Prevention starts here: effectiveness of substance abuse prevention module among adolescent students in Bengaluru - a quasi experimental study.

OBJECTIVES: This study aims to evaluate the effectiveness of a structured educational module on substance abuse prevention program among adolescents in enhancing their knowledge against substance abuse. METHODS: A quasi-experimental design was employed involving 120 students (mean age: 14.3±1.03 years, 59.2% boys) from two English medium schools. Participants were exposed to a structured module on substance abuse over a month. The study assessed changes in knowledge through pretest and post-test evaluations. Statistical analyses examined improvements in scores and the relationship between class of study and post-test knowledge scores. RESULTS: The intervention significantly improved students' knowledge about substance abuse (p<0.001) across all measured domains, genders, and classes, with the exception of the 7th class. A positive correlation was found between the class of study and post-test scores (Rs=0.288, p<0.001), indicating that higher classes were associated with greater improvements in knowledge. These findings suggest that the training effectively increased awareness and understanding of substance abuse among participants. CONCLUSIONS: The substance abuse prevention program successfully enhanced adolescents' knowledge and equipped them with resilience and coping strategies, thus reducing their vulnerability to peer pressure and substance abuse. Despite the lack of significant improvement in the 7th class, the overall positive outcomes underscore the importance of implementing such educational interventions to foster healthy development and well-being among students. Further research is encouraged to explore the specific barriers to effectiveness in younger classes and to refine program content accordingly.

A Community Trial in Coastal Karnataka using Life Style Modifications to Assess its Impact on Hypertension and Diabetes.

Introduction: In the management of hypertension and diabetes mellitus, a systematic response like modifications in lifestyles is needed along with the medication. The study was conducted to determine the impact of comprehensive lifestyle modifications on hypertension and diabetes and to compare it with that of physical activity alone as a health education intervention. Materials and Method: A risk factor-based community intervention trial was conducted for one year in 3 villages in coastal Karnataka. The sample of 305 was calculated depending on the expected change in blood pressure and an equal sample size was drawn from each of the villages using a systematic random sampling method. Baseline data on blood pressure level, random blood sugar, and HbA1c levels were recorded. After 1 year of intervention, all the parameters were further recorded along with the adherence to medication for these non-communicable diseases. Results: The mean difference between the groups suggested that participants with physical activity intervention reported a statistically significant reduction in systolic blood pressure. In the comprehensive lifestyle modification group, there was a significant reduction in both diastolic blood pressure and glycated hemoglobin levels (21 mmHg and 2.1%; p < 0.001). Conclusion: The study indicates that in the management of hypertension and diabetes mellitus, the impact of comprehensive lifestyle modifications was more significant compared to physical activity alone.

Understanding the need for developing a structured competency-based curriculum for health policy and programs among community medicine postgraduates: A grounded theory approach.

Introduction: Many plans and policy changes about health outcomes have evolved, but none of them have ever given a definite shape to the postgraduate (PG) curriculum so as to make it more intensive and integrative, which needs to be so structured and tailored that it is more patient, community centric, and less knowledge based. Objectives: The objective of this study was to identify the gap in existing curriculum in learning of health policy and program among PGs of community medicine and recommend a structured model for the same. Materials and Methods: A qualitative study (grounded theory approach) with all PGs of community medicine in one teaching institute in South India (8 PG students) was taken up. Results: PGs felt that they never had any day-to-day update. They wanted to understand the working pattern and ground reality of policy and program which was unavailable to them. People who came to postgraduation after being medical officers felt that the monitoring and evaluation done by inexperienced MD Community Medicine students was never accepted by state public health because they did not understand the implementation problems and so could not rightly critically evaluate the programmatic challenges. Conclusion: With the shift in medical education patterns and expectations of residents, it becomes important to justify the need of developing a structured based curriculum, more so for policy and programs, which will make them capable enough by polishing their managerial and financial skill set. The evaluation technique should focus more on practical aspects on field instead of their theory examination.

Challenges faced by frontline health managers during the implementation of COVID-19 related policies in India: A qualitative analysis.

Background & objectives: The COVID-19 pandemic exposed the strengths and weaknesses of the healthcare systems across the world. Many directives, guidelines and policies for pandemic control were laid down centrally for its implementation; however, its translation at the periphery needs to be analyzed for future planning and implementation of public health activities. Hence, the objectives of this study were to identify the challenges faced by frontline health managers in selected States in India during the pandemic with regard to implementation of the COVID-19-related policies at the district level and also to assess the challenges faced by the them in adapting the centrally laid down COVID-19 guidelines as per the local needs of the district. Methods: A qualitative study using the grounded theory approach was conducted among frontline district-level managers from eight different States belonging to the north, south, east and west zones of India. The districts across the country were selected based on their vulnerability index, and in-depth interviews were conducted among the frontline managers to assess the challenges faced by them in carrying out COVID-19 related activities. Recorded data were transcribed verbatim, manually coded and thematically analyzed. Results: Challenges faced in implementing quarantine rules were numerous, and it was also compounded by stigma attached with the disease. The need for adapting the guidelines as per local considerations, inclusion of components of financial management at local level, management of tribal and vulnerable populations and migrants in COVID context were strongly suggested. The need to increase human resource in general and specifically data managers and operators was quoted as definite requirement. Interpretation & conclusions: The COVID-19 guidelines provided by the Centre were found to be useful at district levels. However, there was a need to make some operational and administrative modifications in order to implement these guidelines locally and to ensure their acceptability.

Evaluation of risk factors for non-alcoholic fatty liver disease in India: A systematic review and meta-analysis.

INTRODUCTION: NAFLD is emerging as an important cause of liver disease in India. It is estimated that 16-32% of general population in India (nearly 120 million) has NAFLD. OBJECTIVE: This study aimed to identify the risk factors of NAFLD and to identify the association of lifestyle (dietary and physical activity), genetic, and environmental factors with NAFLD in India. MATERIALS AND METHODS: A systematic literature search was conducted using an international electronic database: PubMed (MEDLINE) and Google Scholar from the date of inception 31st March 2021 to 28th September 2021. We included studies examining patients with NAFLD: Adults above 18 years of age. Studies with or without a control population were both eligible. The studies with a diagnosis of NAFLD based solely on abnormal liver tests were excluded. We tried to get unpublished data but they were not of the quality of inclusion. Meta-analysis was performed using the software STATA 14.2 (StataCorp, College Station, TX, USA). For each of the studies, the standard error was calculated using the reported number of outcomes and the sample size. A forest plot was used to graphically represent the study-specific and pooled prevalence estimates for overall and subgroup analysis. RESULTS: In a systematic review and meta-analysis of 8 studies including data from over 1800 individuals, we found that among components of lipid profile, LDL and HDL had a negative effects on NAFLD while triglycerides had a positive effect on NAFLD. CONCLUSION: Type 2 Diabetes Mellitus, Hypertension, and Obesity were the potential risk factors for NAFLD but the evidence generated was only from single studies.

An economic evaluation of diabetes mellitus in India: A systematic review.

BACKGROUND: Approximately 88 million people throughout Southeast Asia have diabetes, of which 77 million reside in India. India had an annual estimated diabetes treatment cost of Rs.10,000 to 12,000 crore in 2003, which is likely to rise to as high as Rs. 1,26,000 crores by 2025. AIM: To assess the annual mean expenditure for an individual with diabetes mellitus. METHODS: We used search terms and Boolean operators to identify studies on the economic burden of diabetes mellitus patients in India between 2015 and 2020. Thereafter, we used the checklists of STROBE, as well as the PRISMA, Drummonds and down, and Black criteria, to assess the quality of included studies. Then, Meta xl was used to calculate the weighted means and weighted proportion based on the quality assessment findings. RESULTS: Mean expenditure with a maximum weightage of 100% was found in a community-based study, whereas the lowest weightage obtained was 20%. The mean expenditure on diabetes and its complications was calculated as INR 15,535/-(USD 209.3) per year, with a pooled mean of INR 17, 080(USD 230.1)per year. On average, the OPD charges were 3%-5% of the total annual income of the individual. However, when there were complications and hospitalization, the average expenditure was higher (21%) which averages to around 11,000 INR. CONCLUSIONS: While patients spent 3% of their annual income on only OPD charges on average, complications substantially increased the total cost by more than 10%, which amounts to catastrophic health expenditure.

Effectiveness of using technology as health education tool among diabetes patients in South India: A comparative analysis and community based intervention.

Introduction: Type 2 diabetes mellitus is a serious, progressive condition presenting with chronic hyperglycemia. Its prevalence is gradually increasing at a global level. A diabetic has to make multiple choices daily about the management of their condition, such as appropriate dietary intake, physical activity and adherence to drugs. There is hardly any input from a healthcare professional for guidance on a daily basis. Objectives: The aims of this study were to assess the change in knowledge by using various methods of health education as intervention and to compare the effect of technology as a tool of health education as compared to conventional methods of health education. Materials and Methods: A community-based interventional study was done in the field practice area of our Institute in South India. Two groups of people were selected from 40 adopted houses. One from urban; for intervention with technology, that is, health education using videos and the second group from rural population; for intervention with conventional method of health education, that is, using charts. Results: The mean baseline knowledge score in urban and rural area was 3.76 and 9.97, respectively. There was statistically significant increase in knowledge among both the groups. By the use of technology in the urban population knowledge level increased from 3.76 to 10.15 and was found to be statistically significant. The difference in increase in knowledge was higher in the technology group as compared to conventional group. Conclusion: In the era of smartphone, technology-based health education can reduce the total health care manpower which is deficient. Technology is a boon to introduce lifestyle modification in chronic diseases like Diabetes Mellitus.

Physical activity adaptation towards control of selected noncommunicable diseases-A detailed part of large community trial in rural areas of India.

Objectives: The primary aim of this study was to assess the impact of systematically induced health education on physical activity over control of hypertension, diabetes. The secondary aim of this study was to assess the changed pattern of physical activity among hypertensives and diabetics with continuous follow-up. Methods: This is part of a larger study A community trial in coastal Karnataka with three villages where one village was introduced with physical activity alone. A total of 105 participants who are known hypertensives with SBP more than 130 mm Hg or DBP more than 90 mm Hg and diabetics with Hb1Ac more than 7% were included. A specific module for physical activity was prepared, introduced to participants with involvement of family members, followed up for 1 year, and survey was done. The outcomes of median SBP, DBP, and RBS with Physical activity introduction as compared to baseline were done. Statistical analysis--Median, Interquartile range, and Wilcoxon sign rank test--was used. Results: There was 9-15 mm Hg change before and after intervention reduction in SBP and DBP. The median RBS reduced from 264 mg/dL to 205 mg/dL. Moderate activities time markedly increased & sitting hours decreased to half. Conclusion: There is an impact of systematically induced health education on physical activity over control of hypertension and diabetes & change in the pattern of physical activity with continuous health education module and follow-up.

Effectiveness of lifestyle modification on quality of life among uncontrolled diabetics and hypertensives in India - Community based intervention study.

Background: Diabetes and hypertension contribute to more than half of morbidity, mortality and years lived with disability in developing countries like India. It impacts the quality of life (QoL) of patients and their family. Management of these diseases is in infancy and emphasis is laid on pharmacological interventions. Though nonpharmacological measures are crucial for management, their implementation is questionable. Hence, this study was conducted to measure the effectiveness of lifestyle modifications on QoL among uncontrolled hypertensives and diabetics in rural India. Methods: An interventional study was done in 3 villages with 100 participants each, where village one received lifestyle modification as intervention and village two physical activity and village three control receiving standard care. The baseline data included socio-demographic characteristics such as awareness of hypertension, diabetes, lifestyle pattern and physical activity, and WHO QoL. The participants were trained, followed up, and assessed after 12 months following intervention. QoL scores between groups and pre- and post-intervention in the group were compared using Mann-Whitney U and Wilcoxon signed-rank test, respectively. Results: In this study, there was a significant improvement in overall QoL and in all the four domains, namely physical, psychological, social relationship, and environmental domains in both the intervention villages. QoL was significantly better in both the intervention groups following intervention than compared to the control group. Conclusions: QoL improves with intervention on uncontrolled diabetics and hypertensives. It is time to emphasize on the collaboration among physicians and on the holistic integrative health services delivery for non-communicable diseases.

Assessment of Challenges and Opportunities and Identification of Approaches and Innovations in COVID-19 Pandemic Management by Different States in India: A Qualitative Approach.

OBJECTIVE: The primary objective of the study was to compare the challenges in implementing various COVID-19-related public health strategies and activities between the selected high health index and low health index states. The secondary objective was to identify the differently managed mechanisms adopted by the health-care delivery system across the states to maintain their functioning during the COVID-19 pandemic. SETTING: Eight states were divided into two groups; based on their health index and vulnerability index ranking-Kerala, Maharashtra, Gujarat, and Karnataka in top four (Group 1) and Delhi, Tripura, Rajasthan, and Orissa in bottom four states (Group 2). RESULTS: There was lack of private sector involvement in both the groups of the states, more so in Group 2. Although transport-related issues were similar in both groups, lack of provision of vehicles for transport for carrying out various COVID and non-COVID activities seemed to be more prominent in Group 2. More obstacles related to infrastructure were observed in Group 1 states. In terms of innovations, commonalities lay in convergence of multiple departments for monitoring, contact tracing, essential supplies, and transportation. Both groups managed routine health services and fund allocation with nearly equal vigour. Major challenges faced were related to human resource, policy management, transportation, routine health services, data management, and infrastructure. HR-related challenges in top four states included confusion due to frequent change in guidelines, unclear micro-containment, and testing guidelines. Discharge guidelines and SOPs related to home isolation of slum dwellers, inter-departmental cooperation and coordination issues faced in greater proportion in top four states; issues with fund allocation for local needs were faced by the Group 2 states. Innovations implemented to meet hurdles faced during the pandemic could be categorized under heads of 'human resource', 'community actions', 'policy management', 'inter-departmental coordination', 'use of technology and media', and 'fund allocations'. There was private-public partnership; use of other human resource for health-care delivery; use of technology for health-care delivery was seen in all states but more so in Group 1 states. CONCLUSION: States with higher health index and lower vulnerability index, i.e., Group 1 states faced fewer challenges than those in Group 2. Innovative measures taken at local level to tackle problems posed by the pandemic were unique to the situations presented to them and helped control the disease as effectively as they could.

A community-level educational intervention trail to study the impact of life style modification in control of hypertension and diabetes- A non-randomized trial (Before and after intervention study without control).

Background: Dietary habits and physical inactivity are related to the risks of non-communicable diseases (NCDs), such as cardiovascular diseases, Diabetes and Hypertension, of which burdens are increasing all over the world. . It is essential that lifestyle modification and nondrug treatment measures such as health education, reduction in weight through regular exercise, changing in eating patterns is essential to control of Diabetes and Hypertension. Hence the present study is taken up with objectives. Objectives: 1. to assess and compare the impact of health education on life style modification (diet modification) on control of hypertension and diabetes of intervention group. 2. To assess and compare the practice of changed pattern of life style modification (diet modification) of known hypertensives and diabetics with continuous health education module and follow up. Methodology: This community-level education intervention trial to reduce the burden of Non communicable diseases (hypertension and diabetes) was conducted in coastal Karnataka. The study was taken up in a rural area of coastal Karnataka . A specific module for physical activity, diet modification separately for hypertension and diabetics was prepared by experts and this specific module trained social worker introduced diet modification, exercise pattern and habits to the village enrolled participants with involvement of family member who actually cooks at home for 2 months. Results: In the study subjects, it was observed that, the subjects who had higher systolic and diastolic pressure before intervention, changed to the lower levels after intervention. Though the change in blood pressure is not statistically significant. The intervention of overall lifestyle intervention, there was increased subjects with Hb1Ac in the range of 7-9% and reduced subjects with Hb1Ac of >9.1%. Though it was not statistically significant. There was significant improvement in the mean duration of physical activity in order to control the hypertension and Diabetes mellitus. We also noticed that there was reduction in the sedentary hours, though the difference was not statistically significant. Conclusion: Life style intervention with continuous monitoring is essential to bring down the blood pressure and diabetic sugars. We donot need doctors alone to bring the life style modifications and the health workers can initiate it in the villages. The intervention of life style modifications have brought in better care and quality of life in the villages compared to control village.

Challenges and solutions adopted by frontline health managers in the management of routine health services during the COVID-19 pandemic at the grassroots level in India: A qualitative quest.

Background: The public health emergency due to COVID-19 has placed an immense burden on the health care system. The strain for provision of health care services has also extended to routine services. The future impact of this decline in facility provision can be seen in morbidity and mortality indicators of the country. In a time when the country is working toward meeting the sustainable development goals (SDGs), COVID-19 has become a setback. Objective: This study tries to find the very challenges faced by frontline workers and the measures adopted to overcome the same. Materials and Methods: This was a mixed methods study conducted at various selected states across the country based on their vulnerability index. Data was collected via in-depth interviews among 120 frontline managers. Transcribed responses were coded. Framework analysis with preformed codes were done. Quantitative data are represented as frequencies and percentages. Results: Analysis showed increased work pressure, innovative approach adopted locally, and allaying fear by reinstating services helped as coping mechanisms to take care of routine health care services at the grassroots level. Conclusions: The conscious effort of all involved with the use of local solutions and innovations, along with intersectoral coordination and efficient use of resources paved the way for a good deliverance of health care to the society. The frontline managers minimized the damage by using available resources consciously and wisely.

Dietary Risk with Other Risk Factors of Breast Cancer.

Breast cancer is one of the most common and feared cancers. The incidence of breast cancer is persistently on the rise due to urbanization and lifestyle changes. Breast cancer cannot be prevented fully but can be effectively treated and controlled if risk factors are determined accurately. Detection of breast cancer at an early stage along with the advancement in treatment options has provided a greater chance of survival. OBJECTIVES: The objective of the study was (a) To determine the most common risk factors of breast cancer in women and (b) to identify the risk ratio of dietary risk factors among breast cancer patients. METHODOLOGY: A hospital-based case-control study was conducted at a tertiary care center in coastal Karnataka, India. RESULTS: Total 240 participants were included in the study, 120 cases and 120 controls, who were matched by ± 2-year age range. All the study participants were between 34 and 70 years of age group; the occurrence of breast cancer was found more among females within the normal range of body mass index and with a history of breast cancer among first-degree relatives. A statistically significant association was found with consumption of red meat, fatty food consumption, and bad dietary habit. CONCLUSION: High fat-low fiber diet is the most important risk factor for breast Cancer.

Provision of Care Following Road Traffic Injuries in a District in South India: A Qualitative Analysis of Stakeholder Perspective.

INTRODUCTION: It is essential to explore ways to prevent and reduce the severity of injuries in road crashes. This study attempts at getting a ground-level understanding of perspectives surrounding road traffic injury among various stakeholders. MATERIALS AND METHODS: In-depth interviews and focused group discussions were conducted over a period of 6 months among traffic police, toll booth operators, road transport officers, nurses, and intensive care specialists. The transcribed data were coded and analyzed, and a percentage of final themes as well as codes were drawn. RESULTS: The common reasons cited for delay in transport of accident victims were fear regarding medicolegal issues among the first responders (36.9%) and delay in ambulance (41.5%). 26.1% agreed that time delay in transport can be reduced by generating awareness. Teaching first aid to the general public is essential as opined by 75% of nursing staff and 66.7% of emergency physicians. Documentation procedures (15.4%), long waiting hours (10.2%), and out-of-pocket expenditure and financial constraints (10.2%) were the commonly cited reasons for problems faced by patient bystanders. CONCLUSIONS: Creating awareness and improving access to ambulance were the two essential recommendations to prevent delay in prehospital care. Majority of the care providers and patient bystanders agreed that improving insurance coverage is essential to reduce financial constraints.

Epidemiological Correlates of Psychological Distress in a Rural Community of South India: A Cross-sectional Study.

CONTEXT: Integration of mental health into primary care is essential to establish access to mental health services. Screening the community for psychological distress is the first step. AIMS: The aim of the study was to estimate the burden and the determinants of psychological distress in a rural community. SETTINGS AND DESIGN: This was a community-based cross-sectional study among adult members of a rural community of Nitte Village in Udupi district in Karnataka, South India. METHODOLOGY: Three hundred and ten households were surveyed using the World Health Organization Self-Reported Questionnaire (SRQ). A cutoff value of 8 in SRQ was taken as screening positive. STATISTICAL ANALYSIS USED: Descriptive data were analyzed in proportions, whereas Chi-square test and regression analysis were used to explore associations. RESULTS: Hypertension and diabetes were the two common comorbidities. The prevalence of psychological distress was 42.4 per thousand. "Being easily tired" and "feeling tired all the time" were the two most common responses out of the SRQ checklist. Distress was significantly associated with gender, educational status, and marital status. CONCLUSIONS: The prevalence of psychological distress was 42.4 per thousand, and somatic complaints were common presentations of distress in the study population.

Violence against Educated Women by Intimate Partners in Urban Karnataka, India.

BACKGROUND: Initially viewed as a human rights issue, partner violence is increasingly seen as an important public health problem of international concern. OBJECTIVES: To assess the extent of physical, sexual, psychological, and controlling behavior of intimate partners against women in an educated society and find the association with age, age of marriage, married years, educational status of the women and that of partner. MATERIALS AND METHODS: A prevalence of 15% was taken and final sample was 200, after considering loss of follow-up. STATISTICAL METHODS: Proportion, Z-test, Chi-square test. RESULTS: The prevalence of violence against intimate partner in educated society was found to be 40.5% in a South Indian city. Physical assault was high in 30-50 years and increased with duration of marriage from 5.5% at 5 years to 33.3% in 10-20 years of married life. Sexual and psychological assault also increased in <5 years of married life to 35% and 47.6% in 10-20 years duration of marriage, which was statistically significant. Sexual and psychological assault showed a bimodal presentation. Less educated women and their partners were found to report more violence, which was statistically significant. CONCLUSION: Violence against women is not uncommon in the educated society.

Proportion of depression among the elderly population in a rural health care setting.

INTRODUCTION: Depression among elderly has serious public health implications. Integration of mental health into primary care may help in reaching the elderly population better and in identifying depression among them. OBJECTIVES: This study was done to determine the proportion and the correlates of depression among the elderly population which attended the rural psychiatry services and to compare the proportion with that of the middle aged population. MATERIAL AND METHODS: The outpatient data of the past one year in the rural psychiatry centre was analysed. Correlates of depression among the elderly were studied by Chi square test and the proportion in elderly was compared with that of the middle aged population using Z-test. RESULTS AND CONCLUSION: Depression among the elderly attendees was significantly higher than that in the middle aged group. Depression was more common among the young old and females and co-morbidities were more commonly seen in males and the young old compared to those who were aged 80 years and above.

Prevalence and patterns of demyelinating central nervous system disorders in urban Mangalore, South India.

There is a dearth of epidemiological data about multiple sclerosis (MS) and related demyelinating disorders in India. In this study, a registry method was used for collecting data from secure sources and the index cases were verified Seventy nine patients were identified . A crude prevalence of 8.3/100,000 was obtained for MS and 6.2/100,000 for clinically-isolated syndrome (CIS). Age-standardized prevalence of MS relative to the world population was 7.8/100,000. Neuromyelitis optica (NMO) and spectrum disorders (NMOS) constituted 13.9% of all demyelinating disorders, with a prevalence of 2.6/100,000. Larger studies with more refined survey methodologies are required to understand the true prevalence of demyelinating disorders in India.

Self-medication patterns among medical students in South India.

BACKGROUND: Self-medication results in wastage of resources, increases resistance of pathogens and generally causes serious health hazards such as adverse drug reactions, prolonged suffering and drug dependence. This study was undertaken to determine the reasons for self-medication and the pattern of self-medication among medical students. METHOD: This cross-sectional descriptive study was conducted at the K.S. Hegde Medical Academy, Mangalore. The participants were medical students from first to final year. Medical students were selected through convenience sampling. The data was collected using a pre-tested semi-structured questionnaire. The data was analysed using SPSS version 16 and the results expressed as proportions. RESULTS: A total of 200 students, 121 (60.5%) female and 79 (39.5%) male, were included in the study. Of the medical students surveyed, self-medication was reported among 92%. The respondents who used self-medication found it to be time- saving in providing relief from minor ailments. The most common ailments for which self-medication were used were: the common cold (69%), fever (63%) and headache (60%). The students consulted their textbooks (39%) and seniors or classmates (38%) for the medications. Antipyretics (71%), analgesics (65%), antihistamines (37%) and antibiotics (34%) were the most common self- medicated drugs. Of the respondents, 33% were unaware of the adverse effects of the medication and 5% had experienced adverse reactions. The majority (64%) of students advised medications to others, more often to family and friends. CONCLUSION: The prevalence of self-medication among medical students is high, facilitated by the easy availability of drugs and information from textbooks or seniors. A significant number of students are unaware of the adverse effects of the medication that they themselves take and suggest to others. Therefore, potential problems of self-medication should be emphasised to the students.