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Full-Text Articles in Public Health and Community Nursing

The Effects Of The Transition From Pre-Nursing To Nursing On Mental Health, Andrew J. Davis, Paige R. Mullins, Kimberly A. Sell May 2022

The Effects Of The Transition From Pre-Nursing To Nursing On Mental Health, Andrew J. Davis, Paige R. Mullins, Kimberly A. Sell

Undergraduate Honors Theses

Mental health is an ever-growing crisis among adolescents and young adults, with suicide as second leading cause of death and the number of those negatively affected continually on the rise. Transitions are one of the major stressors prevalent among these age groups, placing individuals at risk for mental health deficits. This quantitative voluntary response comparative study assesses the transitional mental health of pre-nursing students and students in the nursing program at East Tennessee State University. Emailed to all with a declared major of pre-nursing or nursing, this study measured mental health using evidenced based assessment tools. The PHQ-9 for depression …


Nurses Leading In Bridging The Culture Gap: Communicating With The Deaf Community, Veronica C. Leftridge May 2022

Nurses Leading In Bridging The Culture Gap: Communicating With The Deaf Community, Veronica C. Leftridge

Electronic Theses and Dissertations

Nurses provide patient care in clinics, hospitals, homes, churches, schools, communities, and military, as well as on emergency medical helicopters. When a nurse is assigned to care for a patient, the patient expects the nurse to be culturally competent, communicate effectively, and provide safe quality care. However, cultural incompetence is observed when nurses provide care for Deaf patients, but they are unfamiliar with Deaf culture. In addition, communication is a fundamental skill nurses learn in nursing school, but course content in nursing programs rarely touches on how to communicate effectively with Deaf patients. Of the approximately 325 million people in …


Covid-19 Vaccine Uptake Among College Students, Erin Hoening, Elizabeth Morse, David Phillippi, Krystal Huesmann Apr 2022

Covid-19 Vaccine Uptake Among College Students, Erin Hoening, Elizabeth Morse, David Phillippi, Krystal Huesmann

DNP Projects

Background: Public health strategies to improve COVID-19 vaccine uptake among college students living in residential communities varied, some universities opted to mandate COVID-19 vaccines while other universities opted to promote and influence the choice for vaccination.

Purpose: This descriptive, cross-sectional study examined the voluntary uptake of COVID-19 vaccines among residential students on a college campus in the southeastern U.S. that elected an evidence-driven health promotion strategy that included strong health promotion messaging coupled with coordinated efforts to make the vaccine accessible and appealing to students on campus.

Methods: Analysis of vaccine uptake was derived from campus electronic health records during …


Communicating Comfort In Crisis: A Literature Review On Overcoming The Emergency Room Environment To Foster The Nurse-Patient Relationship, Faith G. Davenport Apr 2022

Communicating Comfort In Crisis: A Literature Review On Overcoming The Emergency Room Environment To Foster The Nurse-Patient Relationship, Faith G. Davenport

Senior Honors Theses

The average emergency room patient is not receiving the compassionate nurse-patient communication that patients experience on other hospital floors. Fewer positive nurse-patient interactions prompt patients to state that they feel uncomforted and dissatisfied on hospital exit surveys, inciting hospital management to investigate how to reverse this trend to retain their federal funding. Emergency room nurses cite multiple barriers inherent in their work environment that prevent them from building rapport with their patients, including a layout not conducive to private conversations, strict time constraints, and a fluctuating workload. Working for a prolonged period under these conditions is driving many nurses to …


Usability Of Health-Related Websites By Filipino-American Adults And Nursing Informatics Experts, Kathleen Begonia Feb 2022

Usability Of Health-Related Websites By Filipino-American Adults And Nursing Informatics Experts, Kathleen Begonia

Dissertations, Theses, and Capstone Projects

Filipino-Americans are an understudied minority group with high prevalence and mortality from chronic conditions, such as cardiovascular disease and diabetes. Facing barriers to care and lack of culturally appropriate health resources, they frequently use the internet to obtain health information. It is unknown whether they perceive health-related websites to be useful or easy to use because there are no published usability studies involving this population. Using the Technology Acceptance Model as a theoretical framework, this study investigated the difference between website design ratings by experts and the perceptions of Filipino-American users to determine if usability guidelines influenced the perceived ease …


Rural Pregnant Women’S Experiences With Substance Use Disorder: A Qualitative Study, Cami Weber Jan 2022

Rural Pregnant Women’S Experiences With Substance Use Disorder: A Qualitative Study, Cami Weber

Dissertations

Rural pregnant women with substance use disorder (SUD) are an understudied vulnerable population that often experiences poor pregnancy outcomes (Higgins et al., 2019; Jumah, 2016; Kramlich et al., 2018; Shaw et al., 2015). Despite the high prevalence and high burden associated with SUD, rural women are less likely than non-pregnant women to seek addiction treatment and complete an outpatient treatment program during pregnancy (Shaw et al., 2015). This study aimed to give voice to rural Missouri women with SUD. The research questions explored the life experiences and motivations for seeking treatment using a qualitative, descriptive research design with grounded theory …


Black Hearts Matter: A Comparative Study Of Sociodemographic, Clinical, And Psychosocial Characteristics In Black And White Persons With Heart Failure, Hannah M Anderson Hughes Jan 2022

Black Hearts Matter: A Comparative Study Of Sociodemographic, Clinical, And Psychosocial Characteristics In Black And White Persons With Heart Failure, Hannah M Anderson Hughes

Theses and Dissertations

Heart failure (HF) is a chronic, progressive, debilitating illness that disproportionately affects Black individuals, often leading to poor quality of life (QOL). Various sociodemographic, clinical, and psychological characteristics are related to QOL in patients with HF. Because most studies do not include representative Black samples or report findings from racial subgroup analyses, these relationships and any existing racial differences are not well understood. The purpose of this descriptive, comparative study was to explore the relationships among sociodemographic, clinical, and psychological characteristics and QOL in patients with HF and to determine if there were racial differences between Black and White individuals. …


Unpacking The Influence Of Islamic Religious Culture And Individual Religious Affiliation On Testing Hiv-Positive, Brittany Hayes, Amy Adamczyk Jan 2022

Unpacking The Influence Of Islamic Religious Culture And Individual Religious Affiliation On Testing Hiv-Positive, Brittany Hayes, Amy Adamczyk

Publications and Research

The distribution of HIV cases varies cross-nationally. We separate the influences of Islam at the macro-and micro-levels to understand the role of religion in shaping the spread of HIV. Drawing on biomarker data from the Demographic and Health Surveys, we construct a multilevel database (Individual N= 568,476; Country N= 30). We examine a series of national-and individual-level predictors that may mediate the relationship between Islam and testing HIV-positive. Individual religious affiliation and proportion Muslim retained their risk-reducing effects even when accounting for a range of mediators and suppressors. Islam has a sui generis effect on testing HIV-positive.


Intention To Breastfeed: Breastfeeding Attitudes, Norms, Self-Efficacy, Social Support Network And Community Resources Of African American, Low-Income, Emerging Adult Women, Pregnant For The First Time, Sara E. Brown Dec 2021

Intention To Breastfeed: Breastfeeding Attitudes, Norms, Self-Efficacy, Social Support Network And Community Resources Of African American, Low-Income, Emerging Adult Women, Pregnant For The First Time, Sara E. Brown

Theses & Dissertations

African American (AA) women continue to have the lowest rates of breastfeeding. This continues to create a health disparity even though breastfeeding is extensively recognized in the scientific and health care communities as the optimal feeding choice for infants. This study examined the relationship between the external variables (social support network and community resources) and the explanatory variables (attitudes, norms, and perceived self-efficacy) and intention to breastfeed, for the AA, first time, low-income, emerging adult pregnant woman. The Integrated Behavior Model (IBM) was used as the theoretical framework to guide this study in better understanding the variables influencing breastfeeding intention. …


Effects Of Abstinence-Based Sexual Education Compared To Evidence-Based Sexual Education In K-12 Schools, Lily Probst Dec 2021

Effects Of Abstinence-Based Sexual Education Compared To Evidence-Based Sexual Education In K-12 Schools, Lily Probst

The Eleanor Mann School of Nursing Undergraduate Honors Theses

Background: Historically, sexual education in the United States has been abstinence-based (ABSE), meaning that sexual education is centered around encouraging adolescents to abstain from sexual activity outside of wedlock. On the other hand, evidence-based sexual education (EBSE) includes abstinence in its curriculum but does not emphasize it, instead highlighting contraception and prevention strategies. Additionally, EBSE teaches adolescents about healthy relationships, attitudes towards sexuality, gender roles, and provides resources for sexual and reproductive health services. Supplying adolescents in K-12 schools with access to evidence-based sexual education may not only decrease teen pregnancy rates and incidence of sexually transmitted infections (STIs) but …


Culturally Sensitive Care For Hispanic Americans, Christopher Dodson, Courtney Hall Nov 2021

Culturally Sensitive Care For Hispanic Americans, Christopher Dodson, Courtney Hall

Scholars Week

The number of individuals that speak another language that is not English as their primary language is at an all time high in the United States, and this can make healthcare harder to access for this portion of the population. This research examines what barriers are present for those who do not speak English as their primary language, such as miscommunications, reduced trust in their provider related to being unable to speak directly with them, parts of their cultural practices and alternative medicines being ignored or misunderstood by healthcare providers, and not feeling secure enough to reveal sensitive information to …


Health Disparities And Covid-19 Pandemic: Increasing Clinical Research Participation Among African Americans, Kashica J. Webber-Ritchey, Abbi D. Lane-Cordova Jul 2021

Health Disparities And Covid-19 Pandemic: Increasing Clinical Research Participation Among African Americans, Kashica J. Webber-Ritchey, Abbi D. Lane-Cordova

Journal of Health Disparities Research and Practice

Health disparities in African Americans is a persistent issue. Higher rates and severity of the novel coronavirus-19 [COVID-19] among African Americans only widens health disparities. Effective COVID-19 treatment options are imperative, requiring representation of African Americans in clinical research. However, low participation and under-representation of African Americans is complex in nature. This article describes health disparities, the impact of COVID-19, and participation in clinical research among African Americans. We offer strategies for researchers to enhance the inclusion of African Americans. We also offer strategies in conducting clinical research during COVID-19.


The Associations Of Chronic Stress, Social Support, Health Behaviors And Metabolic Syndrome Among Hispanic Women, Edna Esquer May 2021

The Associations Of Chronic Stress, Social Support, Health Behaviors And Metabolic Syndrome Among Hispanic Women, Edna Esquer

Dissertations

The Associations of Chronic Stress, Social Support, Health Behaviors and Metabolic Syndrome Among Hispanic Women

Background: Metabolic syndrome (MetS) prevalence is 25% among Mexican American women 30 – 49 years of age, compared to 22% among non-Hispanic Whites in the United States. Little is known about the additional contributions of chronic stress, social support and health behaviors to the development of MetS among this population.

Purpose: Describe the associations between chronic stress, social support, and health behaviors and the presence of MetS in Hispanic women living in an underserved community.

Methods: A retrospective cohort study design. The Adult Treatment Panel …


Standardized Education On Physician Orders For Life Sustaining Treatment (Polst) Conversations, Venessa Oteniya May 2021

Standardized Education On Physician Orders For Life Sustaining Treatment (Polst) Conversations, Venessa Oteniya

Doctor of Nursing Practice Final Manuscripts

According to research literature, 15% of Medicare beneficiaries spend more than 7 days in the intensive care unit before they die. These Medicare beneficiaries receive aggressive, life-prolonging medical treatments that might not be in agreement with their wishes. Approximately 13% of SNF residents have improperly completed POLST forms that can result in intensive treatments that patients did not want. One barrier to the lack of POLST completion in SNFs is staff difficulty with understanding and explaining the form, a result of inadequate education.

In August 2020, the San Diego Coalition for Compassionate Care formed an education program to provide virtual …


Understanding Older Adults Living In Medically Underserved Areas Perspectives Regarding Type 2 Diabetes Care Received, Christopher Rogers May 2021

Understanding Older Adults Living In Medically Underserved Areas Perspectives Regarding Type 2 Diabetes Care Received, Christopher Rogers

Seton Hall University Dissertations and Theses (ETDs)

Older adults with type 2 diabetes living in medically underserved areas (MUAs) have unique health and social needs that must be taken into consideration when supporting their type 2 diabetes treatment and management care. Effective treatment and management of type 2 diabetes for older adults living in MUAs requires incorporating the preferences, desires, needs, values, and goals of the person at the center of the care into his/her care plan. Shifting care to be conducive to the treatment and management goals and plans co-created with older adults living in MUAs based on their individual physical, psychological, social, and spiritual preferences, …


Eastern European Orthodox Christian Immigrant Women: A Pilot Study And Needs Assessment, Kimberly A. Babich-Speck May 2021

Eastern European Orthodox Christian Immigrant Women: A Pilot Study And Needs Assessment, Kimberly A. Babich-Speck

Doctor of Nursing Practice Scholarly Projects

The healthcare perceptions of the Eastern European Orthodox Christian immigrant women (EEOCIW) to the United States (U.S.) are under-represented in the literature. Although they appear similar to Americans, their cultural and religious traditions are outside the mainstream American culture. This pilot study and health needs assessment examines the women’s healthcare perceptions of 14 EEOCIW and identifies similarities and differences with 25 U.S. born Orthodox Christian women (USOCW). Between September and November 2020, interviews were conducted with Orthodox Christian immigrant women from Eastern Europe and Orthodox Christian women born in the U.S. Questions covered the perceptions of women’s healthcare, factors influencing …


Evaluating Va Nurse Acceptance Of Virtual Healthcare Technology During The Coronavirus Outbreak, Francesca Bryan-Couch May 2021

Evaluating Va Nurse Acceptance Of Virtual Healthcare Technology During The Coronavirus Outbreak, Francesca Bryan-Couch

Doctor of Nursing Practice Scholarly Projects

At a regional Veterans Administration (VA) hospital, nurses performing case management were unable to perform face-to-face visits with patients due to coronavirus. Care coordination and discharge planning efforts occurred through telephonic case management to preserve personal protective equipment and reduce transmission rates through social distancing. Trust and rapport between patients and nurses were reduced without personal contact. Peplau’s theory of interpersonal relations described six nurse roles and three phases of relationship development required to create therapeutic nurse-patient relationships. Connectedness was a key concept considered to be the path to a successful meaningful therapeutic nurse-patient relationship (Hrabe, 2005).

To evaluate current …


Treatment Access For Dual Diagnosis Substance Use And Mental Health Disorders, Pedro Banuelos May 2021

Treatment Access For Dual Diagnosis Substance Use And Mental Health Disorders, Pedro Banuelos

Electronic Theses, Projects, and Dissertations

In 2018, of 1.3 million Latinx adults in the United States facing concurrent issues with substance use disorders (SUD) and mental health disorders (MHD) 93% remained untreated for either diagnosis. This is concerning since Substance Abuse and Mental Health Services Administration (SAMHSA) data reveals that this population is at greater risk for suicidal thoughts, plans, and attempts. They also face structural barriers such as employment, housing, legal involvement, and insurability that further impede access to treatment.

This study’s purpose was to examine barriers to accessing treatment for Latinx populations confronting co-occurring SUDs and MHDs. This study used a qualitative design …


Examining The Effect Of Provider Bias On Pain Management In Black Patients: A Systematic Literature Review, John Massey, Monica Gambilado Apr 2021

Examining The Effect Of Provider Bias On Pain Management In Black Patients: A Systematic Literature Review, John Massey, Monica Gambilado

Thinking Matters Symposium

Black Americans face unequal treatment for pain management when seeking care. The aim of this systematic literature review is to examine the impact of provider bias on Black patients receiving appropriate pain management interventions in the clinical setting. This review followed the Preferred Reporting Items for Systematic Literature Reviews and Meta-Analysis guidelines. CINAHL and PubMed were searched with the following key search terms: Black/African American, bias, prejudice, discrimination, unconscious bias, pain management, pain reduction, pain control and analgesic. A self-developed Critical Appraisal Tool was used for quality assessment of the studies included in the review. A total of 101 probable …


Impact Of Group Prenatal Care On Health Outcomes For Women Of Color In The United States: A Systematic Literature Review, Morgan Brockington, Emily Bauer, Julie Kameisha Apr 2021

Impact Of Group Prenatal Care On Health Outcomes For Women Of Color In The United States: A Systematic Literature Review, Morgan Brockington, Emily Bauer, Julie Kameisha

Thinking Matters Symposium

Women of color in the United States experience disproportionately higher rates of adverse pregnancy-related outcomes, both in the prenatal and postpartum period. Group prenatal care (GPC) has been gaining popularity in recent years and has demonstrated improved health outcomes. The aim of this systematic literature review was to examine and summarize the impact of group prenatal care on health outcomes for women of color in the United States. Using a systematic approach and PRISMA guidelines, two electronic databases—CINAHL and PubMed—were used to search the literature. Quantitative research studies that were published in peer-reviewed journals between 2010 and 2020, written in …


A Descriptive Study Of Health-Related Risks And Outcome Differences By Loneliness Status In A Sample Of Older Veterans, Rachael Beard Apr 2021

A Descriptive Study Of Health-Related Risks And Outcome Differences By Loneliness Status In A Sample Of Older Veterans, Rachael Beard

Dissertations

There is a need to understand the influences and outcomes related to loneliness in veterans living with complex illness. Patients require self-care to manage complications and exacerbations associated with complex illness. Deficits in self-care result in negative health outcomes and drive resource utilization upward. The identification of potential factors related to self-care is important. Loneliness may be one factor that influences patients’ ability and desire to care for themselves. Descriptive correlational design was used to evaluate loneliness both as a predictor and outcome in veterans admitted to the hospital for three complex respiratory illnesses (heart failure, chronic obstructive pulmonary disease, …


The Efficacy Of A Communication Guide On Stress Experienced By Family Members Of Patients Admitted In The Intensive Care Unit With Covid-19, Kandace Williams Apr 2021

The Efficacy Of A Communication Guide On Stress Experienced By Family Members Of Patients Admitted In The Intensive Care Unit With Covid-19, Kandace Williams

The Eleanor Mann School of Nursing DNP Capstone Projects

Coronavirus disease (COVID-19), first introduced in the United States on January 20, 2020, has created worldwide panic due insufficient research and understanding of the nature of this new disease. Patients suffering from COVID-19 often require intensive care unit (ICU) admissions, resulting in stress and confusion amongst patients and their families. The high transmissibility of the disease has caused hospitals to adopt firm visitor restrictions to protect the public from exposure and spread. Families experience increased anxiety and stress due to ineffective communication with staff and restricted access to their hospitalized loved ones. A needs assessment revealed a gap in care …


The Lived Experience Of Syrian Refugees In Canada: A Phenomenological Study, Khaldoun Aldiabat, Enam Alsrayheen, Catherine Aquino-Russell, Michael Clinton, Roger Russell Feb 2021

The Lived Experience Of Syrian Refugees In Canada: A Phenomenological Study, Khaldoun Aldiabat, Enam Alsrayheen, Catherine Aquino-Russell, Michael Clinton, Roger Russell

The Qualitative Report

Health care providers in Canada are expected to take care of people from a variety of cultural backgrounds, and it is difficult for health care providers to deeply understand the lived experiences of some individuals to provide them with culturally sensitive care. Syrian refugees comprise one such group of newcomers to Canada. This phenomenological study aimed to uncover the meaning of the lived experiences of Syrian refugees using Giorgi’s (2009) method. Seven participants’ descriptions were viewed through the lens of the social determinants of health model. Seven essences of the general structural description or the meaning Syrian refugees gave to …


"There Is Always Violence": An Exploratory Study Of Phnom Penh, Cambodia, Street-Involved Children, Jarrett D. Davis, Glenn M. Miles, Sean Blackburn, Erika Mosebach-Kornelsen Jan 2021

"There Is Always Violence": An Exploratory Study Of Phnom Penh, Cambodia, Street-Involved Children, Jarrett D. Davis, Glenn M. Miles, Sean Blackburn, Erika Mosebach-Kornelsen

Dignity: A Journal of Analysis of Exploitation and Violence

As the economic center of Cambodia, Phnom Penh has long been a hotspot for street-involved children and families. While violence is a common facet of life on the street, risk and vulnerability among children is notoriously difficult to measure. Most large-scale surveys tend to sample children within homes and schools, which overlook street-involved children who are commonly unregistered, irregularly attend school, and live outside of houses. This research paper is one of a series of studies on such groups in Southeast Asia. The study conducted 94 semi-structured interviews with street-involved children eight to 18 years of age in Phnom Penh. …


Depression, Anxiety, Perceived Social Support And Associated Factors Among Elderly Nursing Home Residents In The Klang Valley, Pritiss Nair Jan 2021

Depression, Anxiety, Perceived Social Support And Associated Factors Among Elderly Nursing Home Residents In The Klang Valley, Pritiss Nair

Student Works (2020-2029)

Introduction: Depression and anxiety among the elderly brings about various adversities which affects the physical and psychological state of an individual and is a leading cause of disability worldwide and a primary contributor to the global burden of disease. Meanwhile, perceived social support from family members, relatives or friends, may improve an individual’s conduct, coping, physical and psychological well-being. Objectives: This study aims to determine the prevalence of depression and anxiety, perceived social support as well as the socio-demographic correlates among elderly residents residing in nursing homes in the Klang Valley. Study Design: It is a cross-sectional study conducted among …


The Relationship Between Early Discharge Planning And Length Of Stay, Kandiss Hearn Dec 2020

The Relationship Between Early Discharge Planning And Length Of Stay, Kandiss Hearn

MSN Capstone Projects

Discharge planning (DCP) and early discharge intervention has proven to have a direct effect on reducing hospital length of stay (LOS), reducing readmissions, reducing patient morbidity, improving patient satisfaction and possibly reducing patient healthcare cost. This proposal specifically addresses hospital length of stay but with research it was found that early DCP also has the potential to improve outcomes in several areas adjacent to both the patient aspect and business aspect of health care. The proposed question is as follows: In adult hospitalized patients (P), how does discharge planning within the first 24 hours of admission (I) compared to late …


The Youthful Pandemic, Brook Sahlemariam Dec 2020

The Youthful Pandemic, Brook Sahlemariam

Nursing | Senior Theses

This paper attempts to examine the neurological, physical, and societal effects of e-cigarette use among youth and young-adults in North America. Furthermore, the paper investigates the parallels between e-cigarette users, tobacco users, and dual users in regard to behavioral patterns, reasons for use, and age of initiation.


Development And Implementation Of A Healthcare Volunteer Retention Program, Sandra Gomez Dec 2020

Development And Implementation Of A Healthcare Volunteer Retention Program, Sandra Gomez

Student Scholarly Projects

Practice Problem: Healthcare volunteer responders are an asset during disasters, and their retention is necessary to meet rising demands. This project aimed to develop and implement an evidence-based practice change using a healthcare volunteer retention program and evaluate its influence on retention.

PICOT: The PICOT question that guided this evidence-based practice project was: In healthcare volunteers, how does the participation in a formal healthcare volunteer retention program influence healthcare volunteer retention rate, intent to stay, and volunteer satisfaction 12 weeks after Healthcare Volunteer Retention Program introduction?

Evidence: The evidence from the literature supported mentoring, education and training, …


Gender, Technology And Innovation In Health Care Panel, Melanie Katsivo Nov 2020

Gender, Technology And Innovation In Health Care Panel, Melanie Katsivo

Africa-Western Collaborations Day 2020

8 graduate student/recent graduate presentations on gender, technology, and innovation in health care. Moderated by Dr. Melanie Katsivo. Reporting of panel done by current GHS students of the 2021 class. Abstracts can be found under "Africa-Western Collaborations Day 2020 Abstracts". Presenters as follows:

Florence Wullo Anfaara, "To Include or Not to Include: Men and the Liberian Women's Peace Hut Initiatives Towards Transformational Justice"

Uche Ikenyei, "Diversification of Research Methodological Approach During Model Enhancements in Health Information System Research"

Denise Kamyuka, "Female Social Entrepreneurship in Sport, in the African Context: Systemic Review"

Ebenezer Martin-Yeboah, "Through the Lens of Egocentric Design: Do …


Determining The Effectiveness Of A Peer Support Person In Individuals With Depression Symptoms, Donna K. Reeves Nov 2020

Determining The Effectiveness Of A Peer Support Person In Individuals With Depression Symptoms, Donna K. Reeves

Electronic Theses and Dissertations

Abstract

This study’s aim was to evaluate the effectiveness of an existing peer support program as an adjunct treatment for patients with depression. This retrospective evaluation analyzed the total scores of 110 patients with depression on the PHQ-9 questionnaire at the initial assessment (Time 1), at 6-weeks (Time 2), and then at 12-weeks (Time 3). The participants were divided into two groups, those who enrolled in a peer support program (n = 55) and those without peer support (n = 55). PHQ-9 total scores for each time interval were compared for the two groups utilizing independent sample t-tests …