Health Services Research Commons^™

Using Process Mining To Assess The Fidelity Of A Home Visiting Program, Riyad Haq, Sofia Campos Vidal Pires, Julie M. Kapp, Sara Schlemper, Eduardo J. Simoes

Frontiers in Public Health Services and Systems Research

Background: The Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program is a federal public health initiative which supports at-risk families through evidence-based programs and promising approaches for pregnant women, and childhood development for children aged 0 to 5. These public health program funding mechanisms commonly include process evaluation mandates.

Purpose: The use of process mining was explored as a methodology to assess the fidelity of the MIECHV programs’ actual workflow to that of their intended models.

Methods: Research Electronic Data Capture (REDCap) data files that were populated with program process data elements from the local implementing agencies were …

Putting Parity Into Practice – Integrating Opioid-Use Disorder Treatment Into The Hospital Setting, Laura Fanucchi, Michelle R. Lofwall

Center for Health Services Research Faculty Publications

No abstract provided.

An Examination Of African Americans' Utilization Of Health Care, Brittany Powell

Dissertations

The study examined the relationship between perceptions of discrimination, social support, quality of health care received, and utilization of health care services among African Americans. Data was analyzed from 99 African American respondents that completed either an online or paper questionnaire. The responses demonstrated significant relationships existed between discrimination and quality of health care as well as social support and utilization of health care. Results concluded that the more discrimination one perceives, the lower quality of health care they are to expect, and therefore they are less likely to utilize services. However, the data also reflected that even in the …

Countdown To 2015 Country Case Studies: What Can Analysis Of National Health Financing Contribute To Understanding Mdg 4 And 5 Progress?, Carlyn Mann, Courtney Ng, Nadia Akseer, Zulfiqar Ahmed Bhutta, Josephine Borghi, Tim Colbourn, Patricia Hernández-Peña, Luis Huicho, Muhammad Ashar Malik, Melisa Ashar Martinez-Alvarez, Spy Munthali, Ahmad Shah Salehi, Mekonnen Tadesse, Mohammed Yassin, Peter Berman

Community Health Sciences

Background

Countdown to 2015 (Countdown) supported countries to produce case studies that examine how and why progress was made toward the Millennium Development Goals (MDGs) 4 and 5. Analysing how health-financing data explains improvements in RMNCH outcomes was one of the components to the case studies.

Methods

This paper presents a descriptive analysis on health financing from six Countdown case studies (Afghanistan, Ethiopia, Malawi, Pakistan, Peru, and Tanzania), supplemented by additional data from global databases and country reports on macroeconomic, health financing, demographic, and RMNCH outcome data as needed. It also examines the effect of other contextual factors presented in …

A Livelihood Intervention To Improve Economic And Psychosocial Well-Being In Rural Uganda: Longitudinal Pilot Study, Bernard Kakuhikire, Diego Suquillo, Elly Atuhumuza, Rumbidzai Mushavi, Jessica M. Perkins, Atheendar S. Venkataramani, Sheri D. Weiser, David Bangsberg, Alexander C. Tsai

OHSU-PSU School of Public Health Faculty Publications and Presentations

HIV and poverty are inextricably intertwined in sub-Saharan Africa. Economic and livelihood intervention strategies have been suggested to help mitigate the adverse economic effects of HIV, but few intervention studies have focused specifically on HIV positive persons. We conducted three pilot studies to assess a livelihood intervention consisting of an initial orientation and loan package of chickens and associated implements to create poultry microenterprises. We enrolled 15 HIV-positive and 22 HIV-negative participants and followed them for up to 18 months. Over the course of follow-up, participants achieved high chicken survival and loan repayment rates. Median monthly income increased, and severe …

A Framework To Address Challenges In Communicating The Developmental Origins Of Health And Disease, Liana Winett, Lawrence Wallack, Dawn M. Richardson, Janne Boone-Heinonen, Lynne C. Messer

OHSU-PSU School of Public Health Faculty Publications and Presentations

Findings from the field of Developmental Origins of Health and Disease (DOHaD) suggest that some of the most pressing public health problems facing communities today may begin much earlier than previously understood. In particular, this body of work provides evidence that social, physical, chemical, environmental, and behavioral influences in early life play a significant role in establishing vulnerabilities for chronic disease later in life. Further, because this work points to the importance of adverse environmental exposures that cluster in population groups, it suggests that existing opportunities to intervene at a population level may need to refocus their efforts “upstream” to …

Variation Of Driving Skill Among Elderly Drivers Compared To Young Drivers In Japan, Indri Hapsari Susilowati, Akira Yasukouchi

Kesmas

Penelitian ini menganalisis kemampuan mengemudi pada pengemudi lanjut usia (lansia) dibandingkan dengan usia muda di Jepang dan melihat keterampilan mengemudi yang kurang sehingga dapat memengaruhi risiko kecelakaan di jalan raya. Subjek penelitian adalah pengemudi usia muda dan lansia, terdiri dari 10 mahasiswa (20 - 24 tahun) dan 25 pengemudi lansia (14 laki-laki dan 11 perempuan) berasal dari The Silver Menpower Center, organisasi bagi lansia > 60 tahun. Pengemudi lansia dibagi menjadi dua kelompok, yaitu lansia 1 berusia 60 - 65 tahun (10 orang) dan lansia 2 berusia > 65 tahun (15 orang). Kemampuan mengemudi dievaluasi dengan simulator permainan mengemudi dalam laboratorium. Analisis …

Rural-Based Health Promotion Model For Pregnant Women In Banyumas District, Elviera Gamelia, Dian Anandari, Dyah Umiyarni Purnamasari

Kesmas

Penelitian sebelumnya menunjukkan bahwa pengetahuan pelayanan prenatal di wilayah pedesaan masih rendah yang berdampak pada perilaku buruk sehingga mengembangkan model promosi kesehatan dibutuhkan untuk meningkatkan pengetahuan prenatal, sikap dan perilaku. Penelitian ini bertujuan untuk mengembangkan model promosi kesehatan pelayanan prenatal di wilayah pedesaan berdasarkan penilaian kebutuhan. Penelitian dilakukan pada Juni 2015 dengan pendekatan kualitatif melibatkan 16 ibu hamil pertama di trimester ketiga dengan kehamilan berisiko sebagai informan kunci dan 16 anggota keluarga yang tinggal bersama ibu hamil dan mengetahui kehidupan sehari-harinya, 27 bidan dan 3 tokoh agama sebagai informan tambahan. Teknik pengumpulan data adalah wawancara mendalam dan observasi untuk ibu …

Role Of Hearth Program With Undernutrition Incidence Among Toddlers In Tangerang City, Gizella Gizella, Dany Hilmanto, Dedi Rachmadi

Kesmas

Kelompok yang rentan terhadap gizi kurang adalah balita. World Health Organization (WHO) menyatakan kematian anak bawah lima tahun (balita) akibat gizi kurang sebesar 54% pada tahun 2002. Di Indonesia, prevalensinya mengalami peningkatan dari 17,9% pada tahun 2010 menjadi 19,6% pada tahun 2013. Di Kota Tangerang, terdapat 1,43% balita yang mengalami gizi buruk pada tahun 2013. Penelitian ini bertujuan untuk membuktikan secara valid hubungan antara Program Pos Gizi yang meliputi perilaku pemberian makan, perilaku kebersihan balita, perilaku mencari pelayanan kesehatan dan perilaku pengasuhan balita dengan kejadian gizi kurang pada balita. Penelitian ini merupakan penelitian kuantitatif, potong lintang, menggunakan data primer serta …

Good Corporate Governance Implementation And Performance Of Civil Servant, Muhammad Hasan, Dumilah Ayuningtyas, Misnaniarti Misnaniarti

Kesmas

Dalam rangka mencapai visi dan misi, setiap rumah sakit harus menjalankan tata kelola perusahaan yang baik (Good Corporate Governance/GCG). Penerapan GCG sendiri bertujuan untuk meningkatkan kinerja pegawai secara optimal, yang akhirnya akan meningkatkan kinerja organisasi. Penelitian ini bertujuan untuk menganalisis hubungan penerapan prinsip-prinsip GCG terhadap kinerja pegawai negeri sipil (PNS) Rumah Sakit Umum Lapangan Natuna Kabupaten Kepulauan Anambas. Jenis penelitian ini adalah deskriptif analitik dengan desain potong lintang pada 56 PNS. Pengumpulan data dilakukan pada tahun 2012 dengan kuesioner terstruktur. Digunakan analisis dengan uji kai kuadrat dan regresi logistik, dan untuk penyederhanaan model dilakukan eliminasi terhadap faktor perancu dengan menggunakan …

Well Water Consumed And Urolithiasis In Gedangsari Subdistrict, Yogyakarta, Sulistyawati Sulistyawati, Fardhiasih Dwi Astuti, Ruri Trisasri, Asep Rustiawan

Kesmas

Tanah di wilayah Kecamatan Gedangsari mengandung batuan kapur. Masyarakat di daerah ini banyak yang mengkonsumsi air minum dari sumur gali yang mengandung kadar kalsium tinggi, dan banyak yang menderita urolithiasis. Penelitian ini bertujuan untuk mendapatkan gambaran distribusi kalsium atau Ca(OH)2 pada air sumur dan menjelaskan hubungannya dengan kejadian urolithiasis. Penelitian dilakukan di Kecamatan Gedangsari, Kabupaten Gunungkidul selama Juli sampai November 2013. Penelitian dilakukan secara potong lintang dengan konfirmasi uji titrasi di laboratorium. Sejumlah 94 sampel sumur dipilih secara acak dari populasi 3.849 sumur. Kriteria pemilihan sampel adalah sumur gali yang telah digunakan untuk minum oleh penduduk berusia lebih dari 30 …

Identification Of Pathogenic Leptospira In Rat And Shrew Populations Using Rpob Gene And Its Spatial Distribution In Boyolali District, Dyah Widiastuti, Zumrotus Sholichah, Agustiningsih Agustiningsih, Nastiti Wijayanti

Kesmas

Leptospirosis merupakan masalah kesehatan di Indonesia. Hingga April 2014, dilaporkan kasus leptospirosis yang ditularkan oleh tikus di Kabupaten Boyolali dengan angka kematian 83,3%. Genus Leptospira terdiri dari ratusan serovar dan tipe genetik yang hidup di pelbagai jenis habitat. Pengelompokan spesies Leptospira berdasarkan gen rpoB dapat digunakan karena tingkat polimorfisme gen tersebut tinggi. Penelitian ini bertujuan untuk mengidentifikasi serovar bakteri Leptospira pada populasi tikus di Kabupaten Boyolali menggunakan analisis hubungan kekerabatan didasarkan pada polimorfisme gen rpoB dan menggambarkan distribusi spasial tikus positif Leptospira di Kabupaten Boyolali. Penelitian potong lintang dilaksanakan pada bulan April 2014 di Desa Sindon Kecamatan Ngemplak dan Desa …

Environmental, Behavioral Factors And Filariasis Incidence In Bintan District, Riau Islands Province, Zainul Ikhwan, Lucky Herawati, Suharti Suharti

Kesmas

Tingkat mikrofilaria filariasis di Kabupaten Bintan masih tinggi, khususnya di Kecamatan Teluk Bintan, Teluk Sebong, dan Sri Kuala Lobam. Penelitian ini bertujuan untuk mengetahui hubungan faktor risiko lingkungan (faktor fisik, biologi, kimia, sosial budaya, ekonomi) dan faktor perilaku dengan kejadian filariasis. Jenis penelitian observasional analitik yang dilakukan pada Mei – September 2015 dengan desain kasus kontrol, yang terdiri dari jumlah kasus 33 orang penderita filariasis dan kontrol 65 orang bukan penderita filariasis dengan teknik cluster sampling. Populasi penelitian adalah masyarakat di Kabupaten Bintan. Data yang diperoleh dianalisis menggunakan uji kai kuadrat dan regresi logistik. Hasil menunjukkan adanya hubungan pengetahuan (nilai …

Measles Immunization And Vitamin A For Prevention Of Pneumonia In Indonesia, Ratno Widoyo

Kesmas

Pneumonia merupakan penyebab kematian tertinggi pada anak di Indonesia setelah diare. Pengendalian pneumonia dapat dilakukan dengan peningkatan cakupan imunisasi campak, pertusis, Streptococcus pneumoniae (Spn), dan Haemophilus influenzae b (Hib). Vaksin Spn dan Hib belum masuk ke dalam kategori imunisasi wajib di Indonesia. Vaksin campak lebih memiliki pengaruh langsung terhadap pneumonia dibandingkan dengan vaksin pertusis. Pemberian imunisasi yang disertai pemberian vitamin A akan meningkatkan titer antibodi pada anak. Penelitian ini bertujuan untuk mengetahui pengaruh pemberian imunisasi campak dan vitamin A terhadap kejadian pneumonia. Metode penelitian adalah potong lintang dengan menggunakan 13.062 data anak yang terdapat pada data Survei Demografi dan Kesehatan …

Living With Traumatic Brain Injury In A Rural Setting: Supports And Barriers Across The Continuum Of Care, Anne L. Harrison, Elizabeth G. Hunter, Heather Thomas, Paige Bordy, Erin Stokes, Patrick H. Kitzman

Physical Therapy Faculty Publications

Purpose: Traumatic brain injury (TBI) is prevalent in Kentucky and comes with a high cost in care and quality of life for individuals and caregivers affected. Many people living with the condition of TBI have unmet needs. Research among people living with TBI in rural areas is limited. The purposes of this study were to (1) increase understanding of the lived experience of people with TBI and caregivers in rural regions of Kentucky across the continuum of their care and (2) provide their perspectives on barriers and facilitators of optimal function and well-being.

Methods: A qualitative descriptive interview study was …

Socioecological Factors Influencing Women’S Hiv Risk In The United States: Qualitative Findings From The Women’S Hiv Seroincidence Study (Hptn 064), Paula M. Frew, Kimberly Parker, Linda Vo, Danielle Haley, Ann O'Leary, Dazon Dixon Diallo, Carol E. Golin, Irene Kuo, Lydia Soto-Torres, Jing Wang, Adaora A. Adimora, Laura A. Randall, Carlos Del Rio, Sally Hodder

Environmental & Global Health Faculty Research

Understanding the current status of parents’ vaccine decision making is crucial to inform public policy. We sought to assess changes in vaccine decisions among parents of young children. … See full text for complete abstract.

Understanding Health Care Costs In A Wisconsin Acute Leukemia Population, Patricia Steinert, Ron A. Cisler

Journal of Patient-Centered Research and Reviews

Purpose

We investigated factors driving health care costs of patients with a diagnosis of acute myeloid and acute lymphoblastic leukemia.

Methods

Standard costs identified in insurance claims data obtained from the Wisconsin Health Information Organization were used in a sample of 837 acute leukemia patients from April 2009 to June 2011. The Andersen behavioral model of health care utilization guided selection of patient and community factors expected to influence health care costs. A generalized linear model fitting gamma-distributed data with log-link technique was used to analyze cost.

Results

Type of treatment received and disease severity represented significant cost drivers, and …

Sharing Experiences And Expertise: The Health Care Systems Research Network Workshop On Patient Engagement In Research, Sarah Madrid, Leah Tuzzio, Cheryl D. Stults, Leslie A. Wright, Gina Napolitano, Ellis Dillon, Heather Tabano, Sarah M. Greene

Journal of Patient-Centered Research and Reviews

The Health Care Systems Research Network’s (HCSRN) Patient Engagement in Research Scientific Interest Group (PER SIG) held a half-day workshop for researchers attending HCSRN’s 22nd annual conference, April 16, 2016, in Atlanta, Georgia. The workshop blended didactic and interactive content to facilitate co-learning. Both researchers and patient partners developed the content, including three broad topics: engagement of patient partners in developing research studies, nurturing partnerships, and assessing the impact of patient engagement in research. Each module presented approaches relevant to the specific topic, including lessons from the literature and in-the-field experience. Patient partners reflected on their experience related to each …

Advancing Population Health: New Models And The Role Of Research. An Overview Of The 22nd Annual Health Care Systems Research Network Conference, Robert T. Greenlee, Lois E. Lamerato, Sarah M. Greene

Journal of Patient-Centered Research and Reviews

The Health Care Systems Research Network (HCSRN; formerly HMO Research Network) held its annual conference in Atlanta, Georgia, in April 2016. A consortium of research organizations affiliated with 20 large health care delivery systems, the HCSRN met for the 22^nd consecutive year to report on scientific achievements, develop and share skills and best practices, and promote new research collaborations. The 2016 conference, with a theme of “Advancing Population Health: New Models and the Role of Research,” was co-hosted on behalf of HCSRN by Marshfield Clinic Research Foundation and Henry Ford Health System’s Public Health Sciences Department. The 350 conference …

Surveillance, Epidemiological, And Virological Detection Of Highly Pathogenic H5n1 Avian Influenza Viruses In Duck And Poultry From Bangladesh, Wahedul Karim Ansari, Md Safiullah Parvej, Mohamed E. El Zowalaty, Sally Jackson, Stephen A. Bustin, Adel K. Ibrahim, Md Tanvir Rahman, Han Zhang, Mohammad Ferdousur Rahman Khan, Md Mostakin Ahamd, Md. Fasiur Rahman, Marzia Rahman, Khm Nazmul H. Nazir, Sultan Ahmed, Md Liakot Hossenn, Md Abdul Kafi, Mat Yamage, Nitish C. Debnath, Graba Ahmed, Hossam Ashour, Md Masoud, Ayman Noreddin, Md B. Rahman

Pharmacy Faculty Articles and Research

Avian influenza viruses (AIVs) continue to pose a global threat. Waterfowl are the main reservoir and are responsible for the spillover of AIVs to other hosts. This study was conducted as part of routine surveillance activities in Bangladesh and it reports on the serological and molecular detection of H5N1 AIV subtype. A total of 2169 cloacal and 2191 oropharyngeal swabs as well as 1725 sera samples were collected from live birds including duck and chicken in different locations in Bangladesh between the years of 2013 and 2014. Samples were tested using virus isolation, serological tests and molecular methods of RT-PCR. …

Young Adult E-Cigarette Exposure: Implications For Policy And Prevention, Monica Page Daniel Dobbs

Graduate Theses and Dissertations

Objective. The purpose of this study is to examine factors associated with e-cigarette use among college students to better understand their behavior. Using Ajzen’s Reasoned Action Approach, this study sought to better understanding the influence of attitudes, Social norms, and perceived behavioral controls (PBCs) on college students’ intention to try e-cigarettes (even one puff) in the next 30 days.

Methodology. This study employed three phases for a mixed methods design that took place between December 2015 and April 2016. Phase 1 used Middlestadt’s salient belief elicitation procedure to capture responses through an open ended survey (n=58). Phase 2, a pilot …

Reliability Of Pressure Ulcer Rates: How Precisely Can We Differentiate Among Hospital Units, And Does The Standard Signal-Noise Reliability Measure Reflect This Precision?, Vincent S. Staggs, Emily Cramer

Manuscripts, Articles, Book Chapters and Other Papers

Hospital performance reports often include rankings of unit pressure ulcer rates. Differentiating among units on the basis of quality requires reliable measurement. Our objectives were to describe and apply methods for assessing reliability of hospital-acquired pressure ulcer rates and evaluate a standard signal-noise reliability measure as an indicator of precision of differentiation among units. Quarterly pressure ulcer data from 8,199 critical care, step-down, medical, surgical, and medical-surgical nursing units from 1,299 US hospitals were analyzed. Using beta-binomial models, we estimated between-unit variability (signal) and within-unit variability (noise) in annual unit pressure ulcer rates. Signal-noise reliability was computed as the ratio …

Geographical Location And Stage Of Breast Cancer Diagnosis: A Systematic Review Of The Literature, Faustine Williams, Aimee S. James, Stephen Jeanetta

ETSU Faculty Works

Objective: To examine systematically the literature on the effect of geographical location variation on breast cancer stage at diagnosis, race/ethnicity, and socioeconomic status.

Methods. Eight electronic databases were searched using combination of key words. Of the 312 articles retrieved from the search, 36 studies from 12 countries were considered eligible for inclusion.

Results. This review identified 17 (47%) of 36 studies in which breast cancer patients residing in geographically remote/rural areas had more late-stage diagnosis than urban women. Ten (28%) studies reported higher proportions of women diagnosed with breast cancer resided in urban than rural counties. Nine …

Using The Theory Of Planned Behavior To Predict Executives’ Intentions To Hire Psychologists In Federally Qualified Health Centers, Robert M. Tolliver

Electronic Theses and Dissertations

Health psychologists with training in integrated care are ideal candidates to work in Federally Qualified Health Centers (FQHCs). However, despite the large documented need for more behavioral health providers in FQHCs, psychologists are underrepresented in this setting compared to other behavioral health professions. The purpose of this study was to: 1) examine the specific beliefs that are most relevant to executives’ intentions to hire psychologists, 2) determine how executives’ perceived control over hiring psychologists varies by several demographic variables, and 3) examine how well the Theory of Planned Behavior (TPB) predicts executives’ intentions to hire psychologists. Method: Executives (N …

An Analysis Of The Implementation Of The Policy To Integrate Of National Defense Components In Managing Non-Military Threats In The Health Sector, Sugeng Winarno, Prastuti Soewondo

Journal of Indonesian Health Policy and Administration

This research was based on the Minister of Defense’s Decree No. 16/2012 that stated that all national defense components to integrate into one unit when they encounter military and non-military threats. The Ministry of Health, as the main player, and other governmental and private agencies would also play a role in overcoming complex and multidimensional non-military threats, especially in the health sector. Among those threats are infectious diseases such as HIV/AIDS and Ebola. We aim to discover the implementation process of the law above in the management of those two diseases. This was a qualitative analytical research with in-depth interviews. …

Policy Implementation Of Health Coverage For Indonesian Migrant Workers, Risky Kusuma Hartono, Budi Hidayat, Pujiyanto Pujiyanto

Journal of Indonesian Health Policy and Administration

The purpose of this research is to analyze the policy implementation of health coverage for TKI. This research uses a qualitative method with in-depth interview. The framework of this research consists of the aspect of the advisable policy, the implementation factors, and the schematic representation of the problem by using SWOT. The result of this research is the health insurance owned by TKI comes from TKI insurance, the membership of JKN, and insurance during their employment abroad. TKI insurance policy is the instruction of Law No. 39 of 2004 which regulates the obligation of the ownership of the social security …

Study On Public Health Financing In Pidie Jaya District In 2013, Hanifah Hasnur, Purnawan Junadi

Journal of Indonesian Health Policy and Administration

Albeit high dependency on central government transfer (around 69% of total health expenditure), funding from local PAD has been increasing. The revenue shall support priority health programs. This study aims to analyze local health financing system and as input for health program planning. Health financing portrait how fund being spent, and identfying who the agents are as well as the beneficiaries. The study shows spending on health from local budget is Rp130,000. Expenditures on operational costs for direct activities and community-based health efforts or Upaya Kesehatan Masyarakat (UKM) are still low (41%). Puskesmas needs to do more health-related activities for …

A Century Of Trends In Adult Human Height, Con Burns, Tara Coppinger

Publications

Being taller is associated with enhanced longevity, and higher education and earnings. We reanalysed 1472 population-based studies, with measurement of height on more than 18.6 million participants to estimate mean height for people born between 1896 and 1996 in 200 countries. The largest gain in adult height over the past century has occurred in South Korean women and Iranian men, who became 20.2 cm (95% credible interval 17.5–22.7) and 16.5 cm (13.3–19.7) taller, respectively. In contrast, there was little change in adult height in some sub-Saharan African countries and in South Asia over the century of analysis. The tallest people …

When Actions Speak Louder Than Words: Extending The Reach Of Qualitative Data Collecting, Justine M. Mcgovern

Publications and Research

Through the lens of a study exploring dementia care partnering, the purpose of this methods article is to focus on the role of artifacts and embodied data in data collection. In addition, it illustrates how to use a range of data collecting methods. The article identifies benefits of additional data collecting methods to research and care. These include the need to expand data collecting methods beyond spoken word, integrate a range of data collecting approaches into research courses across disciplines, increase support of qualitative research, and advocate for greater inclusivity in research. Data collecting approaches can also have implications for …

Injury-Related Infant Deaths: A State Analysis Of A Public Health, Health Care, Policy Network, Sharla Smith, Xi Zhu, Mary Aitken

Frontiers in Public Health Services and Systems Research

Introduction: This research examines a state-level public health, health care, and policy network focused on efforts to reduce unintentional childhood injuries. The network is composed of 12 organizations: four public health, four health care, and four policy.

Methods: A 23-item survey was administered to the 12 organizations between January and June 2015. Analyses were conducted using HyperResearch and UCInet 6.

Results: More organizations worked together on assessment and planning efforts that identify and quantify the nature of at-risk infants in the community and strategies for reducing injury-related infant deaths. The Injury Prevention Center, the most central organization, interacted most frequently …