the latest biomedical HIV prevention strategy, HIV pre-exposure prophylaxis (PrEP). This study explored the psychosocial and sociocultural dimensions of PrEP use among LGBTQ adults. We interviewed 23 LGBTQ adults who were current or former users of PrEP. Results included that PrEP users’ experiences were shaped by multiple forms of stigma. Participants …

Supporting Nursing Home Staff Through Person-Centered Care Practices, Diana White, Sarah Dys, Jaclyn Winfree, Serena Hasworth, Ozcan Tunalilar

Institute on Aging Publications

Policies and practices have increasingly focused on person-centered care (PCC) to improve quality of life for long-term care residents and staff. Adequate staffing has been a consistent barrier to implementing and sustaining PCC practices. The purpose of this paper is to explore the association between job satisfaction and PCC practices. This research was conducted in a stratified random sample of 33 Oregon nursing homes which were representative in terms of quality, profit/nonprofit ownership, and urban/rural location. Data were collected from 415 staff who completed the staff assessment of person-directed care, direct care worker job satisfaction scale, turnover intention, and organizational …

Internet Addiction, Smartphone Addiction, And Hikikomori Trait In Japanese Young Adult: Social Isolation And Social Network, Masaru Tateno, Alan R. Teo, Wataru Ukai, Junichiro Kanazawa, Ryoko Katsuki, Hiroaki Kubo, Takahiro A. Kato

OHSU-PSU School of Public Health Faculty Publications and Presentations

Background: As the number of internet users increases, problems related to internet overuse are becoming more and more serious. Adolescents and youth may be particularly attracted to and preoccupied with various online activities. In this study, we investigated the relationship of internet addiction, smartphone addiction, and the risk of hikikomori, severe social withdrawal, in Japanese young adult.

Methods: The subjects were 478 college/university students in Japan. They were requested to complete the study questionnaire, which consisted of questions about demographics, internet use, the Internet Addiction Test (IAT), the Smartphone Addiction Scale (SAS)–Short Version (SV), the 25-item Hikikomori Questionnaire …

Exploring The Extent Of The Hikikomori Phenomenon On Twitter: Mixed Methods Study Of Western Language Tweets, Pereira-Sanchez, Miguel Angel Alvarez-Mon, Angel Asunsolo Del Barco, Melchor Alvarez-Mon, Alan R. Teo

OHSU-PSU School of Public Health Faculty Publications and Presentations

Background: Hikikomori is a severe form of social withdrawal, originally described in Japan but recently reported in other countries. Debate exists as to what extent hikikomori is viewed as a problem outside of the Japanese context. Objective: We aimed to explore perceptions about hikikomori outside Japan by analyzing Western language content from the popular social media platform, Twitter. Methods: We conducted a mixed methods analysis of all publicly available tweets using the hashtag #hikikomori between February 1 and August 16, 2018, in 5 Western languages (Catalan, English, French, Italian, and Spanish). Tweets were first classified as to whether they described …

Impacts Of An Opioid Overdose Prevention Intervention Delivered Subsequent To Acute Care, Caleb J. Banta-Green, Phillip O. Coffin, Joseph O. Merrill, Jeanne M. Sears, Chris Dunn, Norbert D. Yanez, Multiple Additional Authors

OHSU-PSU School of Public Health Faculty Publications and Presentations

Background Opioid overdose is a major and increasing cause of injury and death. There is an urgent need for interventions to reduce overdose events among high-risk persons.

Methods Adults at elevated risk for opioid overdose involving heroin or pharmaceutical opioids who had been cared for in an emergency department (ED) were randomised to overdose education combined with a brief behavioural intervention and take-home naloxone or usual care. Outcomes included: (1) time to first opioid overdose-related event resulting in medical attention or death using competing risks survival analysis; and (2) ED visit and hospitalisation rates, using negative binomial regression and adjusting …

Relative Wealth, Subjective Social Status, And Their Associations With Depression: Cross-Sectional, Population-Based Study In Rural Uganda, Meghan L. Smith, Bernard Kakuhikire, C. Baguma, Justin D. Rasmussen, David Bangsberg, Multiple Additional Authors

OHSU-PSU School of Public Health Faculty Publications and Presentations

Depression is a leading cause of disability worldwide, and has been found to be a consistent correlate of socioeconomic status (SES). The relative deprivation hypothesis proposes that one mechanism linking SES to health involves social comparisons, suggesting that relative SES rather than absolute SES is of primary importance in determining health status. Using data from a whole-population sample of 1,620 participants residing in rural southwestern Uganda, we estimated the independent associations between objective and subjective relative wealth and probable depression, as measured by the depression subscale of the Hopkins Symptom Checklist (HSCLD). Objective relative wealth was measured by an asset …

Portrayals Of Mental Illness, Treatment, And Relapse And Their Effects On The Stigma Of Mental Illness: Population-Based, Randomized Survey Experiment In Rural Uganda, Justin D. Rasmussen, Bernard Kakuhikire, C. Baguma, Scholastic Ashaba, Christine E. Cooper-Vince, Jessica M. Perkins, David Bangsberg, Alexander C. Tsai

OHSU-PSU School of Public Health Faculty Publications and Presentations

Background

Mental illness stigma is a fundamental barrier to improving mental health worldwide, but little is known about how to durably reduce it. Understanding of mental illness as a treatable medical condition may influence stigmatizing beliefs, but available evidence to inform this hypothesis has been derived solely from high-income countries. We embedded a randomized survey experiment within a whole-population cohort study in rural southwestern Uganda to assess the extent to which portrayals of mental illness treatment effectiveness influence personal beliefs and perceived norms about mental illness and about persons with mental illness.

Methods and findings

Study participants were randomly assigned …

Trace Amine-Associated Receptor Gene Polymorphism Increases Drug Craving In Individuals With Methamphetamine Dependence, Jennifer M. Loftis, Michael Lasarev, Xiao Shi, Jodi Lapidus, Aaron Janowsky, William Hoffman, Marilyn Huckans

OHSU-PSU School of Public Health Faculty Publications and Presentations

Background: Methamphetamine (MA) is a potent agonist at the trace amine-associated receptor 1 (TAAR1). This study evaluated a common variant (CV) in the human TAAR1 gene, synonymous single nucleotide polymorphism (SNP) V288V, to determine the involvement of TAAR1 in MA dependence.

Methods: Participants (n = 106) with active MA dependence (MA-ACT), in remission from MA dependence (MA-REM), with active polysubstance dependence, in remission from polysubstance dependence, and with no history of substance dependence completed neuropsychiatric symptom questionnaires and provided blood samples. In vitro expression and function of CV and wild type TAAR1 receptors were also measured.

Results: The V288V polymorphism …

Emerging Strategies For Engaging Young People In Systems Of Care, Research And Training Center For Pathways To Positive Futures, Portland State University

School of Social Work Faculty Publications and Presentations

Systems of care are increasingly serving older youth and young adults up to age 24, and in our research and training work with providers, we hear about the challenges of engaging young people in typical services. Many providers are responding to the unique developmental needs of this population by adapting the design and delivery of their services to better engage and retain young people in system of care supports. Overall, strategies include expansion of drop-in center programming, adaptations to practice models like Wraparound, and new outreach efforts using social media and other technologies. Our purpose here is to share some …

Barriers And Facilitators To Recruitment And Enrollment Of Hiv-Infected Individuals With Opioid Use Disorder In A Clinical Trial, Kim Hoffman, Robin Baker, Lynn Elizabeth Kunkel, Elizabeth Needham Waddell, Paula J. Lum, Dennis Mccarty, P. Todd Korthuis

OHSU-PSU School of Public Health Faculty Publications and Presentations

Background

The CTN-0067 CHOICES trial tests implementation of extended-release naltrexone (XR-NTX) versus treatment-as-usual (TAU) for opioid use disorders (OUD) in HIV clinics to improve HIV viral suppression. The study team investigated recruitment strategies to elucidate the barriers and facilitators to recruitment and enrollment in the study.

Main text

Methods: Semi-structured, in-depth, digitally recorded interviews were completed with study recruitment-related staff and medical providers (n = 26) from six participating HIV clinics in the fall of 2018. Interviews probed 1) factors that might prevent prospective participants from engaging in study recruitment and enrollment procedures and 2) strategies used by study …