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Articles 91 - 120 of 155
Full-Text Articles in Community Health
Engagement Of Community Stakeholders To Develop A Framework To Guide Research Dissemination To Communities, Jennifer Cunningham-Erves, Tilicia Mayo-Gamble, Yolanda Vaughn, Jim Hawk, Mike Helms, Claudia Barajas, Yvonne Joosten
Engagement Of Community Stakeholders To Develop A Framework To Guide Research Dissemination To Communities, Jennifer Cunningham-Erves, Tilicia Mayo-Gamble, Yolanda Vaughn, Jim Hawk, Mike Helms, Claudia Barajas, Yvonne Joosten
Health Policy & Community Health: Faculty Publications
Background: Dissemination of research findings to past study participants and the community-at-large is important. Yet, a standardized process for research dissemination is needed to report results to the community. Objective: We developed a framework and strategies to guide community-academic partnerships in community-targeted, dissemination efforts.
Methods: From 2017 to 2019, a community-academic partnership was formed in Nashville, Tennessee, and iteratively developed a framework and strategies for research dissemination using cognitive interviews. A deductive, constant comparative analysis was conducted on interview responses to examine framework and strategy content. Feedback was used to finalize the framework and strategies for the evaluation. …
“En Defensa Por La Salud”: Los Actores Sociales En La Construcción Del Movimiento Social En Chile, Karina Martinez
“En Defensa Por La Salud”: Los Actores Sociales En La Construcción Del Movimiento Social En Chile, Karina Martinez
Independent Study Project (ISP) Collection
This investigation aimed to describe the construction of the social movement for health demands in the frame of the social outbreak in Chile in October 2019. In addition to identifying the main health demands of this movement, it also had a focus on understanding the role of social organizations in the construction of the movement and placing it within the broader socio-political movement that arises from the social outbreak. The research design was qualitative and descriptive. Having been a remote investigation, it was largely based on literature review with the support of information from a semi-structured interview. Regarding the results, …
Feasibility Of Long Acting Pre-Exposure Prophylaxis (Prep) In Rural Communities, William A. Mase, Ellie Purdy
Feasibility Of Long Acting Pre-Exposure Prophylaxis (Prep) In Rural Communities, William A. Mase, Ellie Purdy
Health Policy & Community Health: Faculty Publications
Published as part of the "Eagles Talking About the Public’s Health" Commentaries.
Link: https://jphcoph.georgiasouthern.edu/opr/etaph/
Mhpaea & Marble Cake: Parity & The Forgotten Frame Of Federalism, Taleed El-Sabawi
Mhpaea & Marble Cake: Parity & The Forgotten Frame Of Federalism, Taleed El-Sabawi
Dickinson Law Review (2017-Present)
No abstract provided.
Effect Of Influenza Vaccination On Mortality And Risk Of Hospitalization In Elderly Individuals With And Without Disabilities: A Nationwide, Population-Based Cohort Study, Yu-Chia Chang, Ho-Jui Tung, Yu-Tung Huang, Chin-Te Lu, Ernawaty Ernawaty, Szu-Yuan Wu
Effect Of Influenza Vaccination On Mortality And Risk Of Hospitalization In Elderly Individuals With And Without Disabilities: A Nationwide, Population-Based Cohort Study, Yu-Chia Chang, Ho-Jui Tung, Yu-Tung Huang, Chin-Te Lu, Ernawaty Ernawaty, Szu-Yuan Wu
Health Policy & Community Health: Faculty Publications
Purpose: The effects of influenza vaccines are unclear for elderly individuals with disabilities. We use a population-based cohort study to estimate the effects of influenza vaccines in elderly individuals with and without disabilities. Methods: Data were taken from the National Health Insurance Research Database and Disabled Population Profile of Taiwan. A total of 2,741,403 adults aged 65 or older were identified and 394,490 were people with a disability. These two groups were further divided into those who had or had not received an influenza vaccine. Generalized estimating equations (GEE) were used to compare the relative risks (RRs) of …
A Health Disparity Action Plan: Achieving Equity Through Clinical Trials, Affordable Care, And Professional Development, Daniel Schafer, Shefa Moten, Ayesha Khan, Mauro Ferrari, Boris Lushniak, Edwin Burkett, Asad Moten
A Health Disparity Action Plan: Achieving Equity Through Clinical Trials, Affordable Care, And Professional Development, Daniel Schafer, Shefa Moten, Ayesha Khan, Mauro Ferrari, Boris Lushniak, Edwin Burkett, Asad Moten
Journal of Health Disparities Research and Practice
Given the threatened nature of affordable care in the United States, it is crucial to underscore its importance. What is more, the reason such care is so important is the presence of an oft-unacknowledged disparity in access to quality care in this country and, indeed, around the world. A world without health disparities can be achieved and will be characterized by prompt and quality care available to all and at all stages of the care continuum. Further insurance reform is needed beyond the Affordable Care Act, while local care must be more accessible in rural, urban, and other underserved areas. …
A Scoping Review Of Theoretical Models And Conceptual Frameworks Used In Public Health Services And Systems Research (Phssr) Literature, Zahra Shahin, Anna Messick, Jenna Harris, Kristie C. Waterfield, Gulzar H. Shah
A Scoping Review Of Theoretical Models And Conceptual Frameworks Used In Public Health Services And Systems Research (Phssr) Literature, Zahra Shahin, Anna Messick, Jenna Harris, Kristie C. Waterfield, Gulzar H. Shah
Health Policy & Community Health: Faculty Publications
Objectives
Theoretical models and conceptual frameworks are often used to design research methods. This study aims to provide an overview of the application of theoretical models and conceptual frameworks in Public Health Services and Systems Research (PHSSR). We also examine how the integration of such terms in research can improve intervention designs and support the decision-making process within the field of public health practice.
Methods
A scoping review was conducted using publications from public health journals to identify relevant articles in the field of PHSSR. The eligibility of studies was determined after performing evaluations through a full-text review of each …
Maternal Mortality Among African American Women In The State Of Georgia, Causes, Policy, And Ethical Considerations, Zahra Shahin, Isabella M. Hardwick, Nancy Jeffery, Jalisa Jordan, William Mase
Maternal Mortality Among African American Women In The State Of Georgia, Causes, Policy, And Ethical Considerations, Zahra Shahin, Isabella M. Hardwick, Nancy Jeffery, Jalisa Jordan, William Mase
Health Policy & Community Health: Faculty Publications
Background
The U.S. is currently one of thirteen countries where maternal mortality rates (MMR) is worse now than it was fifteen years ago. Reducing maternal mortality is one of the significant challenges facing the health system in the United States, especially in the State of Georgia, which has one of the highest MMR in the nation. The purpose of this review is to explore the causes, policy, and ethical contextual factors contributing to increased maternal mortality rates among African American women in the State of Georgia. Also, identifying and addressing weaknesses and gaps that exist in the healthcare system and …
Associations Among Knowledge, Attitudes, And Practices Toward Palliative Care Consultation Service In Healthcare Staffs: A Cross-Sectional Study, Li-Chun Huang, Ho-Jui Tung, Pei-Chao Lin
Associations Among Knowledge, Attitudes, And Practices Toward Palliative Care Consultation Service In Healthcare Staffs: A Cross-Sectional Study, Li-Chun Huang, Ho-Jui Tung, Pei-Chao Lin
Health Policy & Community Health: Faculty Publications
Background
The palliative care consultation service (PCCS) of the National Health Insurance payments has been promoted in Taiwan since 2011, although few studies have been conducted on healthcare staffs’ knowledge, attitudes, and practices regarding PCCS in Taiwan; consequently, the main objective of this study was to explore any correlations regarding the above by cross-sectional design using convenience sampling.
Methods
A total of 210 healthcare staff members were enrolled from a regional hospital from June 1, 2018, to September 30, 2018. Questionnaire items on the Palliative Care Consultation Service Inventory (KAP-PCCSI) were used to measure healthcare staff’s knowledge, attitudes, and practices …
Adicción Como Un Hecho Político Económico: Un Análisis De Servicios De Atención De Abuso De Drogas Y Alcohol En Arica, Chile, Jack Steffy
Independent Study Project (ISP) Collection
Research question – What is the current landscape of drug abuse in Chile and how has the state attempted to address this problem?
Objectives – The objectives of the paper were to characterize drug use patterns in Chile since 1994, revise drug abuse services, and offer possible improvements for the system of drug abuse treatment.
Background – Chile, despite being one of the most well economically-developed countries in South America, has some of the worst mental health indicators, one of these being drug abuse. Since 1994, use of alcohol and marihuana has increased, while use of cocaine products has remained …
A Need For Patient-Friendly Language For Those With Low Health Literacy In Advanced Care Planning, Denisha Allicock, Addison Mickens, Tilicia Mayo-Gamble
A Need For Patient-Friendly Language For Those With Low Health Literacy In Advanced Care Planning, Denisha Allicock, Addison Mickens, Tilicia Mayo-Gamble
Health Policy & Community Health: Faculty Publications
Work published by Georgia Southern University Press.
Characteristics Of The Health Information Technology Workforce In Georgia, Imaobong Ekpo, Emmanuel Akowuah, Bettye Apenteng, Samuel T. Opoku
Characteristics Of The Health Information Technology Workforce In Georgia, Imaobong Ekpo, Emmanuel Akowuah, Bettye Apenteng, Samuel T. Opoku
Health Policy & Community Health: Faculty Publications
Background: Advancement in medical technology, as well as the Health Information Technology for Economic and Clinical Health Act, has in part influenced the demand for health information technology (HIT) workers. While other sectors have experienced a tremendous increase in the information technology workforce, the health sector lags in this regard. The aim of this study was to describe the characteristics of the HIT workforce in Georgia, relative to surrounding states and the United States.
Methods: The supply of the HIT workforce in Georgia, surrounding states, and the United States was estimated using data from the 2014-2016 American Community Survey (ACS). …
Leveraging Technology To Address Patient-Centered Outcomes In Sickle Cell Disease, Tilicia Mayo-Gamble, Delores P. Quasie-Woode
Leveraging Technology To Address Patient-Centered Outcomes In Sickle Cell Disease, Tilicia Mayo-Gamble, Delores P. Quasie-Woode
Health Policy & Community Health: Faculty Publications
Work published by Georgia Southern University Press.
An Analysis And Critique Of Mental Health Treatment In American State Prisons And Proposal For Improved Care, Shelby Hayne
An Analysis And Critique Of Mental Health Treatment In American State Prisons And Proposal For Improved Care, Shelby Hayne
Scripps Senior Theses
Mental health treatment in state prisons is revealed to be highly variable, under-funded, and systematically inadequate. Existing literature exposes this injustice but fails to provide a comprehensive proposal for reform. This paper attempts to fill that gap, outlining a cost-effective, evidence-based treatment proposal, directly addressing the deficits in care revealed through analysis of our current system. In addition, this paper provides historical overviews of the prison system and mental health treatment, utilizing theoretical perspectives to contextualize this proposal in the present state of affairs. Lastly, the evidence is provided to emphasize the potential economic and social benefits of improving mental …
The Critical Need For Mental Health Education To Be Mandated In New Mexico's Public Schools, Bonnie L. Murphy
The Critical Need For Mental Health Education To Be Mandated In New Mexico's Public Schools, Bonnie L. Murphy
Shared Knowledge Conference
Based on a review of research and best practices in mental health awareness and skills, this inquiry project argues for state legislative policies that would require mental health awareness and skills in the K-12 curriculum. Mental health affects individual accomplishments in every stage of people’s lives beginning in early childhood and throughout the life cycle. Prevention and treatment of mental illness plays a key role in the ability of an individual to cope with loss and develop resiliency and perseverance in challenging times and to make better decisions that improve the individual’s life and the lives of those around them. …
The Life She Deserves: Medical Marijuana In The United States, John Hudak, George Burroughs, Maritza Bermudez
The Life She Deserves: Medical Marijuana In The United States, John Hudak, George Burroughs, Maritza Bermudez
Brookings Scholar Lecture Series
Brookings Mountain West offered an event titled, "The Life She Deserves: Medical Marijuana in the United States on Monday, November 5, 2018. This event featured a viewing of the film, and was followed by a panel discussion with John Hudak, George Burroughs, and Maritza Bermudez. “The Life She Deserves” is an intimate portrait of Jennifer Collins and her family’s struggle to find a treatment to control her debilitating epilepsy. Because her legal pharmaceutical treatments cause severe side effects, Jennifer and her mother move across the country to access medical marijuana. The therapy provides Jennifer and her family with the relief …
Adapting Medical Guidelines To Be Patient-Centered Using A Patient-Driven Process For Individuals With Sickle Cell Disease And Their Caregivers, Robert M. Cronin, Tilicia Mayo-Gamble, Sarah-Jo Stimpson, Sherif M. Badawy, Lori E. Crosby, Jeannie Byrd, Emmanuel J. Volanakis, Adetola A. Kassim, Jean L. Raphael, Velma Mcbride Murry, Michael Debaun
Adapting Medical Guidelines To Be Patient-Centered Using A Patient-Driven Process For Individuals With Sickle Cell Disease And Their Caregivers, Robert M. Cronin, Tilicia Mayo-Gamble, Sarah-Jo Stimpson, Sherif M. Badawy, Lori E. Crosby, Jeannie Byrd, Emmanuel J. Volanakis, Adetola A. Kassim, Jean L. Raphael, Velma Mcbride Murry, Michael Debaun
Health Policy & Community Health: Faculty Publications
Background: Evidence-based guidelines for sickle cell disease (SCD) health maintenance and management have been developed for primary health care providers, but not for individuals with SCD. To improve the quality of care delivered to individuals with SCD and their caregivers, the main purposes of this study were to: (1) understand the desire for patient-centered guidelines among the SCD community; and (2) adapt guideline material to be patient-centered using community-engagement strategies involving health care providers, community -based organizations, and individuals with the disease.
Methods: From May–December 2016, a volunteer sample of 107 individuals with SCD and their caregivers gave …
2491: Parental Concerns About Child Participation In S Reflect A Need To Move Beyond Traditional Notions Of Trust And Race, Jennifer Cunningham-Erves, Tilicia Mayo-Gamble, Consuelo H. Wilkins
2491: Parental Concerns About Child Participation In S Reflect A Need To Move Beyond Traditional Notions Of Trust And Race, Jennifer Cunningham-Erves, Tilicia Mayo-Gamble, Consuelo H. Wilkins
Health Policy & Community Health: Faculty Publications
OBJECTIVES/SPECIFIC AIMS: The objective of this study was to identify factors influencing parental willingness of adolescent participation in clinical trials. METHODS/STUDY POPULATION: We applied community engaged research principles to conduct a theory-based, cross-sectional study of parental willingness. Parents (N=307) were given a survey from November 2014 to April 2015. Factors influencing parental willingness were identified using binary logistic regression. SPSS version 22.0 was used to perform analyses, and p
Healthcare Utilization For Behavioral Health Disorders: Policy Implications On Nationwide Readmissions, And Outcomes In The States Of Nebraska And New York, Rajvi J. Wani
Theses & Dissertations
The main goal of this dissertation was to estimate national-level inpatient readmissions and state-level hospital-based emergency department (ED) visits with behavioral health (BH) conditions in the states of Nebraska and New York. The dissertation aims to assess the impact of the policy mandates under the Patient Protection and Affordable Care Act on these state and national estimates. The Nationwide Readmissions Database and the State Emergency Department databases maintained by the Healthcare Cost and Utilization Project were used for this dissertation. US Adult population with high-risk of readmissions in the inpatient departments for alcohol-related disorders (ARD) and of visiting ED for …
Identifying The Newly Insurable Medicaid Coverage Gap Population Under The Affordable Care Act: Who They Are And Where They Live, Samuel L. Woodruff
Identifying The Newly Insurable Medicaid Coverage Gap Population Under The Affordable Care Act: Who They Are And Where They Live, Samuel L. Woodruff
Capstone Experience: Master of Public Health
The goal of this Capstone Project is to better define and geographically locate the potential distribution of individuals who fall within the current Medicaid Coverage Gap and those populations who would be eligible for Medicaid under the expansion of Medicaid within the state of Nebraska. Using data from multiple United States Census Bureau sources, along with available data from the Health Resources and Services Administration (HRSA), this project looks to also locate populations of these individuals that may live within established Medically Underserved Areas (MUA's) or Health Professional Shortage Areas (HPSA's) within the state. American Community Survey 5-year Public Use …
The Predictors Of Juvenile Recidivism: Testimonies Of Adult Students 18 Years And Older Exiting From Alternative Education, La Toshia Palmer
The Predictors Of Juvenile Recidivism: Testimonies Of Adult Students 18 Years And Older Exiting From Alternative Education, La Toshia Palmer
Dissertations
Purpose: The purpose of this descriptive, qualitative study was to identify and describe the importance of the predictors of juvenile recidivism and the effectiveness of efforts to prevent/avoid juvenile recidivism as perceived by previously detained, arrested, convicted, and/or incarcerated adult students 18 years of age and older exiting from alternative education in Northern California. A second purpose was to explore the types of support provided by alternative schools and the perceived importance of the support to avoid recidivism according to adult students 18 years of age and older exiting from alternative education.
Methodology: This qualitative, descriptive research design identified …
Gun Violence: Chicago, Illinois, Kayla Dillon
Gun Violence: Chicago, Illinois, Kayla Dillon
Global Issues in Public Health
Gun violence has been, and continues to be, a significant problem in Chicago, Illinois. There have been several programs in place that have worked towards improving the level of gun violence. One of the most noticeable being Project Safe Neighborhood, which began in 2001. Part of what makes these programs, and programs similar to it, necessary is that it targets the populations most at-risk of gun violence. By targeting these specific regions of the city, these programs can provide the resources necessary to improve the condition of the city in the long-term, as well as prevent the condition from spreading …
Of Rats And Men, Thomas S. Walsh
Of Rats And Men, Thomas S. Walsh
Capstones
This capstone is a data-driven investigation into New York City's rat problem. By using publicly available government data to map rat activity in NYC, I identified several socio-economic variables that correlate with rat populations at the community district, borough, and city-scale. I used these findings (mainly that rat problems are linked to lower incomes) as the basis of an investigation, which includes interviews with residents, experts, and city officials. Prof. Bobby Corrigan, urban rodentologist and formerly with the NYC Department of Health criticizes the city's efforts for the first time on the record.
https://thomasseiyawalsh.wixsite.com/ratstone
Suicide Prevention: Do San Francisco Afsp Community Walks Reduce Hopelessness?, Tyson Peltz
Suicide Prevention: Do San Francisco Afsp Community Walks Reduce Hopelessness?, Tyson Peltz
Master's Projects
Community-based outreach programs have been found to be effective, helping to educate people, and reduce suicide through outreach and peer group support. The American Foundation for Suicide Prevention (AFSP) has been at the forefront of the battle to reduce suicide through education, fund raising, lobbing, and support efforts to those in need of suicide prevention services, as well as those who have lost someone. One of the ways they have done this is through community walks and fundraising throughout the nation for anyone affected by suicide. These events are called Out of the Darkness Walks, which allow the community to …
2484: Establishment Of The Tennessee-Sickle Cell Disease Network As A Mechanism For Engaging A Rare Disease Population In Patient Centered Outcomes Research, Tilicia Mayo-Gamble, Velma Mcbride Murry, Michael R. Debaun
2484: Establishment Of The Tennessee-Sickle Cell Disease Network As A Mechanism For Engaging A Rare Disease Population In Patient Centered Outcomes Research, Tilicia Mayo-Gamble, Velma Mcbride Murry, Michael R. Debaun
Health Policy & Community Health: Faculty Publications
OBJECTIVES/SPECIFIC AIMS: Despite the high prevalence of individuals diagnosed with sickle cell disease (SCD) in Tennessee, comprehensive care and education for patients with SCD is not as widely available as healthcare services for individuals managing other chronic illnesses. We aimed to engage SCD stakeholders in patient-centered outcomes research (PCOR) as a mechanism for advancing care and translational research for this rare disease population. METHODS/STUDY POPULATION: Through a partnership with the Sickle Cell Foundation of Tennessee, we implemented Community Health Ambassadors to systematically engage patient partners with SCD and their caregivers, aged 18–50 from rural and urban communities throughout Tennessee, in …
Analyzing The Effectiviness Of A Prescription Drug Monitoring Program Targeting At-Risk Opioid Abuse Patients, Treadway Childs
Analyzing The Effectiviness Of A Prescription Drug Monitoring Program Targeting At-Risk Opioid Abuse Patients, Treadway Childs
Public Administration ETDs
The effectiveness of a prescription drug monitoring program in coordination with a prescription opioid recidivism program was examined at a semi-rural community hospital. Patients were identified by a multi-disciplinary committee to be at-risk for opioid misuse or abuse, and were denied prescription opioids. Patients were considered eligible for the program if they had over 12 emergency department visits in the previous 12 months, or 6 visits in the previous 6 months, depending on how long the hospital had records on a patient. Patients who were placed in the prescription opioid recidivism program could not receive opioids at this hospital. The …
Fine Particles In Homes Of Predominantly Low-Income Families With Children And Smokers: Key Physical And Behavioral Determinants To Inform Indoor-Air-Quality Interventions, Neil E. Klepeis, John Belletierre, Suzanne C. Hughes, Benjamin Nguyen, Vincent Berardi, Sandy Liles, Saori Obayashi, C. Richard Hofstetter, Elaine Blumberg, Melbourne F. Hovell
Fine Particles In Homes Of Predominantly Low-Income Families With Children And Smokers: Key Physical And Behavioral Determinants To Inform Indoor-Air-Quality Interventions, Neil E. Klepeis, John Belletierre, Suzanne C. Hughes, Benjamin Nguyen, Vincent Berardi, Sandy Liles, Saori Obayashi, C. Richard Hofstetter, Elaine Blumberg, Melbourne F. Hovell
Psychology Faculty Articles and Research
Children are at risk for adverse health outcomes from occupant-controllable indoor airborne contaminants in their homes. Data are needed to design residential interventions for reducing low-income children's pollutant exposure. Using customized air quality monitors, we continuously measured fine particle counts (0.5 to 2.5 microns) over a week in living areas of predominantly low-income households in San Diego, California, with at least one child (under age 14) and at least one cigarette smoker. We performed retrospective interviews on home characteristics, and particle source and ventilation activities occurring during the week of monitoring. We explored the relationship between weekly mean particle counts …
New Outpatient Experience Survey Design: A Quality Improvement Case Study, Nathan Paluso
New Outpatient Experience Survey Design: A Quality Improvement Case Study, Nathan Paluso
Muskie School Capstones and Dissertations
The purpose of this capstone project is to evaluate the implementation process for a new survey methodology introduced by Maine Medical Partners (MMP), by following the Plan-Do-Study-Act (PDSA) quality improvement cycle framework. This new survey has been implemented to collect data on patients’ experiences in the MMP outpatient facilities, and is offered to the patients via iPad at check-out after their appointment. Through observation at MMP practices and MMP staff interviews, strengths and weaknesses of the implementation process have been identified. Evidence-based solutions pertaining to the identified weaknesses have been selected through a literature review and are incorporated in recommendations …
Reconnecting The Mind And Body: A Pilot Study Of Developing Compassion For Persistent Pain, Sarah L. Parry Dr, Zoey Malpus Dr
Reconnecting The Mind And Body: A Pilot Study Of Developing Compassion For Persistent Pain, Sarah L. Parry Dr, Zoey Malpus Dr
Patient Experience Journal
As an alternative to the more typical cognitive behavioural approach to pain management, a novel pain management group based on the principles of compassionate mind training was developed for a particular sub-group of patients. Participants were patients of a community pain clinic, who were invited to participate in this alternative approach to pain management. The eight-week Compassion in Pain Groups included psychoeducation around persistent pain, the underlying principles of compassionate mind training, practical exercises such as diaphragmatic breathing, followed by a series of compassionate imagery exercises and group discussions. Both quantitative and qualitative analyses were undertaken to gain further insights …
Experiences Of Communication Barriers Between Physicians And Immigrant Patients: A Systematic Review And Thematic Synthesis, Salim Ahmed, Sonya Lee, Nusrat Shommu, Nahid Rumana, Tanvir Turin
Experiences Of Communication Barriers Between Physicians And Immigrant Patients: A Systematic Review And Thematic Synthesis, Salim Ahmed, Sonya Lee, Nusrat Shommu, Nahid Rumana, Tanvir Turin
Patient Experience Journal
Frequent immigration of peoples from outside often challenges various systems of any country; healthcare sector is the most confronted one. One of the most prominent reasons for this confrontation is communication gap between physicians and immigrant patients. In this systematic narrative review, we studied existing literature on physician-immigrant patient communication. We systematically searched the repositories of literature and followed some criteria to select literature. We selected 32 literatures for information extraction. Three themes emerged from the synthesis: Physicians’ viewpoint about communication barrier with their immigrant patients, Immigrant patients’ viewpoint about the communication barrier with their physicians, and Interpreter as a …