Public Health Commons^™

Labour Market Participation After Sickness Absence Due To Cancer: A Dynamic Cohort Study In Catalonia (Spain), Amaya Ayala-Garcia, Fernando G Benavides, Laura Serra

Faculty, Staff and Student Publications

BACKGROUND: The consequences of cancer on working until retirement age remain unclear. This study aimed to analyse working life considering all possible labour market states in a sample of workers after sickness absence (SA) due to cancer and to compare their working life paths to those of a sample of workers without SA and with an SA due to other diseases.

METHODS: This was a retrospective dynamic cohort study among social security affiliates in Catalonia from 2012-2018. Cases consisted of workers with an SA due to cancer between 2012-2015 (N = 516) and were individually age- and sex-matched with those …

Learning From Women Veterans Who Navigate Invisible Injuries, Caregiving, And Reintegration Challenges, Nicholas A. Rattray, Diana Natividad, Katrina Spontak, Marina Kukla, Ai Nghia L. Do, Leah Danson, Richard M. Frankel, Gala True

School of Medicine Faculty Publications

Background: As women comprise a greater proportion of military service members, there is growing recognition of how their experiences in the early phase of military to civilian transitions have an important influence on their health and reintegration outcomes. Qualitative accounts of women veterans can inform programs that support transitioning service members. Objectives: We examined narratives of civilian reintegration among women veterans to understand their experiences of adjusting to community life while coping with mental health challenges. Methods/Participants: We interviewed 16 post-911 era women who were within 5 years of separating from military service and developed a case study based on …

Feasibility, Enablers And Challenges Of Using Timeliness Metrics For Household Contact Tracing And Tb Preventive Therapy In Pakistan, Bushra Jamil, Divya Nair, Pruthu Thekkur, Neelofar Laeeq, Anum Adil, Mohammed Khogali, Rony Zachariah, Selma Dar Berger, Srinath Satyanarayana, Ajay M V Kumar

Department of Medicine

Introduction: Screening household contacts of TB patients and providing TB preventive therapy (TPT) is a key intervention to end the TB epidemic. Global and timely implementation of TPT in household contacts, however, is dismal. We adapted the 7-1-7 timeliness metric designed to evaluate and respond to infectious disease outbreaks or pandemics, and assessed the feasibility, enablers and challenges of implementing this metric for screening and management of household contacts of index patients with bacteriologically-confirmed pulmonary TB in Karachi city, Pakistan.
Methods: We conducted an explanatory mixed methods study with a quantitative component (cohort design) followed by a qualitative component (descriptive …

Employing Telepsychiatry Services To Assess The Prevalence And Identify Mental Health Disorders Using The Phq-9 And Gad-7 In Resource-Constrained Regions Of Dadar Mansehra, Pakistan: An Observational Cross-Sectional Study, Iffat Zafar Aga, Sara Saeed Khurram, Mahek Karim, Muhammad Muzzamil, Shahkamal Hashmi, Kashif Shafique

Medical College Documents

Objective: This study aims to measure the prevalence of mental health disorders in low-resource settings through telepsychiatry and evaluate data from Pakistan's Sehat Kahani nurse-assisted online clinics serving low-income communities. This will help to understand the magnitude and nature of the demand for contextual therapies to promote mental health. The paper will discuss the challenges faced in these settings, such as limited access to mental health facilities, stigma and opportunities telemedicine brings.
Design: An observational cross-sectional study of telepsychiatry consultations using Patient Health Questionnaire-9 and Generalised Anxiety Disorder-7 to screen for depression and anxiety was conducted between October and December …

Relation Of Salivary Alpha-Amylase (Saa) Concentration To Fatigue Biomarkers In Palm Oil Office Workers In Jambi Province: Preliminary Study, David Kusmawan, Willia Novita Eka Rini, Wahyu Indah Dewi Aurora

Makara Journal of Science

The salivary α-amylase (sAA) concentration has a potential role as a biological indicator of occupational fatigue. This study aimed to determine the levels of sAA and its influencing factors. This research used a cross-sectional design with a sample of 40 office staff respondents at PT. X (Persero). Mental workload (MWL), sleep quality, and occupational fatigue were measured using the NASA-Total Load Index (TLX), Pittsburgh Sleep Quality Index, and Industrial Fatigue Research Committee, respectively. Meanwhile, the basic sAA levels was measured through the sandwich enzyme-linked immunosorbent assay method using the Bioenzy® Kit Assay. Descriptive analysis showed that the workers were mostly …

Reimagining A Caregiver-Friendly Society, Jodi L. Southerland

Journal of Appalachian Health

Demographic aging is accelerating in the Appalachian Region, resulting in a growing proportion of caregivers living in areas that lack services to support their needs. Strategies are urgently needed in Appalachia to address deficiencies in the region’s long-term supports and services for older adults and their caregivers. Strengthening equitable access to care and community supports for family caregivers is a policy priority for state and community leaders in Appalachia.

The Dna Glycosylase Neil2 Is Protective During Sars-Cov-2 Infection, Nisha Tapryal, Anirban Chakraborty, Kaushik Saha, Azharul Islam, Lang Pan, Koa Hosoki, Ibrahim M Sayed, Jason M Duran, Joshua Alcantara, Vanessa Castillo, Courtney Tindle, Altaf H Sarker, Maki Wakamiya, Victor J Cardenas, Gulshan Sharma, Laura E Crotty Alexander, Sanjiv Sur, Debashis Sahoo, Gourisankar Ghosh, Soumita Das, Pradipta Ghosh, Istvan Boldogh, Tapas K Hazra

Faculty, Staff and Students Publications

SARS-CoV-2 infection-induced aggravation of host innate immune response not only causes tissue damage and multiorgan failure in COVID-19 patients but also induces host genome damage and activates DNA damage response pathways. To test whether the compromised DNA repair capacity of individuals modulates the severity of COVID-19 infection, we analyze DNA repair gene expression in publicly available patient datasets and observe a lower level of the DNA glycosylase NEIL2 in the lungs of severely infected COVID-19 patients. This observation of lower NEIL2 levels is further validated in infected patients, hamsters and ACE2 receptor-expressing human A549 (A549-ACE2) cells. Furthermore, delivery of recombinant …

Beyond Scale-Free Networks: Integrating Multilayer Social Networks With Molecular Clusters In The Local Spread Of Covid-19, Kayo Fujimoto, Jacky Kuo, Guppy Stott, Ryan Lewis, Hei Kit Chan, Leke Lyu, Gabriella Veytsel, Michelle Carr, Tristan Broussard, Kirstin Short, Pamela Brown, Roger Sealy, Armand Brown, Justin Bahl

Faculty, Staff and Student Publications

This study evaluates the scale-free network assumption commonly used in COVID-19 epidemiology, using empirical social network data from SARS-CoV-2 Delta variant molecular local clusters in Houston, Texas. We constructed genome-informed social networks from contact and co-residence data, tested them for scale-free power-law distributions that imply highly connected hubs, and compared them to alternative models (exponential, log-normal, power-law with exponential cutoff, and Weibull) that suggest more evenly distributed network connections. Although the power-law model failed the goodness of fit test, after incorporating social network ties, the power-law model was at least as good as, if not better than, the alternatives, implying …

Capacity Assessment And Spatial Analysis Of Cervical Cancer Services In The Gambia, Meghan E Mali, Ousman Sanyang, Katherine L Harris, Justin Sorensen, Mustapha Bittaye, Jonathan Nellermoe, Raymond R Price, Edward K Sutherland

Faculty, Staff and Student Publications

Background

Cervical cancer is the most common cancer and the leading cause of cancer-related death in Gambian women. The Gambian Ministry of Health is striving to improve access to screening, diagnostic, and treatment services for cervical cancer, but comprehensive data on currently available services is limited making it challenging to appropriately prioritize the ideal next steps for expanding care. This study aims to describe the current services available for the prevention, screening, and treatment of cervical cancer in The Gambia and provide suggestions for expanding geographic access to care.

Methods

A survey aimed at assessing the availability of key cervical …

Injury Inequity Among Nevada Pedestrians: Assessment Using Measurements Of Community Needs, Merika Charupoom, Nicole Bacani, Emily Carter, Emily Strickler, Laura K. Gryder, Kavita Batra, Deborah A. Kuhls Md, Facs

Undergraduate Research Symposium Posters

In 2020, the National Highway Traffic Safety Administration (NHTSA) reported that Nevada was the 10th highest ranking in pedestrian fatality rates. According to a report by Zero Fatalities, in 2021, there were 84 pedestrian deaths. Underserved communities, the elderly, and low income individuals are more likely to use walking, biking, or public transportation as a primary means of transportation due to vehicle expenses. Older adults, racial/ethnic minorities and those with lower socioeconomic statuses (SES) may bear a disproportionate burden of auto-pedestrian crashes.

Opportunities For Mental Health Interventions In Rural Mississippi Communities During The Covid-19 Pandemic: A Quantitative Analysis, Brice Fortinberry

Theses and Dissertations

COVID-19 presented unique challenges for rural Mississippi communities including impacts on the mental health of rural individuals. This research study aimed to identify opportunities for mental health interventions to provide health promotion professionals with quantitative data on the accessibility and the likelihood of engagement with mental health-fostering behaviors. A secondary objective of this research was to categorize these behaviors within the constructs of the Social Ecological Model. Demographics for rural Mississippi communities were collected and displayed, and using multivariate analyses including Spearman’s correlation and a Mann-Whitney U test the correlation between mental health fostering behaviors and demographic factors was obtained. …

The Effects Of Night Shift Work On Heart, Gut, And Reproductive Health, A Systematic Review, Courtney Grayson, Preeti Oza

Pacific Journal of Health

Night shift work, a commonplace in today’s society, creates a variety of health-related challenges for individuals who participate in it. Often, the only adverse health effects discussed in relation to night shift work are sleep dysfunction and mental health issues. This systematic review examined the cardiovascular, gastrointestinal, and fertility health effects that plague individuals working night shift. The goal of this work is to illuminate these lesser known, but equally important, health effects in an effort to bring awareness to the issues. By educating night shift workers and health care providers of the acute risks associated with this type of …

Virginia Refugee’S Access To Covid 19 Health Information, Krunal Patel, Sarah R. Blackstone, Fern R. Hauck

Virginia Journal of Public Health

Background: This study examined how refugees in central Virginia, United States were able to access public health information about COVID-19 and any barriers to following COVID-19 prevention guidelines.

Methods: Individual interviews were conducted with refugees (n = 40) attending a family medicine clinic serving refugees and immigrants. Participants answered questions about their primary methods of obtaining COVID-19 and COVID-19 vaccine information, how they prefer to receive this information, information given by employers, precautions taken at their place of work, and current vaccination status.

Results: We found that television and social media played a large role for refugees in obtaining COVID-19 …

Predictors Of Lung Cancer Screening Recommendation In Virginia Using The Community Health Assessment Survey, Aashish Batheja, Carrie Miller, Sunny Jung Kim, Bernard Fuemmeler F., Rajsh Balkrishnan

Virginia Journal of Public Health

Purpose: The purpose of this analysis was to determine the factors that may influence the probability of being recommended a lung cancer screening by a health professional in Virginia.

Methods: Data were obtained from the Community Health Assessment Survey conducted by the University of Virginia (UVA) Health System and Cancer System in collaboration with Virginia Commonwealth University (VCU) Cancer Center. SAS software was used to conduct a logistic regression with the following variables: age, sex, race, current smoking status, cancer history, education level, income level, insurance, and rurality.

Results: Statistically significant positive predictors included being a current smoker (OR: 3.504, …

Promoting Community Health Research Partnerships Through A Small Grants Program: Processes And Lessons Learned, Sophie G. Wenzel, Amanda J. Nguyen, Kristin Miller, Leigh Guarinello, Allison Mckell, Kathryn Hosig

Virginia Journal of Public Health

While there are multiple ways to engage communities in health research, one approach is through partnership-based research in which community representatives are involved as intentional partners in the research process, from conceptualization and co-creation to implementation, analysis, interpretation, and dissemination. However, there remain numerous challenges to supporting and sustaining such partnerships.

Since its launch in 2019, the integrated Translational Health Research Institute of Virginia (iTHRIV) has sought to foster community engaged health research among its four research/clinical institutions through a community partnership-based grant program. Over five funding cycles, iTHRIV has awarded 14 one-year research grants addressing topics such as opioid …

Empowering Community Health Workers In Guatemala, Oswald M. Attin, Gineska Castillo, Grace Sibert, Andrea Harper

Virginia Journal of Public Health

Introduction:

Community health workers (CHW) have been integral in helping middle- and low-income countries. This research paper discusses the benefits of the involvement of CHWs in health screenings.

Methods:

Health screenings were performed for three rural communities in Guatemala, in 2021, alongside a church in Zacapa, to identify community wide health risks. The screenings included a detailed questionnaire that collected demographic data, height and weight, a blood glucose check, a hemoglobin check, and a blood pressure reading. Additional nutritional data was collected to understand diet patterns and habits. In-depth educational sessions were done with the CHWs, emphasizing preventative care, and …

Detection Of Suicide Clusters Using Small-Area Geographic Data From The Virginia Violent Death Reporting System, 2010 – 2015, Kurtis M. Anthony, Allison Ertl, Rachel A. Leavitt, Alexander E. Crosby, Ryan M. Diduk-Smith, Kevin A. Matthews

Virginia Journal of Public Health

Introduction: From 1999 to 2020, the suicide rate in Virginia increased from 13.1 to 15.9 per 100,000 persons aged 10 years and older. Few studies have examined spatial patterns of suicide geographies smaller than the county level.

Methods: We analyzed data from suicide decedents aged ≥10 years from 2010 through 2015 in the Virginia Violent Death Reporting System. We identified spatial clusters of high suicide rates using spatially adaptive filtering with standardized mortality ratio (SMR) significantly higher than the state SMR (p < 0.001). We compared demographic characteristics, method of injury, and suicide circumstances of decedents within each cluster to decedents outside any cluster.

Results: We identified 13 high-risk suicide clusters (SMR between 1.7 and 2.0). Suicide decedents in the clusters were …

Implicit Bias Among Health Professionals, Kimora H. Toussaint, Javiela Evangelista

Publications and Research

Racism and implicit bias are prevalent in healthcare, which may affect patient well-being. One way implicit bias is most evident is in language. Negative descriptors, such as “sickler”—a term used for those diagnosed with Sickle Cell Disease (SCD), influence how health providers view their patients and determine pain medication prescriptions (Goddu et al.). Patient experience, such as prior use of opioids or using words that imply substance abuse, may block patients from accessing prescriptions and proper care. Black, Indigenous, and People of Color (BIPOC) are disproportionately affected by such negative descriptors (Sun et al., 2022). Among other adverse impacts, treating …

Integrating Stakeholder Feedback Into The Design Of A Peer-Delivered Primary Care Wellness Program: A Rapid Qualitative Study, Emily M. Johnson, Kyle Possemato, Matthew Chinman, Gala True, Jacob Hedges, Brittany N. Hampton, E. Jennifer Edelman, Stephen A. Maisto

School of Medicine Faculty Publications

Background: Individuals seen in Primary Care with behavioral health concerns who decline behavioral health treatment may benefit from the support of peers (consumers in recovery from behavioral health concerns employed to support other consumers). Whole Health STEPS is a new intervention for Veterans in Primary Care with behavioral health concerns which combines essential elements of peers’ role and the Whole Health model using a stepped-care design. We incorporated stakeholder feedback in the Whole Health STEPS design to improve fit with Veterans, peers, and primary care settings. Methods: We conducted semi-structured qualitative interviews with VA staff using questions derived from the …

Championing Awareness Of The Opioid Epidemic Through A Service-Learning Module For Non-Stem Biology Majors, Ryleigh Fleming, Sarah J. Adkins, Marco Esteban, Cinnamin Cross, Amy Hutson Chatham, Samiksha A. Raut

APC Fund

Over 50,000 people die annually from opioid overdoses in the United States leading to what has become known as the “opioid epidemic.” This is of heightened concern in states like Alabama that experience higher rates of overall drug use and overdose deaths. Thus, it is increasingly important for college students in Alabama to learn about how the opioid epidemic is affecting their communities. Previous studies have demonstrated that engaging non-majors in innovative active-learning oriented pedagogies like service-learning can enhance their understanding and awareness about contemporary societal issues. Despite its pedagogical potential, the impact of opioid-related service-learning, particularly for non-majors, continues …

The Evaluation Of Collaborative Disease Prevention And Control Measures For Border Health Between Thailand And Myanmar, Laos, And Cambodia, Orathai Srithongtham, Aomthip Polbupha, Taweewun Srisookkum, Orathai Katkhaw, Thossaphong Buraman

Journal of Health Research

Background: Collaborative disease prevention and control measures for border health between Thailand and three neighboring countries (Myanmar; Lao People’s Democratic Republic (PDR), also known as Laos; Cambodia) were implemented in 2016 - 2017.

Methods: Summative evaluation and a mixed-method design aimed to evaluate the measures for border health between Thailand and three neighboring countries. The participants were public health personnel from provincial, district, and sub-district levels. Data were collected by questionnaire and interview guide. Quantitative data were analyzed by descriptive statistics; and qualitative data were analyzed through content analysis.

Results: The overall collaboration for border health of Thailand …

Predicting Factors Of Health-Related Quality Of Life Among End-Stage Renal Disease Patients Receiving Hemodialysis At A Tertiary Level Hospital In Nepal., Jyoti Gahatraj, Poolsuk Janepanish Visudtibhan, Tiraporn Junda, Nipaporn Butsing

Journal of Health Research

Background: End-stage renal disease (ESRD) puts tremendous burdens upon affected patients and their support persons in Nepal. The health-related quality of life (HRQoL) among Nepalese persons with hemodialysis-dependent ESRD is not well understood. This study aimed to examine HRQoL and its predicting factors among persons undergoing hemodialysis in Nepal.

Methods: A purposive sampling was applied to recruit 106 persons with ESRD receiving hemodialysis at a tertiary hospital in Nepal between October and December 2021. The structured questionnaires included personal information, the World Health Organization Quality of Life instruments (WHOQOL-BREF), the fatigue assessment scale (FAS), the Hamilton depression rating scale (HDRS), …

The Effects Of Cigarette Price Incentive And Regulatory Policies In Taiwan, Che-Ning Yang, Yi-Fan Lin

Journal of Health Research

Background: Price affects the demand for cigarettes, but its direct impact on smoking behaviors remains unclear. This study evaluated the effects of cigarette price increases and non-pricing tobacco control policies on adult smoking behaviors in Taiwan, using data from national annual survey during 2004~2015 with 166,325 valid respondents.

Methods: We established mixed-effects models of logistic regression for each of the three dependent variables, “smoking,” “quit attempts,” and “cessation maintenance,” to characterize smoking behaviors. Socioeconomic and sociodemographic factors were also included in the models.

Results: Non-pricing tobacco control policies had no significant effects on smoking behaviors. Conversely, cigarette price …

Development And Implementation Of A Unique, Tailored School Lunch Training Program For Teachers And Their Stakeholders At Public Primary Schools In Thailand, Kantanit Chammari, Arisa Keeratichamroen, Kitti Sranacharoenpong, Punnee Ponprachanuvut, Nuttarat Srisangwan, Piyanit Churak, Panrawee Praditsorn

Journal of Health Research

Background: Although teachers responsible for the school lunch program were trained by the Ministry of Education (MOE) staff, they were not equipped with the basic knowledge of nutrition for children. This study aimed to develop and implement a unique, tailored school lunch training program for teachers and their stakeholders.

Methods: The training program was developed using the “Design for Learning (D4L) model.” Public primary schools run by the government from all regions of Thailand were selected. Target persons included principals, health teachers, nutrition teachers, cooks, and local staff from the MOE. All participants participated in a 5-day training course. …

Addressing Resource Constraints For Alzheimer’S Dementia Patients And Caregivers In The Global South: An Interdisciplinary Approach, Zaheen Rashed '24

Student Research

There are two main focuses of this paper: to address the care that AD patients in countries with few healthcare resources receive and to explore the experiences of familial caregivers who care for these patients. This thesis will investigate issues including access to the education required to administer informed care, who is ultimately responsible for caring for AD patients in countries with few health facilities, and the lack of resources that is apparent in countries that do not have AD specialists or clinics. This paper will pinpoint the root issue in treating AD patients globally to serve as the first …

Fostering Udl-Informed Library Instruction Practices Developed From The Covid-19 Pandemic, Niki Fullmer, Katie Strand

Library Faculty Research

Purpose: This case study explores how universal design for learning (UDL)-informed online instruction modules developed during COVID-19 can better support student information literacy outcomes. This study will also examine how hybrid learning lends itself to UDL and may resolve some of the issues within library instruction.

Design/methodology/approach: This case study explores how a team of librarians at Utah State University developed three UDL-informed modules to support library instruction and hybrid learning during the height of the COVID-19 pandemic. A survey was sent to composition instructors to understand how they utilized the three new UDL-informed modules and if the modules helped …

Wildland Fires Worsened Population Exposure To Pm25 Pollution In The Contiguous United States, Danlu Zhang, Wenhao Wang, Yuzhi Xi, Jianzhao Bi, Yun Hang, Qingyang Zhu, Qiang Pu, Howard Chang, Yang Liu

Faculty, Staff and Student Publications

As wildland fires become more frequent and intense, fire smoke has significantly worsened the ambient air quality, posing greater health risks. to better understand the impact of wildfire smoke on air quality, we developed a modeling system to estimate daily PM

Chromosome 10q2432 Variants Associate With Brain Arterial Diameters In Diverse Populations: A Genome-Wide Association Study, Minghua Liu, Farid Khasiyev, Sanjeev Sariya, Antonio Spagnolo-Allende, Danurys L Sanchez, Howard Andrews, Qiong Yang, Alexa Beiser, Ye Qiao, Emy A Thomas, Jose Rafael Romero, Tatjana Rundek, Adam M Brickman, Jennifer J Manly, Mitchell Sv Elkind, Sudha Seshadri, Christopher Chen, Saima Hilal, Bruce A Wasserman, Giuseppe Tosto, Myriam Fornage, Jose Gutierrez

Faculty, Staff and Student Publications

Background: Brain arterial diameters (BADs) are novel imaging biomarkers of cerebrovascular disease, cognitive decline, and dementia. Traditional vascular risk factors have been associated with BADs, but whether there may be genetic determinants of BADs is unknown.

Methods and results: The authors studied 4150 participants from 6 geographically diverse population-based cohorts (40% European, 14% African, 22% Hispanic, 24% Asian ancestries). Brain arterial diameters for 13 segments were measured and averaged to obtain a global measure of BADs as well as the posterior and anterior circulations. A genome-wide association study revealed 14 variants at one locus associated with global BAD at genome-wide …

Neonatal Survival After Serial Amnioinfusions For Bilateral Renal Agenesis: The Renal Anhydramnios Fetal Therapy Trial, Jena L Miller, Ahmet A Baschat, Mara Rosner, Yair J Blumenfeld, Julie S Moldenhauer, Anthony Johnson, Mauro H Schenone, Michael V Zaretsky, Ramen H Chmait, Juan M Gonzalez, Russell S Miller, Anita J Moon-Grady, Ellen Bendel-Stenzel, Amaris M Keiser, Radhika Avadhani, Angie C Jelin, Jonathan M Davis, Daniel S Warren, Daniel F Hanley, Joslynn A Watkins, Joshua Samuels, Jeremy Sugarman, Meredith A Atkinson

Faculty, Staff and Student Publications

IMPORTANCE: Early anhydramnios during pregnancy, resulting from fetal bilateral renal agenesis, causes lethal pulmonary hypoplasia in neonates. Restoring amniotic fluid via serial amnioinfusions may promote lung development, enabling survival.

OBJECTIVE: To assess neonatal outcomes of serial amnioinfusions initiated before 26 weeks' gestation to mitigate lethal pulmonary hypoplasia.

DESIGN, SETTING, AND PARTICIPANTS: Prospective, nonrandomized clinical trial conducted at 9 US fetal therapy centers between December 2018 and July 2022. Outcomes are reported for 21 maternal-fetal pairs with confirmed anhydramnios due to isolated fetal bilateral renal agenesis without other identified congenital anomalies.

EXPOSURE: Enrolled participants initiated ultrasound-guided percutaneous amnioinfusions of isotonic fluid …

What We Know About School-Based Health Centers: Literature On Outcomes, Cost Impact, Implementation, And Sustainability, Michelle R. Coble, Valerie F. Mcdaniel

Pacific Journal of Health

Many children lack access to adequate healthcare in the United States. School Based Health Centers (SBHC) are a useful resource for accessing those needed services. The purpose of this study is to evaluate the available research for the strengths of SBHCs with improving health outcomes and health equity, cost impact of SBHCs, and best practices for implementing and sustaining an SBHC. The focus of this study was on reviewing the current literature on the impact of SBHCs on improving health equity, health outcomes, cost impact, and to establish best practices for implementing and sustaining an SBHC. Although the current literature …