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2021

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Full-Text Articles in Medicine and Health Sciences

Reducing Covid-19 Quarantine With Sars-Cov-2 Testing: A Simulation Study, Bo Peng, Wen Zhou, Rowland W Pettit, Patrick Yu, Peter G Matos, Alexander L Greninger, Julie Mccashin, Christopher I Amos Jul 2021

Reducing Covid-19 Quarantine With Sars-Cov-2 Testing: A Simulation Study, Bo Peng, Wen Zhou, Rowland W Pettit, Patrick Yu, Peter G Matos, Alexander L Greninger, Julie Mccashin, Christopher I Amos

Faculty, Staff and Students Publications

OBJECTIVE: To evaluate the effectiveness of SARS-CoV-2 testing on shortening the duration of quarantines for COVID-19 and to identify the most effective choices of testing schedules.

DESIGN: We performed extensive simulations to evaluate the performance of quarantine strategies when one or more SARS-CoV-2 tests were administered during the quarantine. Simulations were based on statistical models for the transmissibility and viral loads of SARS-CoV-2 infections and the sensitivities of available testing methods. Sensitivity analyses were performed to evaluate the impact of perturbations in model assumptions on the outcomes of optimal strategies.

RESULTS: We found that SARS-CoV-2 testing can effectively reduce the …


Ikebana: An Ancient Tradition Of Contemporary Healing And Artful Practice, Jennifer K. Fortuna Phd, Otr/L Jul 2021

Ikebana: An Ancient Tradition Of Contemporary Healing And Artful Practice, Jennifer K. Fortuna Phd, Otr/L

The Open Journal of Occupational Therapy

Dr. Ricardo Carrásco, PhD, OTR/L, FAOTA, is an occupational therapy professor and ikebana artist. He provided the cover art for the Summer 2021 edition of The Open Journal of Occupational Therapy (OJOT). Ikebana is the ancient Japanese art of arranging flowers. “Kanta of the Wind, Sun and Moon” is an ikebana design made from blue and white Phalaenopsis orchids, chrysanthemum, bear grass, and heirloom driftwood. This gendaika, or freestyle design, is a haiku tribute to the wind, sun, and moon. Dr. Carrásco has been practicing occupational therapy and ikebana for more than 5 decades. As an occupational scientist and …


The Potential Of Virtual Reality In Social Skills Training For Autism: Bridging The Gap Between Research And Adoption Of Virtual Reality In Occupational Therapy Practice, Vineeta Pandey, Lori Vaughn Jul 2021

The Potential Of Virtual Reality In Social Skills Training For Autism: Bridging The Gap Between Research And Adoption Of Virtual Reality In Occupational Therapy Practice, Vineeta Pandey, Lori Vaughn

The Open Journal of Occupational Therapy

Impairments in social functioning greatly hinder children and youth with autism spectrum disorder (ASD) from responding appropriately and adapting to various social situations. As a result, individuals with ASD get fewer opportunities for social inclusion, physical well-being, and forming interpersonal relationships. Virtual reality (VR) has been studied extensively in this area, where a large body of evidence shows that VR is a promising tool for social skills training (SST) in individuals with ASD. With the flexibility and projected effectiveness that VR offers, it can provide more opportunities to learn and practice strategies for recognizing daily challenges that involve forming social …


Cognitive Orientation To Daily Occupational Performance (Co-Op): 1-Week Group Intervention With Children Referred For Motor Coordination Difficulties, Rose Martini, Jacinthe Savard Jul 2021

Cognitive Orientation To Daily Occupational Performance (Co-Op): 1-Week Group Intervention With Children Referred For Motor Coordination Difficulties, Rose Martini, Jacinthe Savard

The Open Journal of Occupational Therapy

Background: The aim of this study was to explore the effectiveness of a Cognitive Orientation to daily Occupational Performance (CO-OP) intervention delivered in a group format in a 1-week summer day camp program for children referred for motor coordination difficulties. Transfer of learned skills to self-selected tasks not addressed in the group intervention was also explored.

Method: A quasi-experimental one group pretest-posttest design with a 1-month follow-up was used. Changes in nine children’s self-selected occupational performance goals, as well as their sense of self-efficacy for these goals, were determined using nonparametric statistics.

Results: Findings indicate a significant …


A Comparison Of Two Keyboarding Instruction Methods Over 2 Years For Elementary Students, Denise K. Donica, Peter Giroux, Young Joo Kim, Sydney Branson Jul 2021

A Comparison Of Two Keyboarding Instruction Methods Over 2 Years For Elementary Students, Denise K. Donica, Peter Giroux, Young Joo Kim, Sydney Branson

The Open Journal of Occupational Therapy

Background: As computer and digital device use continues to grow in prevalence for school and work tasks, it is important for elementary-aged students to develop efficient keyboarding skills to support future academic and vocational success.

Method: A quasi-experimental pre-test and post-test study design was used to compare the effect of two different keyboarding instructional approaches on elementary students over a consecutive 2-year period. One group used Keyboarding Without Tears (KWT; N = 592) both years while the other group used free web-based activities the first year and Keyboarding Without Tears the second year (mixed methods; N = 714). …


A Comparison Of Activity Participation Between Children With And Without Asthma, Jacqueline R. Jezioro, Sharon A. Gutman, Stephanie Lovinsky-Desir, Virginia Rauh, Frederica P. Perera, Rachel L. Miller Jul 2021

A Comparison Of Activity Participation Between Children With And Without Asthma, Jacqueline R. Jezioro, Sharon A. Gutman, Stephanie Lovinsky-Desir, Virginia Rauh, Frederica P. Perera, Rachel L. Miller

The Open Journal of Occupational Therapy

Background: Asthma affects approximately 6 million children in the United States and can greatly impact quality of life and occupational engagement. Although occupational therapists are well-equipped to address participation limitations, insufficient evidence exists to support the role of occupational therapists in asthma treatment.

Method: The purpose of this study was to further understand the occupational limitations experienced by children with asthma. We also explored a dual diagnosis of asthma and obesity. The participants included children with (n = 84) and without (n = 63) asthma living in New York City. The Child Behavior Checklist, Youth Self Report, Brief …


Promoting Population Health In Local Communities: Parental Perceptions Of An Embedded Movement And Physical Activity Program For A Preschool Population, Jennifer Hight, Shirley P. O'Brien, Colleen M. Schneck Jul 2021

Promoting Population Health In Local Communities: Parental Perceptions Of An Embedded Movement And Physical Activity Program For A Preschool Population, Jennifer Hight, Shirley P. O'Brien, Colleen M. Schneck

The Open Journal of Occupational Therapy

Background: Many children reach kindergarten lacking age-appropriate motor skills because of a lack of access to early intervention services or a lack of continued early intervention beyond 3 years of age. Research suggests sedentary children become sedentary adults, which contributes to a growing population of unhealthy Americans with chronic health conditions, such as high blood pressure, diabetes, heart disease, and psychosocial difficulties. Parents often are not aware of the benefits of engaging in physical activity or possess a lack of awareness of their local resources. A community based preschool movement program was created to foster physical activity and promote …


Preliminary Measurement Properties Of The Early Childhood Occupational Profile (Ecope), Cary C. Moore Jul 2021

Preliminary Measurement Properties Of The Early Childhood Occupational Profile (Ecope), Cary C. Moore

The Open Journal of Occupational Therapy

Background: This study established the preliminary psychometric properties of the Early Childhood Occupational Profile (ECOPE; Moore & Bowyer, 2018) and investigated the perspectives of occupational therapists on the clinical utility of the tool.

Method: An embedded mixed methods research design was used to support the use of different research questions and unique sets of data. National and international occupational therapists administered the ECOPE on video case studies and on children from their caseload. These data were analyzed using the Rasch goodness of fit statistics to evaluate the validity and reliability of the ECOPE. The participating occupational therapists also …


Plagiocephaly Perception And Prevention: A Need To Intervene Early To Educate Parents, Sonja Burmeister, Allison N. Kayne, Ali R. Yazdanyar, J. Nathan Hagstrom, David B. Burmeister Jul 2021

Plagiocephaly Perception And Prevention: A Need To Intervene Early To Educate Parents, Sonja Burmeister, Allison N. Kayne, Ali R. Yazdanyar, J. Nathan Hagstrom, David B. Burmeister

The Open Journal of Occupational Therapy

Background: Plagiocephaly is a condition where the cranium has been malformed because of external forces or premature cranial suture fusion. This study’s objective was to gather and examine data regarding parent and caregiver awareness of plagiocephaly and its potential impact on development as well as to determine their rate of concern for positional flattening.

Method: A cross-sectional survey study was conducted. Categorical variables were described by frequency and proportions. The study was conducted across eight outpatient pediatric sites. Approximately 1,100 parents and caregivers were targeted. Inclusion criteria required participants to be willing to answer the questionnaire, to be …


Use Of A Caregiver Coaching Model For Implementation Of Intensive Motor Training For Hemiplegic Cerebral Palsy: A Case Study, Sheryl Eckberg Zylstra, Aimee Sidhu Jul 2021

Use Of A Caregiver Coaching Model For Implementation Of Intensive Motor Training For Hemiplegic Cerebral Palsy: A Case Study, Sheryl Eckberg Zylstra, Aimee Sidhu

The Open Journal of Occupational Therapy

Background: There is extensive literature to support the efficacy of both pediatric constraint-induced movement therapy (pCIMT) and hand-arm bimanual intensive therapy (HABIT) for children with hemiplegic cerebral palsy. In addition, there is increasing evidence to support the training of caregivers (parents and other care providers) to carry out therapy interventions in the home. The Family Activity Adaptation Model (FAAM) presents guidelines for parent and caregiver coaching for intensive therapies used in occupational therapy practice.

Method: In this descriptive case study the FAAM was used to frame caregiver training to answer the question: Is a coaching model, using a …


Observing And Promoting Normative Developmental Outcomes: Reciprocity Is Key, Nicki L. Aubuchon-Endsley, Bryan M. Gee, Heather L. Ramsdell, Nancy Devine, Hillary E. Swann-Thomsen, Nicholas Burgett, Leah R. Kollmeyer, Michele R. Brumley Jul 2021

Observing And Promoting Normative Developmental Outcomes: Reciprocity Is Key, Nicki L. Aubuchon-Endsley, Bryan M. Gee, Heather L. Ramsdell, Nancy Devine, Hillary E. Swann-Thomsen, Nicholas Burgett, Leah R. Kollmeyer, Michele R. Brumley

The Open Journal of Occupational Therapy

Background: Occupational therapists focus on caregiver-infant reciprocity, which is influenced by a host of biopsychosocial factors and is predictive of developmental outcomes across domains. It is important for early intervention professions to understand how different forms of reciprocity may predict infant development in salient domains (i.e., language, mobility, and co-occupation). Therefore, the purpose of this study was to investigate associations among related measures of development in and across age, while also exploring how reciprocity influences the acquisition of developmental milestones.

Method: We examined these important areas of development in relation to novel caregiver-infant co-occupational constructs in addition to …


Occupational Therapists’ Perceptions Of Intraprofessional Collaboration When Working With Young Children Aged Birth To 3 Years, Christine Rocchio Mueller, Mindy Garfinkel Jul 2021

Occupational Therapists’ Perceptions Of Intraprofessional Collaboration When Working With Young Children Aged Birth To 3 Years, Christine Rocchio Mueller, Mindy Garfinkel

The Open Journal of Occupational Therapy

Background: Birth to 3 years of age is a critical period in a child’s development, and occupational therapy intervention during this period can serve many purposes. While pediatric occupational therapists may be working in different settings with different specialties, the foundational knowledge all occupational therapists possess provides a common lens through which they approach treatment. Intraprofessional collaboration is considered best practice, as it is not uncommon for young children to receive occupational therapy services by more than one therapist, and in more than one practice setting at the same time.

Method: This study used a qualitative, phenomenological approach. …


Adaptations To Early Intervention Service Delivery During Covid-19, Lauren Little, Ashley Stoffel Jul 2021

Adaptations To Early Intervention Service Delivery During Covid-19, Lauren Little, Ashley Stoffel

The Open Journal of Occupational Therapy

Background: Early Intervention (EI) systems made a rapid shift to telehealth during the COVID-19 pandemic. Given the limited preparation of EI providers in the telehealth service delivery model, it is unclear how providers implemented adaptations. The purpose of this study was to evaluate the factor structure of the Service Delivery Adaptations Questionnaire and examine the influence of provider type, years of EI experience, and willingness to return to in-person services on the questionnaire’s subscales.

Method: We used exploratory factor analysis (EFA) to examine the structure of the Service Delivery Adaptations Questionnaire among n = 704 EI providers. We …


Occupational Therapists’ Perspectives On Family-Centered Practices In Early Intervention, Irma J. Pereira, Francine M. Seruya Jul 2021

Occupational Therapists’ Perspectives On Family-Centered Practices In Early Intervention, Irma J. Pereira, Francine M. Seruya

The Open Journal of Occupational Therapy

Background: Early intervention (EI) requires service provision in natural settings while incorporating interventions based on family-centered practice (FCP). This study sought to understand (a) how occupational therapists define and implement FCP in their daily interventions and (b) therapists’ perspectives on using this model of practice in EI.

Method: This study used a qualitative, phenomenological approach. Nine licensed occupational therapists from six states with a minimum of 3 years of working experience in the area of EI participated. Semi-structured interviews were recorded, transcribed, and subsequently coded and analyzed for emergent themes.

Results: The therapists had an average of …


They Said: Preparing Future Ei Providers Across Disciplines Through An Academic Partnership, Beth K. Elenko Jul 2021

They Said: Preparing Future Ei Providers Across Disciplines Through An Academic Partnership, Beth K. Elenko

The Open Journal of Occupational Therapy

No abstract provided.


They Said: Coaching Alongside Families In Early Intervention, Beth K. Elenko Jul 2021

They Said: Coaching Alongside Families In Early Intervention, Beth K. Elenko

The Open Journal of Occupational Therapy

No abstract provided.


Bringing The Family To The Center Of Early Intervention Practice In Occupational Therapy, Beth K. Elenko Jul 2021

Bringing The Family To The Center Of Early Intervention Practice In Occupational Therapy, Beth K. Elenko

The Open Journal of Occupational Therapy

No abstract provided.


Pain Control: Opioid Vs. Nonopioid Analgesia During The Immediate Postoperative Period, Shamsie M. Lumpkin Bsn, Srna, Isaac W. Parrish Bsn, Srna, Austin S. Terrell Bsn, Srna, Dwayne S. Accardo Dnp, Aprn, Crna Jul 2021

Pain Control: Opioid Vs. Nonopioid Analgesia During The Immediate Postoperative Period, Shamsie M. Lumpkin Bsn, Srna, Isaac W. Parrish Bsn, Srna, Austin S. Terrell Bsn, Srna, Dwayne S. Accardo Dnp, Aprn, Crna

Doctor of Nursing Practice Projects

Background Opioid analgesia has become the mainstay for acute pain management in the postoperative setting. However, the use of opioid medications comes with significant risks and side effects. Due to increasing numbers of prescriptions to those with chronic pain, opioid medications have become more expensive while becoming less effective due to the buildup of patient tolerance. The idea of opioid-free analgesic techniques has rarely been breached in many hospitals. Emerging research has shown that opioid-sparing approaches have resulted in lower reported pain scores across the board, as well as significant cost reductions to hospitals and insurance agencies. In addition to …


2021-07-15_Michiganoverview_Covidschooloutbreak, Michigan Department Of Health & Human Services Jul 2021

2021-07-15_Michiganoverview_Covidschooloutbreak, Michigan Department Of Health & Human Services

Michigan COVID-19 Outbreak Reports

The School Outbreak Data page was obtained from Michigan's COVID-19 data page: https://www.michigan.gov/coronavirus/0,9753,7-406-98163_98173_102480---,00.html.

This report is created by the Michigan Department of Health & Human Services from data self-reported by local health departments. Data is updated every week.

In accordance with the Council of State and Territorial Epidemiologists’ outbreak definition, schools that have been found by their local health department to have two (2) or more COVID-19 cases who may have shared exposure at the school grounds and are not from the same household (with the exception of dorms and off-campus housing) are included. If your child’s school is …


Improving Outcomes For Sexual Assault Patients In Alignment With Hiv Npep Clinical Guidelines, Maria Dahlke, Rachel Kanz Jul 2021

Improving Outcomes For Sexual Assault Patients In Alignment With Hiv Npep Clinical Guidelines, Maria Dahlke, Rachel Kanz

Nursing DNP Projects

Purpose and Rationale

The purpose of this project is to improve the follow-up care given to adult patients, 18 years and older, who require human immunodeficiency virus (HIV) non-occupational post-exposure prophylaxis (nPEP) treatment after a sexual assault. The goal is to determine if organizational alignment with HIV nPEP clinical guidelines through staff education improves medication adherence for adult sexual assault patients. Currently, sexual assault survivors have the lowest medication adherence rate to HIV nPEP among those at risk for HIV.

Synthesis of Evidence

The evidence supports the standardization of care for sexual assault patients' individual needs. Educating health care professionals …


2021-07-15_Michiganoverview_Misc, Michigan Department Of Health & Human Services Jul 2021

2021-07-15_Michiganoverview_Misc, Michigan Department Of Health & Human Services

Michigan COVID-19 MIS-C Data

The MIS-C Data page was obtained from Michigan's COVID-19 data page: https://www.michigan.gov/coronavirus/0,9753,7-406-98163_98173_104661---,00.html.

This report is created by the Michigan Department of Health & Human Services from data self-reported by health care providers and local health departments. Data is updated on the first and third Thursdays of the month.

Multisystem Inflammatory Syndrome in Children (MIS-C) is a condition in children and adolescents under 21 years of age where multiple organ systems become inflamed or dysfunctional which occurs in association with illness. Children with MIS-C may have a fever and various symptoms, including abdominal (gut) pain, vomiting, diarrhea, neck pain, rash, …


2021-07-15_Michiganoverview_Covidoutbreak, Michigan Department Of Health & Human Services Jul 2021

2021-07-15_Michiganoverview_Covidoutbreak, Michigan Department Of Health & Human Services

Michigan COVID-19 Outbreak Reports

The Outbreak Data page was obtained from Michigan's COVID-19 data page: https://www.michigan.gov/coronavirus/0,9753,7-406-98163_98173_102057---,00.html.

This report is created by the Michigan Department of Health & Human Services from data self-reported by local health departments. Data is updated every week.

COVID-19 outbreaks are generally defined as two or more cases with a link by place and time indicating a shared exposure outside of a household. Local health departments report the number of new and ongoing outbreaks they are investigating by the setting of the outbreak. New outbreaks are those outbreaks that were first identified during the current reporting week. Ongoing outbreaks are …


Evaluation Of A Hypertension Bundle To Improve Maternal Outcomes, Jamie Jetton Jul 2021

Evaluation Of A Hypertension Bundle To Improve Maternal Outcomes, Jamie Jetton

Dissertations

Abstract

Problem: Hypertensive disorders of pregnancy continue to be on the rise in the United States, contributing to an increase in both maternal morbidity and mortality rates. These disorders not only have an effect on the pregnant women, but also the neonate. Early recognition and treatment of increased blood pressure findings can improve maternal and fetal outcomes.

Methods: This Quality Improvement (QI) project used a descriptive design and was comprised of a retrospective chart review, focused on the effectiveness of evaluating a hypertension bundle to improve maternal outcomes. The data collected for this project encompassed six months pre and post …


Examining The Antecedent Role Of Movement Proficiency In Child Development: Study Protocol, Catherine M. Capio, Kerry Lee, Rachel A. Jones, Rich S. W. Masters Jul 2021

Examining The Antecedent Role Of Movement Proficiency In Child Development: Study Protocol, Catherine M. Capio, Kerry Lee, Rachel A. Jones, Rich S. W. Masters

Health Sciences Faculty Publications

Background: Decades of research, largely from associational studies, show that the relationships of movement proficiency with the cognitive and social aspects of development are particularly strong in early childhood. Children who move proficiently tend to have better cognitive skills and social behaviors. However, the mechanisms that underpin these relationships remain unclear and research that explores causation is necessary. This study will explore the antecedent role of movement proficiency in the cognitive and social domains of child development, by examining whether a targeted movement skills training program facilitates improvements in cognitive and social skills.

Methods: A group-randomized controlled trial will be …


Object Control Skills Training For Children With Intellectual Disability: An Implementation Case Study, Catherine M. Capio, Kathlynne F. Eguia Jul 2021

Object Control Skills Training For Children With Intellectual Disability: An Implementation Case Study, Catherine M. Capio, Kathlynne F. Eguia

Health Sciences Faculty Publications

Children with intellectual disability (ID) tend to have difficulty with mastering fundamental movement skills, associated with cognitive deficits that impair skill acquisition. In this case study, motor learning evidence was transformed into an object control skills training program for children with ID in a school context. An implementation framework was used for program design, pilot, and evaluation. Research evidence on error-reduced motor learning was combined with practitioners’ insights to inform the program design. Children with ID in the participant school were allocated to a training or control group for the pilot; object control skills proficiency was the measured outcome. The …


What’S In Wildfire Smoke?: A Toxicologist Explains The Health Risks And Which Masks Can Help, Luke Montrose Jul 2021

What’S In Wildfire Smoke?: A Toxicologist Explains The Health Risks And Which Masks Can Help, Luke Montrose

Public and Population Health Faculty Publications and Presentations

Smoke is turning the sky hazy across a large swath of the country as dozens of large fires burn, and a lot of people are wondering what’s in the air they’re breathing.

As an environmental toxicologist, I study the effects of wildfire smoke and how they differ from other sources of air pollution. We know that breathing wildfire smoke can be harmful. Less clear is what the worsening wildfire landscape will mean for public health in the future, but research is raising red flags.


Notch Signaling Represses Cone Photoreceptor Formation Through The Regulation Of Retinal Progenitor Cell States, Xueqing Chen, Mark M. Emerson Jul 2021

Notch Signaling Represses Cone Photoreceptor Formation Through The Regulation Of Retinal Progenitor Cell States, Xueqing Chen, Mark M. Emerson

Publications and Research

Notch signaling is required to repress the formation of vertebrate cone photoreceptors and to maintain the proliferative potential of multipotent retinal progenitor cells. However, the mechanism by which Notch signaling controls these processes is unknown. Recently, restricted retinal progenitor cells with limited proliferation capacity and that preferentially generate cone photoreceptors have been identified. Thus, there are several potential steps during cone genesis that Notch signaling could act. Here we use cell type specific cis-regulatory elements to localize the primary role of Notch signaling in cone genesis to the formation of restricted retinal progenitor cells from multipotent retinal progenitor cells. Localized …


The Effect Of Mindfulness Meditation On Sleep Quality, Crystal Gonzalez, Russell Souders Jul 2021

The Effect Of Mindfulness Meditation On Sleep Quality, Crystal Gonzalez, Russell Souders

Abington Jefferson Health Nurse Residency Posters

No abstract provided.


General Public Perception Of Social Media, Impact Of Covid-19 Pandemic, And Related Misconceptions, Rabiya Ali, Shireen Jawed, Mukhtiar Baig, Ahmed Azam Malik, Fatima Syed, Rehana Rehman Jul 2021

General Public Perception Of Social Media, Impact Of Covid-19 Pandemic, And Related Misconceptions, Rabiya Ali, Shireen Jawed, Mukhtiar Baig, Ahmed Azam Malik, Fatima Syed, Rehana Rehman

Department of Biological & Biomedical Sciences

Objectives: To investigate the general public perception of social media (SM), impact of COVID-19 (SARS-CoV-2) pandemic, and related misconceptions among Pakistani population.
Methodology: Cross-sectional study conducted during the peak of COVID-19 in Pakistan between May-June 2020 comprised of 2307 Pakistani male and female participants. Subjects under 18 years of age and nationality other than Pakistani were excluded. An online questionnaire was administered via the Internet using various kinds of social media.
Results: The study comprised of 2307 male and female participants; 2074(89.90%) were using SM for seeking COVID-19 information, 450 (20%) were using both Facebook (FB) and WhatsApp (WA) and …


Multiple Baseline Interrupted Time Series: Describing Changes In New Mexico Medicaid Behavioral Health Home Patients’ Care, Jessica Reno Jul 2021

Multiple Baseline Interrupted Time Series: Describing Changes In New Mexico Medicaid Behavioral Health Home Patients’ Care, Jessica Reno

Mathematics & Statistics ETDs

In 2016, the CareLink New Mexico behavioral health homes program began enrolling Medicaid recipients with the goal of increasing care coordination, improving access to services, and decreasing long-term costs of care for adults with serious mental illness (SMI) and children with severe emotional disturbance (SED). To evaluate these aims, a retrospective interrupted time series study using Medicaid claims data was designed. First, a comparable subset of non-enrolled individuals was selected from the pool of Medicaid recipients with SMI or SED using propensity score matching. Then, segmented regression was applied to three outcomes: total Medicaid charges, number of outpatient behavioral health …