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Health Policy

2019

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Full-Text Articles in Public Health

Characterizing Systems Of Reporting And Mitigating Anthrax Outbreaks Near Mto Wa Mbu, Monduli District, Tanzania, Megan Levy Apr 2019

Characterizing Systems Of Reporting And Mitigating Anthrax Outbreaks Near Mto Wa Mbu, Monduli District, Tanzania, Megan Levy

Independent Study Project (ISP) Collection

Northern Tanzania has experienced several anthrax outbreaks in the recent past. In Monduli district, an outbreak in 2016 prompted an organization of district officials to create an updated outbreak response action plan. The pastoralist community is often affected by these outbreaks due to their frequent direct contact with cattle and herds’ proximity to wild species potentially affected by the disease. This characterization of the existing systems of reporting and mitigating anthrax outbreaks was accomplished through structured interviews with ward and village officers, local veterinarians, and members of the pastoralist community in Monduli district near Mto wa Mbu. The purpose of …


Z4, A Slow Puncture: An Autoethnographic Exploration Of Language, Embodiment, And Meaning-Making, Charlotte Rose Samuels Apr 2019

Z4, A Slow Puncture: An Autoethnographic Exploration Of Language, Embodiment, And Meaning-Making, Charlotte Rose Samuels

Independent Study Project (ISP) Collection

In my ISP, I explored language as it relates to the ways in which people living in Cato Manor make sense of HIV/AIDS in their community. With 7.1-7.2 million people living with HIV (PLWHIV) in South Africa, individuals across the country are either infected or affected by illness. KwaZulu-Natal (KZN), the province with the highest rate of HIV, is also the province that was surveyed with the disproportionately highest internal stigma rates for PLWHIV. High prevalence of HIV, particularly in KZN, calls for a constant contextualization of life in the presence of illness.

Throughout the world, metaphor and symbolism is …


Cancer Management In Kenya - Awareness And The Struggles Patients Face To Access Treatment, Care & Support, Ashley Nmoh Apr 2019

Cancer Management In Kenya - Awareness And The Struggles Patients Face To Access Treatment, Care & Support, Ashley Nmoh

Independent Study Project (ISP) Collection

The amount of cancer cases in Africa, and Kenya specifically, are rising at an alarming rate. This study was conducted to determine the challenges that patients with cancer in Kenya face to access treatment, care and support. Thirty-nine cancer patients were interviewed and thirty cancer patients filled out a questionnaire about their experiences of having cancer in Kenya. In addition, twenty key informants were interviewed including doctors, caregivers, cancer NGO executives, a researcher, a psychologist, a National Health Insurance Fund official and a director from the Ministry of Health. A breast cancer awareness survey was also administered to fifty-nine women …


Exploring Mobility Help-Seeking Behavior Among People With Physical Disabilities: A Case Study Of Jaipur Foot, Alex Podell Apr 2019

Exploring Mobility Help-Seeking Behavior Among People With Physical Disabilities: A Case Study Of Jaipur Foot, Alex Podell

Independent Study Project (ISP) Collection

It is estimated that as many as 90 million people living in India experience some sort of disability (The World Bank, 2007). As India’s population keeps growing and aging, not only will the medical aspects, but also the societal impacts of disability need to be brought to the forefront of discussion, developmental strategy, and policy implementation. This study sought to analyze factors influencing the process of seeking help from formal and informal sources for people with physical disabilities. Data was collected from 10 people with physical disabilities receiving a variety of mobility aids from the NGO, Bhagwan Mahaveer Viklang Sahayata …


Nationalizing Services For The Trans-National: How Sub-Saharan Migrants Navigate Healthcare Access In Tunisia, Batoul Hasan Apr 2019

Nationalizing Services For The Trans-National: How Sub-Saharan Migrants Navigate Healthcare Access In Tunisia, Batoul Hasan

Independent Study Project (ISP) Collection

The right to human health and the resources that empower this state is an entitlement recognized under international law. With the circumstances surrounding their journeys, migrants face increased risks and vulnerabilities that necessitate social protections. Nations of reception, due to exclusionary policies or lack of capacity, may fail to guarantee these protections. This study investigates how this phenomenon unfolds in Tunisia, a middle-income nation undergoing a host of political and economic changes, but one that’s nonetheless become an alluring destination for migrants, specifically those from sub-Saharan African nations. The analysis proceeds from an assessment of the public health situation in …


El Rol De Los Agentes Sanitarios Para Mejorar El Acceso A La Salud Sexual Y Reproductiva Para Mujeres En San Carlos, Mendoza. / The Role Of Agentes Sanitarios In Improving Access To Sexual And Reproductive Health For Women In San Carlos, Mendoza., Laura Hult Apr 2019

El Rol De Los Agentes Sanitarios Para Mejorar El Acceso A La Salud Sexual Y Reproductiva Para Mujeres En San Carlos, Mendoza. / The Role Of Agentes Sanitarios In Improving Access To Sexual And Reproductive Health For Women In San Carlos, Mendoza., Laura Hult

Independent Study Project (ISP) Collection

Introducción: Es evidente que Argentina tiene un enfoque que atiende a la salud sexual y reproductiva, dado que tiene cobertura universal y la ley de Programa Nacional de Salud Sexual y Procreación Responsable que establece un estándar de cuidado para toda la población. Sin embargo, cobertura universal no implica acceso universal, el cual que está determinado por el transporte, el idioma y la cantidad de recursos de la región. En lugares como San Carlos, Mendoza, donde no hay transporte regular y hay pocos recursos, existe inequidad en la salud, lo que puede aumentar las tasas de embarazos no intencionales y …


Ecological Determinants Of Respiratory Health: Examining Associations Between Asthma Emergency Department Visits, Diesel Particulate Matter, And Public Parks And Open Space In Los Angeles, California, Jason A. Douglas, Reginald S. Archer, Serena E. Alexander Mar 2019

Ecological Determinants Of Respiratory Health: Examining Associations Between Asthma Emergency Department Visits, Diesel Particulate Matter, And Public Parks And Open Space In Los Angeles, California, Jason A. Douglas, Reginald S. Archer, Serena E. Alexander

Health Sciences and Kinesiology Faculty Articles

Los Angeles County (LAC) low-income communities of color experience uneven asthma rates, evidenced by asthma emergency department visits (AEDV). This has partly been attributed to inequitable exposure to diesel particulate matter (DPM). Promisingly, public parks and open space (PPOS) contribute to DPM mitigation. However, low-income communities of color with limited access to PPOS may be deprived of associated public health benefits. Therefore, this novel study investigates the AEDV, DPM, PPOS nexus to address this public health dilemma and inform public policy in at-risk communities. Optimized Hotspot Analysis was used to examine geographic clustering of AEDVs, DPM, and PPOS at the …


Delays In Antiretroviral Therapy Initiation Among Hiv-Positive Individuals: Results Of The Positive Living With Hiv Study, Krishna C. Poudel, David R. Buchanan, Kalpana Poudel-Tandukar Mar 2019

Delays In Antiretroviral Therapy Initiation Among Hiv-Positive Individuals: Results Of The Positive Living With Hiv Study, Krishna C. Poudel, David R. Buchanan, Kalpana Poudel-Tandukar

Krishna C. Poudel

Background: Lack of early initiation of antiretroviral therapy (ART) remains a major health concern due to increased risk of premature mortality and further HIV transmission. This study explored CD4+ cell count monitoring in relation to delays in ART initiation among HIV-positive individuals in the Kathmandu Valley, Nepal, where ART coverage was only 23.7% in 2011.

Design: We recruited a total of 87 ART-naïve, HIV-positive individuals aged 18 to 60 years through the networks of five non-government organizations working with HIV-positive individuals. We collected data on the history of ART initiation, CD4+ cell count monitoring, socio-demographic variables, perceived family …


Influence Of Decentralization And Type Of Patient On Loss To Follow-Up Among Multidrug-Resistant Tuberculosis Patients In Indonesia From 2014 To 2015, Noerfitri Noerfitri, R. Sutiawan, Tri Yunis Miko Wahyono, Pratiwi Ayuningtyas Hartono Feb 2019

Influence Of Decentralization And Type Of Patient On Loss To Follow-Up Among Multidrug-Resistant Tuberculosis Patients In Indonesia From 2014 To 2015, Noerfitri Noerfitri, R. Sutiawan, Tri Yunis Miko Wahyono, Pratiwi Ayuningtyas Hartono

Kesmas

Drug-resistant tuberculosis (TB) patients have a greater risk of loss to follow-up (LTFU) than drug-sensitive TB patients, due to their longer treatment duration. This study aimed to determine the influence of decentralization and patient type on LTFU among multidrug-resistant TB (MDR-TB) patients in Indonesia. A retrospective cohort study was conducted at all MDR-TB treatment healthcare facilities in Indonesia from 014 to 2015. Using total sampling technique, 961 patients were examined and sampled. Of these patients, 86.03% were decentralized. Patients were classified into types as follows: 35.17% were “relapse” patients, 5.52% were “new,” 13.94% were classified as “after LTFU” patients, 23.10% …


Knowledge And Practice In Household Waste Management, Agnes Fitria Widiyanto, Suratman Suratman, Nisrina Alifah, Tri Murniati, Oktafiani Catur Pratiwi Feb 2019

Knowledge And Practice In Household Waste Management, Agnes Fitria Widiyanto, Suratman Suratman, Nisrina Alifah, Tri Murniati, Oktafiani Catur Pratiwi

Kesmas

Declining environmental quality is one of population caused by household consumption behavior. Some of the highest contaminant contributions are domestic waste, waste, and company waste. Waste contamination will lead to dead fish, decreased water quality and disease transmission. Community approach can be done to solve the waste problem, especially at the household level. This study uses quantitative methods to analyze the effect of intervention and waste management training on changes in household waste management knowledge and practices. This type of research uses quasi experiment with one group of pre and post test design. The results showed that there was an …


Prediction Models For Descreasing Visual Acuity In Wig Makers, Nur Ulfah, Siti Harwanti, Ngadiman Ngadiman Feb 2019

Prediction Models For Descreasing Visual Acuity In Wig Makers, Nur Ulfah, Siti Harwanti, Ngadiman Ngadiman

Kesmas

One of the occupational diseases that can arise for workers with high accuracy is a decrease in their visual acuity. Therefore, it is necessary to study the risk factors of decreasing visual acuity in workers with high accuracy, such as in wig makers. This study aimed to examine the correlation between age, working period, lighting intensity, fatigue, and nutritional status with visual acuity, and to observe the main risk factors that can be used as a reference for predicting decreasing visual acuity. This study was an observational study that used a cross-sectional design. The population number for this study was …


Relationship Model For Occupational Safety And Health Climate To Prevent Needlestick Injuries For Nurses, Ketut Ima Ismara, Adi Heru Husodo, Yayi Suryo Prabandari, Widodo Hariyono Feb 2019

Relationship Model For Occupational Safety And Health Climate To Prevent Needlestick Injuries For Nurses, Ketut Ima Ismara, Adi Heru Husodo, Yayi Suryo Prabandari, Widodo Hariyono

Kesmas

The risk of accidents and disease transmission when working at hospitals is quite high, especially in Indonesia. This study aimed to analyze the relationship model between the Occupational Safety and Health (OSH) climate and behavior intention in OSH performance to prevent needlestick injuries (NSI) based on a theory of planned behavior. A mixed approach using qualitative and quantitative methods was applied. Data were obtained from Structural Equation Model questionnaires, observation, and documentation, and interviews were analyzed qualitatively. The population was 1,042 nurses at Dr. Sardjito General Hospital in Yogyakarta. The sample consisted of 289 respondents determined by purposive random sampling …


Effect Of Condom Utilization On Sexuall Transmitted Infection Among Female Sex Workers, In Tulungagung District, East Java, Indonesia, Ainun Hanifah, Ari Natalia Probandari, Eti Poncorini Pamungkasari Feb 2019

Effect Of Condom Utilization On Sexuall Transmitted Infection Among Female Sex Workers, In Tulungagung District, East Java, Indonesia, Ainun Hanifah, Ari Natalia Probandari, Eti Poncorini Pamungkasari

Kesmas

One effective strategy for preventing sexually transmitted infection (STI) incidence and providing protection for female sex workers (FSWs) from their sexual partners is correct and consistent condom use behavior. This study examined the effect of condom use on STI among FSWs in Tulungagung District, East Java. This analytic and observational study using a cohort prospective design was conducted at Ngujang ex- prostitution area and Gunung Bolo prostitution area, Tulungagung District, from November to January 2017. The total sample selected was 90 FSWs. Data was collected through a set of questionnaires and tracking condom use in a diary. Data were analyzed …


Exclusive Breastfeeding And Decrease Of Upper Respiratory Infection Incidence Among Infants Aged 6-12 Months In Kampar District, Riau Province, Musfardi Rustam, Renti Mahkota, Nasrin Kodim Feb 2019

Exclusive Breastfeeding And Decrease Of Upper Respiratory Infection Incidence Among Infants Aged 6-12 Months In Kampar District, Riau Province, Musfardi Rustam, Renti Mahkota, Nasrin Kodim

Kesmas

Upper Respiratory Infection (URI) is a major cause of morbidity and mortality of infants and toddlers in developing countries. The high infant morbidity and mortality rates in Indonesia are associated with the low exclusive breastfeeding ability. Breast milk is a natural drink for newborns in the first month of life that is beneficial not only for the babies, but also for mothers. The aim of study was to determine exclusive breastfeeding and decrease in incidence of URI among infants aged 6-12 months. This study was conducted by using case control design. Samples were taken by using cluster random sampling. Subject …


The Consumption Of Fresh Vegetables From Street Food And Sanitation Of Street Stalls At Four Locations In Bogor City, Donna Fujie Rahaditha Utami, Winiati P. Rahayu, Lilis Nuraida Feb 2019

The Consumption Of Fresh Vegetables From Street Food And Sanitation Of Street Stalls At Four Locations In Bogor City, Donna Fujie Rahaditha Utami, Winiati P. Rahayu, Lilis Nuraida

Kesmas

The consumption of fresh vegetables at the stalls needs serious attention. This research aimed to estimate the exposure probability due to fresh vegetables consumption of street food consumers, to measure sanitation level of street stalls that serving fresh vegetables, and to recommend a mentoring program for the stalls at four locations in Bogor City. This research was conducted at 16 stalls located at four locations in Bogor City. The number of respondents surveyed was 293 people and determined by stratified sampling method. Food frequency questionnaire was used as a tool in the survey. The survey showed that men consumed more …


Perception Of People Living With Hiv/Aids On Social Stigma Of Hiv/Aids In Sukoharjo District, Titik Haryanti, Wartini Wartini Feb 2019

Perception Of People Living With Hiv/Aids On Social Stigma Of Hiv/Aids In Sukoharjo District, Titik Haryanti, Wartini Wartini

Kesmas

The stigma of wrong society about HIV / AIDS is one of the obstacles to prevention and control of HIV / AIDS in Sukoharjo District. This study aims to determine the relationship of characteristics, causal factors and duration of HIV / AIDS with the perception of people living with HIV to the stigma of society about HIV / AIDS in Sukoharjo District. The research used is analytical descriptive with cross sectional approach. The population is all people with HIV / AIDS until April 2016 amounted to 256 with a sample of 156 people with sampling technique quota sampling. Bivariate analysis …


Optimising Decentralisation For The Health Sector By Exploring The Synergy Of Decision Space, Capacity And Accountability: Insights From The Philippines, Harvy Joy Liwanag, Kaspar Wyss Jan 2019

Optimising Decentralisation For The Health Sector By Exploring The Synergy Of Decision Space, Capacity And Accountability: Insights From The Philippines, Harvy Joy Liwanag, Kaspar Wyss

Ateneo School of Medicine and Public Health Publications

Background

Several studies on decentralisation have used the ‘decision space’ approach to assess the breadth of space made available to decision-makers at lower levels of the health system. However, in order to better understand how decentralisation becomes effective for the health sector, analysis should go beyond assessing decision space and include the dimensions of capacity and accountability. Building on Bossert’s earlier work on the synergy of these dimensions, we analysed decision-making in the Philippines where governmental health services have been devolved to local governments since 1992.

Methods

Using a qualitative research design, we interviewed 27 key decision-makers at different levels …


Deputizing Family: Loved Ones As A Regulatory Tool In The “Drug War” And Beyond, Matthew B. Lawrence Jan 2019

Deputizing Family: Loved Ones As A Regulatory Tool In The “Drug War” And Beyond, Matthew B. Lawrence

Faculty Articles

Many laws use family members as a regulatory tool to influence the decisions or behavior of their loved ones, i.e., they deputize family. Involuntary treatment laws for substance use disorder are a clear example; such laws empower family members to use information shared by their loved ones to petition to force their loved ones into treatment without consent. Whether such deputization is helpful or harmful for a patient’s health is a crucial and dubious question discussed in existing literature, but use of family members as a regulatory tool implicates important considerations beyond direct medical impacts that have not been as …


Culture And The Development Of Traditional Medicine In Africa, Rowland Edet, Oyedolapo Isaac Bello, Julianah Babajide Jan 2019

Culture And The Development Of Traditional Medicine In Africa, Rowland Edet, Oyedolapo Isaac Bello, Julianah Babajide

Department of Sociology: Faculty Publications

Traditional medicine has been the dominant healthcare system in Africa before westernization, civilization and colonialism. For people living in the rural areas, traditional medicine is easily available, accessible and affordable. The purpose of this paper is to examine how the cultural way of the life of Africans has contributed to the emergence and development of traditional therapeutic systems in the continent. By explaining the way Africans perceive illness and disease, this paper argues that various forms of healing were predicated on the sociocultural environment of the people. The paper therefore opts for concerted efforts in the development of traditional medicine …


Making The Business Case For An Addiction Medicine Consult Service: A Qualitative Analysis, Kelsey C. Priest, Dennis Mccarty Jan 2019

Making The Business Case For An Addiction Medicine Consult Service: A Qualitative Analysis, Kelsey C. Priest, Dennis Mccarty

OHSU-PSU School of Public Health Faculty Publications and Presentations

Background

As the drug poisoning crisis worsens in North America and opioid use disorder (OUD)-related hospital admissions increase, policymakers and hospital administrators are beginning to recognize the important role of hospitals in the OUD care continuum. This study explores and describes how U.S. addiction medicine physicians created and presented business propositions to hospital administrators to support the development of addiction medicine consult (AMC) services.

Methods

Fifteen qualitative interviews were completed with board-certified or board-eligible addiction medicine physicians from 14 U.S. hospitals. The interviews occurred as part of a broader mixed methods study exploring hospital service delivery for patients admitted with …


Snake Bite, Meghna Arora, Rajendra Prasad Jan 2019

Snake Bite, Meghna Arora, Rajendra Prasad

Digital Journal of Clinical Medicine

No abstract provided.


Understanding Access To Menstrual Hygiene Products In The Akron Area, Corinne Plas Jan 2019

Understanding Access To Menstrual Hygiene Products In The Akron Area, Corinne Plas

Williams Honors College, Honors Research Projects

Abstract

The purpose of this project is to contribute to the understanding of the nature of access to menstrual hygiene products in the Akron area. Questions being researched are “Do Akron area residents need better access to menstrual hygiene products?”, “What is the nature of current access to products in the Akron area?”, “What influences a lack of access to products, if anything?”, and “What kinds of products are preferred and actually used?” The project consists of a 30-question survey, which was taken online by 51 participants. Completed analyses were cross tabulation analyses using Qualtrics and IBM SPSS programs and …


Put Your Money Where Your Mouth Is: Reforming Organized Dentistry To Address Persistent Oral Health Disparities In The U.S., Aparna Chintapalli Jan 2019

Put Your Money Where Your Mouth Is: Reforming Organized Dentistry To Address Persistent Oral Health Disparities In The U.S., Aparna Chintapalli

Pomona Senior Theses

The importance of oral health has been largely neglected from the conventional standards of healthcare in terms of public understanding & prioritization, the industrial infrastructure, and the scope of prevention & early-intervention services. Its adjunctive locus to the field of medicine has lead to the bifurcation of the oral cavity from the rest of the human body. As a result of this divide, there have been multiple factors that have allowed socially stratified oral health outcomes to manifest. This thesis examines the determinants of oral health disparities through a multidisciplinary lens (i.e. biology, public policy, infrastructure), and offers evidence of …


Patient-Centered Medical Homes And Hospital Value-Based Purchasing: Investigating Provider Responses To Incentives, Lauryn Walker Jan 2019

Patient-Centered Medical Homes And Hospital Value-Based Purchasing: Investigating Provider Responses To Incentives, Lauryn Walker

Theses and Dissertations

Provider incentives are a commonly used policy tool to mold provider behaviors.1 However, while we frequently measure the change in patient outcomes, failure to consistently produce changes in outcomes does not mean that providers are not changing their behavior. This paper focuses on two programs with null or inconsistent quality outcomes to try to identify why such inconsistency occurs. The two programs, both ratified in the Affordable Care Act, are 1) patient-centered medical homes (PCMHs), and 2) the Medicare Hospital Value-Based Purchasing (HVBP) program.

Chapter 1: Using data from the Medical Expenditure Panel survey (MEPS), I match provider characteristic …


Everybody’S Working (But The Weakened): An Assessment Of Medicaid Work Requirements And Their Administrative Burdens, Samuel Misleh Jan 2019

Everybody’S Working (But The Weakened): An Assessment Of Medicaid Work Requirements And Their Administrative Burdens, Samuel Misleh

MPA/MPP/MPFM Capstone Projects

Although Medicaid work requirements are currently halted in both Arkansas and Kentucky, this analysis utilizes the data available to make an assessment and estimate of what Kentucky’s Medicaid enrollment will look like if work requirements similar to those Arkansas had are ever implemented. The relative severity of the administrative burden of such requirements provide a tool for comparison, and a difference-in-differences analysis of the change in Medicaid enrollment between Arkansas and West Virginia, a state that has not implemented and currently has no plans to implement Medicaid work requirements, provide the bases for this estimate. After coding the work requirements …


Immune Thrombocytopenia, Minal Agarwal, Rajendra Prasad Jan 2019

Immune Thrombocytopenia, Minal Agarwal, Rajendra Prasad

Digital Journal of Clinical Medicine

No abstract provided.


Ectopia Lentis, Pratheek Prabhu Jan 2019

Ectopia Lentis, Pratheek Prabhu

Digital Journal of Clinical Medicine

No abstract provided.


Let Me Upgrade You: Common Measures In Public Health Accreditation Action Plans, Gurleen K. Roberts Jan 2019

Let Me Upgrade You: Common Measures In Public Health Accreditation Action Plans, Gurleen K. Roberts

Electronic Theses and Dissertations

Objectives: The purpose of this study is to understand the success rates for health departments pursuing and achieving accreditation in version 1.0 and 1.5 of the Public Health Accreditation Board (PHAB) standards and measures. During the accreditation process, health departments that present performance gaps are asked to complete an Action Plan to specify how they plan to improve to meet the desired conformity. This study will highlight specific measures that are often included in Action Plans so that health departments pursuing accreditation can be better prepared to address these common pitfalls.

Methods: This study is a non-experimental, secondary …


Socioeconomic Correlates Of Overweight And Obesity Among Ever-Married Urban Women In Bangladesh, Tania Sultana Tanwi, Sayan Chakrabarty, Syed Hasanuzzaman, Sue Saltmarsh, Stephen Winn Jan 2019

Socioeconomic Correlates Of Overweight And Obesity Among Ever-Married Urban Women In Bangladesh, Tania Sultana Tanwi, Sayan Chakrabarty, Syed Hasanuzzaman, Sue Saltmarsh, Stephen Winn

Research outputs 2014 to 2021

Background

The escalating prevalence of overweight and obesity globally is reflected amongst urban women in many low-to-middle income countries. Evidence also shows that overweight and obesity is an increasing trend in Bangladesh. The present study assessed the prevalence and socioeconomic determinants of overweight and obesity among urban women in Bangladesh.

Methods

Data were extracted from Bangladesh Demographic and Health Survey (BDHS) 2014. A two-stage stratified sampling technique has been used for data collection in this cross-sectional survey. A sample of 1701 ever-married non-pregnant urban women aged 15–49 years was selected for statistical analysis. Descriptive analysis, multiple binomial logistic regression analysis …


Wellness Policy Awareness Among School Leaders And The Impact On Written Policy Scores, Mariah Reil Jan 2019

Wellness Policy Awareness Among School Leaders And The Impact On Written Policy Scores, Mariah Reil

Electronic Theses and Dissertations

Background: All schools participating in the National School Lunch Program must possess a written School Wellness Policy (SWP) as mandated by the Healthy, Hunger- Free Kids Act of 2010.1 School officials and leaders play a major role in SWP implementation. It is essential to written SWP implementation that school level officials and leaders in the district are aware of the SWP. However, the association between school leader awareness of SWP and policy quality has not yet been studied.
Purpose: The purpose of the present study was to determine if school leader awareness of a SWP impacts the written SWP quality. …