A Healthcare Improvement Initiative to Increase Multidisciplinary Pain Management Referrals for Youth with Sickle Cell Disease.

BACKGROUND: Chronic pain is a complex integration of biological, psychological, and social variables. Multidisciplinary pain management experts design interventions that treat the multidimensional experience. Children and adolescents with sickle cell disease (SCD) are at risk for chronic pain. Increased risk is associated with multiple characteristics including sickle cell genotype, age, gender, frequency of hospitalization, duration of hospitalization, and certain comorbid diagnoses. Referral to pain management professionals for this population is often delayed. AIMS: To increase multidisciplinary pain management referrals for youth with SCD identified to be at risk for chronic pain. DESIGN: Implementation research. SETTING: One pediatric, academic medical facility serving as a regional sickle cell treatment center in the Midwest. PARTICIPANTS: Children greater than 2 years of age and less than 21 years of age with laboratory confirmed SCD. METHODS: Implementation of an evidence-based screening tool using the consolidated framework for implementation research (CFIR) to guide project planning, design, and evaluation. The CFIR model was paired with the Plan-Do-Study-Act (PDSA) quality improvement methodology to operationalize workflow and sustain project aims. RESULTS AND CONCLUSIONS: Eighty-four percent of all eligible patients were screened during their routine sickle cell appointments resulting in a 110% increase in multidisciplinary pain management referrals. Future interventions and PDSA cycles are targeted at improving attendance at scheduled appointments, reducing hospitalizations, decreasing 30-day readmissions, and shortening length of stay.

Stress and the Home Environment in Caregivers of Children with Sickle Cell.

OBJECTIVE: Caregivers of young children with chronic illnesses are at high risk for elevated levels of stress and mental health symptoms. This study examined stress and mental health symptoms as well as the socioeconomic status (SES) and home environments of a cohort of caregivers of infants and toddlers with sickle cell disease (SCD). METHODS: Forty-two caregivers of infants and toddlers (aged 1-34 months) with SCD completed the Brief Symptom Inventory (BSI) and Parent Stress Index (PSI). The Home Observation for Measurement of the Environment (HOME) was used to assess family living environments. RESULTS: Compared to test norms, caregivers reported high levels of situational/demographic life stress [mean difference (MD) 5.7, p = .003] and child distractibility/hyperactivity (MD 3.62, p = .001) on the PSI. However, no significant differences in psychological symptoms of distress were noted on the BSI. Caregivers scored significantly lower than norms on PSI subdomains of acceptability (MD -1.88, p = .03), competence (MD -3.11, p = .002), depression (MD -3.94, p < .001), and the overall parent domain (MD -12.55, p = .005). Significant correlations were found between PSI scores and the HOME and between SES and the HOME. CONCLUSION: Caregivers of infants and toddlers with SCD experience elevated levels of life stress but, in turn, endorse high acceptance of their child and self-competence in parenting. Although life stress may be high in this population, symptoms of psychological distress were not identified. Caregivers reporting elevated life and illness-specific stressors may benefit from environmental supports and interventions.

Direito a não ter dor: cuidado de enfermagem à criança com anemia das células falciformes / Right not to have pain: nursing care for children with sickle cell anemia

A excelência dos cuidados em enfermagem pediátrica tem como fio condutor o bem-estar da criança, visando sempre a maximização da sua saúde e a adaptação a situações relacionadas com o ciclo de vida ou com uma condição de saúde complexa. Enquanto requisitos da humanização desses cuidados importa realçar os cuidados centrados na família, os cuidados não traumáticos e a parceria de cuidados, numa estreita relação com uma abordagem holística e multidisciplinar que visa dar a resposta mais adequada às necessidades de cada criança e família. Cuidar com vista ao bem-estar tem intrínseco a gestão diferenciada da dor enquanto aspeto crucial a ser considerado. Recorrendo ao modelo de sistemas de Neuman enquanto quadro de referência orientador da prática, a dor é identificada enquanto stressor que pode interferir com o bem-estar da criança e família, sendo o controlo da mesma reconhecido enquanto direito, mas ainda considerado uma meta a alcançar. Intervir nesta área implica articular a melhor evidência com as estratégias definidas como prioritárias para melhorar os cuidados referentes ao controlo da dor, nomeadamente o desenvolvimento de modelos de boas práticas, a formação dos profissionais e a literacia da população. Outro aspeto a salientar relaciona-se com a necessidade de consistência e articulação entre o reconhecimento da presença de dor, a implementação de intervenções, a reavaliação e o registo, numa abordagem individualizada e interdisciplinar. O presente relatório pretende refletir o percurso realizado com vista ao desenvolvimento de competências de mestre e de enfermeiro especialista que possibilitam a prestação de cuidados de nível avançado na área da saúde infantil e pediatria. Tem como particular enfoque o controlo da dor da criança, essencialmente no contexto da anemia das células falciformes onde a dor assume uma especial relevância e a sua gestão algumas particularidades. A metodologia envolveu a concretização de um Estágio em diferentes contextos, que permitiu articular teoria e prática, assente sempre numa reflexão crítica contínua das aprendizagens realizadas.

Excellence in pediatric nursing care is guided by the child's well-being, always aiming at maximizing their health and adapting to situations of the life cycle or any complex health condition. To provide such humanistic care it is important to highlight family-centered care, non-traumatic care and partnership in care, in a close relationship with a holistic and multidisciplinary approach that aims to provide the most appropriate response to the needs of each child and family. Differentiated pain management is intrinsic to care and a crucial aspect to consider. According to the Neuman systems model, adopted as reference for practice, pain is identified as a stressor that can interfere with the well-being of the child and family, with its management recognized as a right, and a goal to be achieved. Intervention in this area implies articulating the best evidence with the priority strategies defined to improve care related to pain control, namely the development of models of good practices, the training of professionals and the literacy of the population. Another aspect to be highlighted relates to the need for consistency and articulation between the recognition of the presence of pain, the implementation of interventions, reevaluation and documentation, in an individualized and interdisciplinary approach. This report aims to reflect the path taken to develop the competencies of master and specialist nurse that enable the provision of advanced care in the area of child health and pediatrics. Its particular focus is management of pain in the child, namely in the context of sickle cell disease where pain assumes a special relevance and its control some particularities. The methodology involved the realization of a clinical placement in different settings that allowed the articulation of theory and practice, always based on a continuous critical reflection of the lessons learned.

"Waiting for a miracle": Spirituality/Religiosity in coping with sickle cell disease / "Esperando un milagro": Espiritualidad/Religiosidad en el afrontamiento de la enfermedad de célula falciforme / "À espera de um milagre": espiritualidade/religiosidade no enfrentamento da doença falciforme

ABSTRACT Objective: To understand spirituality/religiosity as experienced by people with sickle cell disease, and its influence on coping with the disease. Method: A qualitative, descriptive, and exploratory study conducted in the State of Bahia. Twenty-nine respondents participated in semi-structured interviews. Content analysis was used to analyze the empirical material. Results: Individuals with sickle cell disease experience spirituality/religiosity motivated by their hope for a miracle, and fear of death; among their rites are: reading religious materials, individual and group prayer, and attendance at worship services. The effects on their health include: comfort by means of coping by comparing two evils, anxiety relief, social support, and lifestyle changes; however, spirituality/religiosity may be impaired. Final considerations: This study demonstrates the need to qualify health professionals to address spiritual issues of these individuals during illness, with the aims of diagnosing suffering and anguish, and providing care, comfort and strengthening of the spiritual bonds of these individuals.

RESUMEN Objetivo: Entender la espiritualidad / religiosidad como la experimentan las personas con enfermedad de células falciformes y su influencia en el afrontamiento de la enfermedad. Método: Un estudio cualitativo, descriptivo y exploratorio realizado en el estado de Bahía. Veintinueve encuestados participaron en entrevistas semiestructuradas. Se utilizó análisis de contenido para analizar el material empírico. Resultados: Las personas con enfermedad de células falciformes experimentan espiritualidad / religiosidad motivadas por su esperanza de un milagro y el miedo a la muerte; entre sus ritos se encuentran: lectura de materiales religiosos, oración individual y grupal, y asistencia a los servicios de adoración. Los efectos en su salud incluyen: comodidad mediante el manejo del afrontamiento, alivio de la ansiedad, apoyo social y cambios en el estilo de vida; sin embargo, la espiritualidad / religiosidad puede verse afectada. Consideraciones finales: Este estudio demuestra la necesidad de preparar a los profesionales de la salud para abordar los problemas espirituales de estos individuos durante la enfermedad, con el objetivo de diagnosticar el sufrimiento y la angustia, y de brindar atención, comodidad y fortalecimiento de los vínculos espirituales de estos individuos.

RESUMO Objetivo: Compreender a Espiritualidade/Religiosidade vivenciadas por pessoas com doença falciforme e sua influência sobre o enfrentamento da doença. Método: Estudo qualitativo, descritivo, exploratório, realizado no Estado da Bahia. Participaram 29 pessoas que responderam a entrevistas semiestruturadas. O material empírico foi submetido a análise de conteúdo. Resultados: Pessoas com doença falciforme vivenciam a Espiritualidade/Religiosidade motivadas pela esperança de um milagre e por medo da morte; seus ritos são as leituras de textos religiosos, orações individuais e em grupo, e frequência a cultos; os efeitos sobre sua saúde são: conforto através do coping de comparação, alívio da ansiedade, apoio social, mudança no estilo de vida, porém a Espiritualidade/Religiosidade podem manifestar-se prejudicadas. Considerações finais: Este estudo ressalta a necessidade da qualificação dos profissionais de saúde para a abordagem das questões espirituais dessas pessoas adoecidas, com a preocupação de diagnosticar possíveis sofrimentos, angústias e assim prestar auxílio, conforto e fortalecer os vínculos espirituais desses indivíduos.

"Waiting for a miracle": Spirituality/Religiosity in coping with sickle cell disease.

OBJECTIVE: To understand spirituality/religiosity as experienced by people with sickle cell disease, and its influence on coping with the disease. METHOD: A qualitative, descriptive, and exploratory study conducted in the State of Bahia. Twenty-nine respondents participated in semi-structured interviews. Content analysis was used to analyze the empirical material. RESULTS: Individuals with sickle cell disease experience spirituality/religiosity motivated by their hope for a miracle, and fear of death; among their rites are: reading religious materials, individual and group prayer, and attendance at worship services. The effects on their health include: comfort by means of coping by comparing two evils, anxiety relief, social support, and lifestyle changes; however, spirituality/religiosity may be impaired. FINAL CONSIDERATIONS: This study demonstrates the need to qualify health professionals to address spiritual issues of these individuals during illness, with the aims of diagnosing suffering and anguish, and providing care, comfort and strengthening of the spiritual bonds of these individuals.

CE: Understanding the Complications of Sickle Cell Disease.

: Sickle cell disease (SCD) is an autosomal recessive genetic condition that alters the shape and function of the hemoglobin molecule in red blood cells. While the overall survival rate among children with SCD has improved in recent years, pediatric rates of hospitalization, ED use, and mortality from complications of SCD remain high. Among patients ages 18 and older, hospital admission and ED usage are even greater-and the median age at death of people with SCD is considerably lower than that of the general population. Nurses who care for patients with SCD have an opportunity to improve health outcomes and quality of life for these patients by recognizing the major SCD-associated complications and providing patients and their caregivers with appropriate educational information. The authors discuss the genetic, hematologic, and clinical features of SCD and describe the major associated health complications. In addition, they review the nursing implications of each complication and provide online links to resources for clinicians, patients, and caregivers.

Exploring Emergency Department Provider Experiences With and Perceptions of Weight-Based Versus Individualized Vaso-Occlusive Treatment Protocols in Sickle Cell Disease.

Treatment of vaso-occlusive episodes (VOEs) is the most common reason for emergency department (ED) treatment of sickle cell disease (SCD). We (1) compared perceptions of the usability and ability to manage VOE pain between ED nurses and other ED provider types, ED sites, and VOE protocols (individualized vs. weight-based), and (2) identified ED nurse and other provider protocol suggestions. A secondary analysis of provider survey data collected immediately after caring for a patient enrolled in a randomized controlled trial comparing weight-based versus individualized opioid dosing for VOE. Research staff asked the ED nurses and other ED providers (nurse practitioners [NPs], physician assistants [PAs], residents, and attending physicians) 5 questions related to the protocol's ease of use and ability to manage pain. There were 236 surveys completed. Attending physicians (n = 15), residents (n = 88), PAs (n = 21), and NPs (n = l) were more satisfied than nurses (n = 111) with the clarity of the analgesic ordering (97.6% vs. 0%, p = 0.0001) and ability to manage the patient's VOE pain (91% vs. 0%, p = 0.0001). When comparing both protocols with the usual ED strategy in their ED to manage VOE, more nurses than other ED providers perceived the study patients' pain management protocol as better (100% vs. 35.2%, p = 0.0001). Other ED providers perceived the individualized versus weight-based protocol as better at managing pain than their usual ED strategy (70.3% vs. 59.5%, p = 0.04). The individualized protocol was perceived as better in managing VOE than the weight-based ED strategy. While physicians were satisfied with the clarity of the protocols, nurses were not. Improved protocol usability is required for widespread ED implementation.

Effectiveness of an Educational Program on Nurses' Knowledge and Practice in the Management of Acute Painful Crises in Sickle Cell Disease.

BACKGROUND: Sickle cell disease (SCD) affects millions of people worldwide and is associated with significant morbidity and mortality. Nurses can have a significant role in improving the outcomes of individuals with SCD. This study examined the effectiveness of an educational program on the knowledge and practice of nurses who provide care for individuals with acute sickle cell crisis. METHOD: A pretest-posttest control group design was used. The study was conducted at two hospitals in the northern region of Egypt. The sample included 77 RNs working in hematologic and genetic units. Data were collected using a self-administered knowledge questionnaire and a clinical performance checklist. RESULTS: Findings indicated a significant difference in nurses' knowledge and care practices after implementing the educational program. CONCLUSION: This educational program enhanced nurses' knowledge and practice for managing SCD. Training and continuing education programs need to be provided for nurses in hospital settings who provide care for individuals with SCD. Moreover, nursing curricula should reflect the standardized care for individuals with sickle cell crisis. [J Contin Educ Nurs. 2019;50(2):87-95.].

Pain Management Issues as Part of the Comprehensive Care of Patients with Sickle Cell Disease.

BACKGROUND: Vaso-occlusive pain crisis is one of the primary complications of sickle cell disease (SCD) and is responsible for the majority of hospital visits in patients with SCD. Stints of severe pain can last for hours to days and are difficult to treat and manage, often resulting in drastically reduced quality of life. PURPOSE: Our purpose is to provide an overview of pain management issues in SCD populations. METHODS: We explored literature using PubMed and Embase for the etiology and management of pain in SCD. Databases were searched employing the following terms: sickle cell, pain pathways, pain perception, pharmacological therapies, psychological therapies, physical therapies and genetics. RESULTS: Pain in SCD can vary from acute to chronic (persistent) or mixed and understanding of the underlying mechanisms is important for proper pain management. Currently, there are many means of managing pain in children with SCD, which involve pharmacological and non-pharmacological approaches. A combination of psychotherapy and pain medications can be used for treatment of pain and other psychosocial co-morbidities in complex persistent pain. CONCLUSIONS: Providing more appropriate medication and optimal dosage based on individual's genomic variations is the future of medicine, and this will allow the physicians to hone in on optimal pain management in patients with SCD.

Sickle Cell Disease: Bone, Joint, Muscle, and Motor Complications.

Sickle cell disease (SCD) is a group of inherited disorders caused by a mutation of the hemoglobin gene, resulting in the formation of abnormal, sickle-shaped red blood cells. It is a lifelong condition characterized by anemia, vaso-occlusion, and decreased blood flow to vital tissues. Sickle cell disease affects every major organ and significantly reduces life expectancy of the affected individuals. Patients with SCD are at an increased risk for developing musculoskeletal complications that decrease quality of life and contribute to the significant burden of the disease. Understanding these complications, as well as the genetics, pathophysiology, and epidemiology of SCD, will assist orthopaedic nurses in providing evidence-informed care.

Use of a depression and sleep impairment treatment guideline to improve quality of life for patients with sickle cell disease.

BACKGROUND: Pain in sickle cell disease (SCD) is often joined by other affective disorders such as depression and/or sleep impairment that can impact pain levels and quality of life (QoL). AIM: To develop a guideline to improve the process of assessment and treatment of depression and sleep impairment in patients admitted with SCD. METHOD: An interdisciplinary team used the Stetler model to create the Guideline for the Evaluation and Treatment of Depression and Sleep Impairment in Sickle Cell Disease. Patients were assessed, offered treatments and reassessed during the project period. RESULTS: Both depression and QoL scores showed significant improvement by the end of the project. Significant correlations were found between pain, depression and sleep; depression, pain, sleep and QoL; sleep, pain and depression; and QoL and depression. CONCLUSIONS: Interdisciplinary teams are effective in creating a guideline to assess and treat depression and sleep impairment and their effects on pain and QoL in patients with SCD.

Identifying Social-Behavioral Health Needs of Adults with Sickle Cell Disease in the Emergency Department.

INTRODUCTION: Sickle cell disease (SCD) is a complex illness with many social-behavioral co-morbidities. The aim of this project was to describe unmet social-behavioral health needs for adults with SCD who presented to the emergency department for treatment of vaso-occlusive episodes (VOEs). METHODS: A descriptive study using 1:1 interviews during an ED visit for a VOE was conducted; a brief social behavioral health screening interview guide was used. A convenience sample of adults with SCD treated in the emergency department for a VOE were eligible for inclusion. RESULTS: We conducted 147 interviews over 14 months. Patients reported transportation and/or scheduling difficulties with clinic appointments in one third of the interviews. Four major themes emerged: clinic appointment barriers, medication barriers, other care barriers, and social-behavioral issues. A majority of patients (53%) reported being brought to the emergency department by a family member at their current visit. Patients cited having insurance coverage issues in more than one quarter (27%) of the interviews. Difficulties in obtaining prescriptions were cited as a result of a financial copay (17%), transportation (11%), and pharmacy (9%) issues. Almost one third of patients (29%) reported feeling depressed, and 20% reported feeling anxious. DISCUSSION: Many patients with SCD who are treated in the emergency department have social or behavioral health risk factors. Emergency departments have an opportunity to screen and refer patients for follow-up. Future research should investigate referral outcomes and their effect on ED and hospital use.

Nurse honours.

A trailblazer who set up England's first nurse-led sickle cell intervention and screening service and campaigned for a Mary Seacole memorial was made a dame by the Queen last week.

Targeting sickle cell disease.

Sickle cell disease is one of the most common global genetic disorders. It is a debilitating condition and children with sickle cell disease are more likely to have a stroke, and experience lower quality of life and shorter life expectancy.

A internalização do cuidado pelo escolar frente à doença falciforme

Este estudo teve por objetivos descrever os instrumentos e signos mediadores da internalização do cuidado pelo escolar frente à doença falciforme; analisar a internalização docuidado pelo escolar frente à doença falciforme nos variados contextos sociais; discutir ainternalização do cuidado pelo escolar com doença falciforme e suas implicações para a saúde. Buscou-se apoio na teoria do desenvolvimento de Vigotski e o conceito de cuidado de Collière, como referenciais teóricos. Trata-se de um estudo qualitativo, com 15 escolares de 6a 12 anos, de um hospital de Vitoria - ES. Um formulário para caracterização dos participantes e uma entrevista semi-estruturada foram utilizados. A análise foi temática. Osresultados apontaram para os cuidados relacionados a hidratação e eliminação; o brincar;prevenção e manejo da crise falcêmica; alimentos e vestuário. Os escolares referiram ingerir variados tipos de líquidos, sendo a água e o suco os mais citados e a sua ingestão estava relacionada à prevenção da crise falcêmica. O atendimento às necessidades de eliminação da criança no contexto escolar mostrou-se prejudicada pela rigidez das normas estabelecidas pelas instituições. Quanto às brincadeiras e atividades físicas, não houve diferença entre o escolar com doença falciforme e as brincadeiras relatadas foram predominantemente ativas. A dor foi um signo mediador da internalização e os auxiliou na identificação de determinadas brincadeiras, como fator desencadeante da crise falcêmica. A interação se estabeleceu entre o escolar e outras crianças ou animais, principalmente no contexto domiciliar e escolar. Os medicamentos citados pelos escolares foram a hidroxiureia e ácido fólico, bem como os analgésicos e antitérmicos associados à manutenção e reparação de sua saúde...

This study had the objective of describing the mediating instruments and signs in the careinternalization by the school child in coping with Sickle Cell disease; To analyse theinternalization of care by the school child in coping with Sickle Cell disease in the severaldifferent social contexts; To discuss the internalization of care of Sickle Cell disease by theschool child, and its implications for the health. The development theory of Vigotski, as wellas the concept of care of Collière, as theoretical references. This is a qualitative study donewith 15 school children from 6 to 12 years old at a hospital of Vitoria - ES. A form for thecharacterization of the participants and a semi-structured interview were used. The analysiswas thematic. The results pointed to care related to hydration and elimination; playing;prevention and management of the Sickle Cell crisis; feeding and clothing. The schoolchildren refered ingesting several different types of liquides, being water and juice the mostcited, and the ingestion was related to the prevention of the Sickle Cell crisis. Meeting theneeds of the child for elimination was impaired in the school context because of the strictrules established by the institutions. In relation to the playing and physical activity there wasno difference between the school child with Sickle Cell disease and the other children, and theplaying was reported as predominantly active. Pain was a mediating sign of theinternalization, and it has helped them to identify certain ways of playing as triggering factorsof the Sickle Cell crisis. There was interaction established between the school child and otherchildren or animals, mainly in the home and school contexts. The drugs reported by theschool children were hydroxyurea and folic acid, as well as analgesics, antipyretic associatedto the maintenance and repare of their health...

Este estudio tuvo como objetivo describir los instrumentos y signos mediadores deinternalización de la atención por el niño en la enfermedad de células falciformes; analizar lainternalización de la atención por el niño en la enfermedad de células falciformes endiferentes contextos sociales; discutir la interiorización de la atención para el niño con laenfermedad de células falciformes y sus consecuencias para la salud. Se buscó seguir la teoríadel desarrollo de Vygotsky y el concepto de atención Collière como referencias teóricas. Estees un estudio cualitativo con 15 niños de 6 a 12, en un hospital de Vitoria - ES. Se utilizó unformulario para caracterizar los participantes y entrevista semi-estructurada. El análisis fuetemático. Los resultados apuntan a la atención relacionada con la hidratación y la eliminación,el juego, la prevención y gestión de crisis de células falciformes, la comida y la ropa. Losniños ingieren varios tipos de líquido, como agua y jugo. Estos eran los más citados y suconsumo se relaciona con la prevención de crisis de células falciformes. La atención a lasnecesidades de eliminación del niño en el contexto escolar resultó ser obstaculizado por larigidez de las reglas establecidas por las instituciones. En cuanto a juegos y actividadesfísicas, se encontró que no hay diferencia entre el niño con la enfermedad de célulasfalciformes y la población infantil en general, se dedican predominantemente a juegos activos.El dolor fue un signo mediador de internalización y les ayudó a identificar ciertos juegoscomo el factor desencadenante de la crisis de células falciformes. La interacción se establecióentre el niño y otros niños o animales sobre todo en el entorno de la casa y de la escuela. Losmedicamentos citados por los niños fueron hidroxiurea y ácido fólico, así como analgésicos yantipiréticos asociados con el mantenimiento y la reparación de su salud...

Non-communicable diseases among children in Ghana: health and social concerns of parent/caregivers.

BACKGROUND: Globally, there is a progressive rise in the burden of non-communicable diseases (NCDs). This paper examined the health and social concerns of parents/caregivers on in-patient care for children with NCDs in Ghana. METHODS: This was a cross-sectional study in three large health facilities in Ghana (the largest in the South, the largest in the North and the largest in the Eastern part of Ghana. Data was collected with a structured questionnaire among 225 caregivers (≥18 years) of 149 children with NCDs in health facilities in the three regions. Data was analyzed with simple descriptive statistics. RESULTS: Most caregivers 169(75.0%) were women, relatively young (median age 35years), mostly married and resided in urban areas. Sickle cell disease was the commonest NCD among the children. All 169(75.0%) caregivers believed children suffer NCDs because of sins of parents/ancestors, 29(12.9%) believed herbalists/spiritualists have insights into treating NCDs and 73(32.6%) have previously used herbs/traditional medicine for child's illness. NCD in children was a burden and caused financial difficulties for families. Most caregivers (>96.0%) indicated NCDs in children should be included in national health insurance benefits package and a comprehensive national NCD policy is needed. CONCLUSION: Absence of national NCD policy for children is a major challenge. The burden of care rests mainly on the parents/caregivers. A national strategic intervention on the importance of awareness generation on the causes, risk factors, prevention and treatment of NCDs for families and communities is essential. Government support through national health and social policy initiatives are essential.