Area-level deprivation and individual-level socioeconomic correlates of the diabetes care cascade among black south africans in uMgungundlovu, KwaZulu-Natal, South Africa.

South Africa is experiencing a rapidly growing diabetes epidemic that threatens its healthcare system. Research on the determinants of diabetes in South Africa receives considerable attention due to the lifestyle changes accompanying South Africa's rapid urbanization since the fall of Apartheid. However, few studies have investigated how segments of the Black South African population, who continue to endure Apartheid's institutional discriminatory legacy, experience this transition. This paper explores the association between individual and area-level socioeconomic status and diabetes prevalence, awareness, treatment, and control within a sample of Black South Africans aged 45 years or older in three municipalities in KwaZulu-Natal. Cross-sectional data were collected on 3,685 participants from February 2017 to February 2018. Individual-level socioeconomic status was assessed with employment status and educational attainment. Area-level deprivation was measured using the most recent South African Multidimensional Poverty Index scores. Covariates included age, sex, BMI, and hypertension diagnosis. The prevalence of diabetes was 23% (n = 830). Of those, 769 were aware of their diagnosis, 629 were receiving treatment, and 404 had their diabetes controlled. Compared to those with no formal education, Black South Africans with some high school education had increased diabetes prevalence, and those who had completed high school had lower prevalence of treatment receipt. Employment status was negatively associated with diabetes prevalence. Black South Africans living in more deprived wards had lower diabetes prevalence, and those residing in wards that became more deprived from 2001 to 2011 had a higher prevalence diabetes, as well as diabetic control. Results from this study can assist policymakers and practitioners in identifying modifiable risk factors for diabetes among Black South Africans to intervene on. Potential community-based interventions include those focused on patient empowerment and linkages to care. Such interventions should act in concert with policy changes, such as expanding the existing sugar-sweetened beverage tax.

Child and adolescent mental health and psychosocial support interventions: An evidence and gap map of low- and middle-income countries.

Background: Mental disorders affect about one in seven children and adolescents worldwide. Investment in effective child and adolescent mental health prevention, promotion and care is essential. To date, however, the evidence from this field is yet to be comprehensively collected and mapped. Objectives: The objective of this evidence and gap map (EGM) is to provide an overview of the existing evidence on the effectiveness of interventions aimed at promoting mental health and reducing or preventing mental health conditions among children and adolescents in lower-middle-income countries (LMICs). Search Methods: We searched for studies from a wide range of bibliographic databases, libraries and websites. All searches were conducted in December 2021 and covered the period between 2010 and 2021. Selection Criteria: We included evidence on the effectiveness of any Mental Health and Psychosocial Support (MHPSS) interventions targeting children and adolescents from 0 to 19 years of age in LMICs. The map includes systematic reviews and effectiveness studies in the form of randomised control trials and quasi-experimental studies, and mixed-methods studies with a focus on intervention effectiveness. Data Collection and Analysis: A total of 63,947 records were identified after the search. A total of 19,578 records were removed using machine learning. A total of 7545 records were screened independently and simultaneously by four reviewers based on title and abstract and 2721 full texts were assessed for eligibility. The EGM includes 697 studies and reviews that covered 78 LMICs. Main Results: School-based interventions make up 61% of intervention research on child and adolescent mental health and psychosocial support. Most interventions (59%) focusing on treating mental health conditions rather than preventing them or promoting mental health. Depression (40%, N = 282) was the most frequently researched outcome sub-domain analysed by studies and reviews, followed by anxiety disorders (32%, N = 225), well-being (21%, N = 143), and post-traumatic stress disorder (18%, N = 125). Most included studies and reviews investigated the effectiveness of mental health and psychosocial support interventions in early (75%, N = 525) and late adolescence (64%, N = 448). Conclusions: The body of evidence in this area is complex and it is expanding progressively. However, research on child and adolescent MHPSS interventions is more reactive than proactive, with most evidence focusing on addressing mental health conditions that have already arisen rather than preventing them or promoting mental health. Future research should investigate the effectiveness of digital mental health interventions for children and adolescents as well as interventions to address the mental health and psychosocial needs of children in humanitarian settings. Research on early childhood MHPSS interventions is urgently needed. MHPSS research for children and adolescents lacks diversity. Research is also needed to address geographical inequalities at the regional and national level. Important questions also remain on the quality of the available research-is child and adolescent MHPSS intervention research locally relevant, reliable, well-designed and conducted, accessible and innovative? Planning research collaborations with decision-makers and involving experts by experience in research is essential.

Racial disparities in psychological distress in post-apartheid South Africa: results from the SANHANES-1 survey.

PURPOSE: South Africa has long endured a high prevalence of mental disorders at the national level, and its unique social and historical context could be a contributor to an increased risk of mental health problems. Our current understanding is limited regarding the relative importance of various social determinants to mental health challenges in South Africa, and how existing racial inequities may be explained by these determinants. METHODS: This study attempted to elucidate potential social determinants of mental health in South Africa using data from the nationally representative South African National Health and Nutrition Examination Survey (SANHANES-1). The main outcome of interest was psychological distress, measured with the Kessler-10 scale. Hierarchical linear regression models included covariates for demographic and socioeconomic factors, count of traumatic events, and a series of stress-related constructs. Analyses were conducted on two populations: the entire sample (n = 15,981), and the African subpopulation (n = 10,723). RESULTS: Regression models on the entire sample indicated racial disparities in psychological distress, with Africans experiencing higher distress than White and Coloured individuals. Results within the African sub-population indicated geo-spatial disparities, with Africans in formal urban settings experiencing higher psychological distress than those living in formal and informal rural locales. Across both samples, results indicated a cumulative association between count of stressors and traumatic events and distress. CONCLUSION: We found racial disparities across several mental health-related domains. Africans had greater exposure to traumatic events, social stressors, and psychological distress. This research is a necessary foundation for public health interventions and policy change to effectively reduce inequities in psychological distress.

An Opportunity to END TB: Using the Sustainable Development Goals for Action on Socio-Economic Determinants of TB in High Burden Countries in WHO South-East Asia and the Western Pacific Regions.

The progress towards ending tuberculosis (TB) by 2035 is less than expected in 11 high TB burden countries in the World Health Organization South-East Asia and Western Pacific regions. Along with enhancing measures aimed at achieving universal access to quality-assured diagnosis, treatment and prevention services, massive efforts are needed to mitigate the prevalence of health-related risk factors, preferably through broader actions on the determinants of the "exposure-infection-disease-adverse outcome" spectrum. The aim of this manuscript is to describe the major socio-economic determinants of TB and to discuss how there are opportunities to address these determinants in an englobing manner under the United Nations Sustainable Development Goals (SDGs) framework. The national TB programs must identify stakeholders working on the other SDGs, develop mechanisms to collaborate with them and facilitate action on social-economic determinants in high TB burden geographical areas. Research (to determine the optimal mechanisms and impact of such collaborations) must be an integral part of this effort. We call upon stakeholders involved in achieving the SDGs and End TB targets to recognize that all goals are highly interlinked, and they need to combine and complement each other's efforts to end TB and the determinants behind this disease.

Depressive symptoms and use of health services among older adults in Israel.

OBJECTIVES: Depressive symptoms are often undetected, particularly among older adults. The purpose of this study is to provide information on the prevalence, characteristics, and patterns of depressive symptoms among older adults residing in the community in Israel, and their health-care utilization. METHODS: A cross-sectional survey was conducted among a random sample of 2502 members of one HMO in Israel, aged 65+. They were interviewed by telephone with the GDS-15 scale, which serves as the gold standard for depressive symptoms. Data from the computerized medical records of the HMO were added to the interview file, including the diagnosis of depression, purchase of antidepressant medication and use of services. RESULTS: The average age of respondents was 73; 54% were women. They tended to be older, living alone, suffering from falls and from sleep disorders, and to have poor subjective health status. 24% scored 6+ on the GDS scale. A significant association was found between a GDS score of 6+ and increased hospitalizations, visits to the emergency room and/or to family physicians and specialists. CONCLUSION: We found a high prevalence of depression. Its negative effects on the individual and increased costs to the health system, supports the screening and treatment of the disease in the older population. This problem should be a national priority, with screening and treatment becoming part of the national quality of care indicators which would then be implemented by the HMOs as part of an integrated disease management program for the elderly.

Do income inequalities in higher weight status depend on social integration?

Those with higher incomes tend to have better health outcomes, including healthy weight status. We use data from the 2003-2008 National Health and Nutrition Examination Survey (NHANES) to examine whether the association between higher weight status and social integration varies by income. We examine gender differences in weight status, measured by BMI and obesity, by social integration and income, and find evidence that high social integration is a risk factor for higher weight status among low-income men. The association between income and higher weight status operates differently for women and men and is dependent, in part, on their level of social integration. Income is negatively associated with weight status for men who are highly integrated, but is positively associated with weight status among men who have low integration. We conclude that higher numbers of close friends and family places low-income men at greater risk of higher weight status.

HIV-infected presumptive tuberculosis patients without tuberculosis: How many are eligible for antiretroviral therapy in Karnataka, India?

For certain subgroups within people living with the human immunodeficiency virus (HIV) [active tuberculosis (TB), pregnant women, children <5years old, and serodiscordant couples], the World Health Organization recommends antiretroviral therapy (ART) irrespective of CD4 count. Another subgroup which has received increased attention is "HIV-infected presumptive TB patients without TB". In this study, we assess the proportion of HIV-infected presumptive TB patients eligible for ART in Karnataka State (population 60million), India. This was a cross-sectional analysis of data of HIV-infected presumptive TB patients diagnosed in May 2015 abstracted from national TB and HIV program records. Of 42,585 presumptive TB patients, 28,964 (68%) were tested for HIV and 2262 (8%) were HIV positive. Of the latter, 377 (17%) had active TB. Of 1885 "presumptive TB patients without active TB", 1100 (58%) were already receiving ART. Of the remaining 785 who were not receiving ART, 617 (79%) were assessed for ART eligibility and of those, 548 (89%) were eligible for ART. About 90% of "HIV-infected presumptive TB patients without TB" were eligible for ART. This evidence supports a public health approach of starting all "HIV-infected presumptive TB patients without TB" on ART irrespective of CD4 count in line with global thinking about 'test and treat'.

Should I stay or should I go? Fitness costs and benefits of prolonged parent-offspring and sibling-sibling associations in an Arctic-nesting goose population.

Theory predicts persistence of long-term family relationships in vertebrates will occur until perceived fitness costs exceed benefits to either parents or offspring. We examined whether increased breeding probability and survival were associated with prolonged parent-offspring and sibling-sibling relationships in a long-lived Arctic migrant herbivore, the Greenland white-fronted goose (Anser albifrons flavirostris). Although offspring associated with parents for 1-13 years, 79 % of these associations lasted two or less years. Only 65 (9.9 %) of the 656 marked offspring bred once in their lifetime, and just 16 (2.4 %) bred twice or more. The probability of birds with siblings breeding successfully in a subsequent year was credibly greater than that of independent birds at ages 5, 6, and 7. Survival of offspring with parents was credibly greater than that of independent/nonbreeder birds at all possible ages (i.e., ages 2-7+). A cost-benefit matrix model utilizing breeding and survival probabilities showed that staying with family groups was favored over leaving until age 3, after which there were no credible differences between staying and leaving strategies until the oldest ages, when leaving family groups was favored. Thus, most birds in this study either departed family groups early (e.g., at age 2, when the "stay" strategy was favored) or as predicted by our cost-benefit model (i.e., at age 3). Although extended family associations are a feature of this population, we contend that the survival benefits are not sufficient enough to yield clear fitness benefits, and associations only persist because parents and offspring mutually benefit from their persistence.

Teaching and addressing health disparities through the family medicine social and community context of care project.

By training future physicians to care for patients with backgrounds different from their own, medical schools can help reduce health disparities. To address the need for education in this area, the leaders of the Family Medicine Clerkship at the Warren Alpert Medical School of Brown University developed the Social and Community Context of Care project, required of all medical students rotating through this clerkship. Students develop a hypothetical intervention addressing a health issue seen at their preceptor site, and are assessed on their grasp of the social and contextual issues affecting that health issue in their particular community. Some interventions are actualized in later clerkships or independent study projects; one example, a health class for pregnant and parenting teens at Central Falls High School, is described here. If made a routine part of medical education, projects such as these may help medical students address the health disparities they will encounter in future practice.

Building a workforce of physicians to care for underserved patients.

There is a shortage of physicians to care for underserved populations. Medical educators at The Warren Alpert Medical School of Brown University have used five years of Health Resources and Services Administration funding to train medical students to provide outstanding primary care for underserved populations. The grant has two major goals: 1) to increase the number of graduating medical students who practice primary care in underserved communities ("Professional Development"); and 2) to prepare all medical school graduates to care for underserved patients, regardless of specialty choice ("Curriculum Development"). Professional Development, including a new scholarly concentration and an eight-year primary care pipeline, has been achieved in partnership with the Program in Liberal Medical Education, the medical school's Admissions Committee, and an Area Health Education Center. Curriculum Development has involved systematic recruitment of clinical training sites and disease-specific curricula including tools for providing care to vulnerable populations. A comprehensive, longitudinal evaluation is ongoing.

The relationship between socio-economic inequalities, intimate partner violence and economic abuse: a national study of women in the Philippines.

Economic abuse against women has for too long remained a relatively 'unseen' part of interpersonal violence, in spite of intimate partner violence (IPV) being a public health problem. Most studies on economic abuse derive especially from the USA and amongst women in shelters, and their findings are not easily generalisable to low-middle-income countries. Socio-economic inequalities render women vulnerable to control and risk of abuse. We investigated the role of socio-economic inequalities in the association between IPV and economic abuse. Logistic regression analyses were performed on cross-sectional data from a nationally representative sample of 8478 women aged 15-49 years in the 2008 Philippines Demographic and Health Surveys. Results indicated strong positive associations between both physical IPV and emotional IPV and all four forms of economic abuse. Measures of socio-economic inequalities and other covariates such as no education, primary education, unemployment and justifying wife beating were also statistically significant. Findings suggest the increased need for health care practitioners to include economic abuse during the assessment of and response to IPV, the implementation of a multidimensional approach to providing tangible support and women-centred responses in reported cases of economic abuse, as well as measures that enhance socio-economic equality and increase economic opportunities for women.

Cardiac risk factors: environmental, sociodemographic, and behavioral cardiovascular risk factors.

Several environmental exposures are associated with increased risk of coronary heart disease (CHD). Exposure to secondhand smoke may increase the risk by as much as 25% to 30%. Exposure to third hand smoke, residual components of tobacco smoke that remain in the environment after a cigarette is extinguished, also appears to increase risk. These residual components can remain in rooms and automobiles for up to 30 years and enter the body through the skin or via inhalation or ingestion. Exposure to particulate matter air pollution from automobile emissions, power plants, and other sources is yet another environmental risk factor for CHD, resulting in tens of thousands of deaths annually in the United States. Exposure to other environmental toxins, particularly bisphenol A and phthalates, also has been linked to CHD. There are sociodemographic risks for CHD, with numerous studies showing that lower socioeconomic status is associated with higher risk. Behavioral risk factors include poor diet, such as frequent consumption of fast food and processed meals; sleep disturbance; and psychological stress, particularly related to marital or work issues. Finally, although high alcohol consumption is associated with increased CHD risk, moderate alcohol consumption (ie, less than 1 to 2 drinks/day), particularly of wine and possibly beer, appears to reduce the risk.

Do we pay our community preceptors? Results from a CERA clerkship directors' survey.

BACKGROUND AND OBJECTIVES: Family medicine clerkships depend heavily on community-based family physician preceptors to teach medical students. These preceptors have traditionally been unpaid, but in recent years some clerkships have started to pay preceptors. This study determines trends in the number and geographic region of programs that pay their community preceptors, identifies reasons programs pay or do not pay, and investigates perceived advantages and disadvantages of payment. METHODS: We conducted a cross-sectional, electronic survey of 134 family medicine clerkship directors at allopathic US medical schools. RESULTS: The response rate was 62% (83/132 clerkship directors). Nineteen of these (23%) currently pay community preceptors, 11 of whom are located in either New England or the South Atlantic region. Sixty-three percent of programs who pay report that their community preceptors are also paid for teaching other learners, compared to 32% of those programs who do not pay. Paying respondents displayed more positive attitudes toward paying community preceptors, though a majority of non-paying respondents indicated they would pay if they had the financial resources. CONCLUSIONS: The majority of clerkships do not pay their community preceptors to teach medical students, but competition from other learners may drive more medical schools to consider payment to help with preceptor recruitment and retention. Medical schools located in regions where there is competition for community preceptors from other medical and non-medical schools may need to consider paying preceptors as part of recruitment and retention efforts.

Child survival: a message of hope but a call for renewed commitment in UNICEF report.

A recent UNICEF report Committing to Child Survival: A Promise Renewed Progress Report 2013 presents a comprehensive analysis of levels and trends in child mortality and progress towards MDG 4. The global under-five mortality rate has been cut nearly in half (47%) since 1990. However, during this same period, 216 million children are estimated to have died before their fifth birthday. Most of these deaths were from leading infectious diseases such as pneumonia, diarrhoea or malaria, or were caused by preventable neonatal causes such as those related to intra-partum complications. The highest mortality rates in the world are observed in low-income countries in sub-Saharan Africa and South Asia. Sub-Saharan Africa faces a particular challenge in that it not only has the highest under-five mortality in the world but it also has the fastest population growth. Progress is possible, however, and sharp reductions in child mortality have been observed at all levels of national income and in all regions. Some of the world's poorest countries in terms of national income have made the strongest gains in child survival. Within countries, new analysis suggests that disparities in under-five mortality between the richest and the poorest households have declined in most regions of the world, with the exception of Sub-Saharan Africa. Furthermore, under-five mortality rates have fallen even among the poorest households in all regions. The report highlights the growing importance of neonatal deaths; roughly 44% of global under-five deaths - now 2.9 million a year - occur during the neonatal period, with up to 50% dying during their first day of life and yet over two-thirds of these deaths are preventable without intensive care. The report stresses how a continuum of care approach across the whole life cycle is the most powerful way of understanding and accelerating further progress.

Socioeconomic status and gender affects utilization of Medical Nutrition Therapy.

AIMS: To identify socioeconomic status and gender inequalities in long and short-term Medical Nutrition Therapy among Israeli adult patients with diabetes. METHODS: An analysis of data was performed on 90,900 patients over the age of 18 who were registered as patients with diabetes mellitus in Maccabi Healthcare Service Register which is the second largest health maintenance organization in Israel. Socioeconomic Rank for each patient was determined from the Israel Central Bureau of Statistics by geographical area of residence. Medical Nutrition Therapy was defined by the number of visits with registered dietitians. Short-term therapy was defined as one visit and long term therapy as two or more visits during the previous two years. Newly diagnosed patients were compared with veteran patients. RESULTS: Only 25.8% of the patients with diabetes received nutrition therapy during the previous two years. Newly diagnosed patients received therapy more frequently than veterans. We found that long term therapy was positively dependent on socioeconomic rank. Women under the age of seventy five had a higher chance of receiving therapy compared to men. CONCLUSIONS: A nationwide nutritional counseling service is available and accessible to all patients with diabetes. However, the patients with higher socioeconomic rank have a higher rate of persistence with long-term nutritional therapy.

Strategies to improve health coverage and narrow the equity gap in child survival, health, and nutrition.

Implementation of innovative strategies to improve coverage of evidence-based interventions, especially in the most marginalised populations, is a key focus of policy makers and planners aiming to improve child survival, health, and nutrition. We present a three-step approach to improvement of the effective coverage of essential interventions. First, we identify four different intervention delivery channels--ie, clinical or curative, outreach, community-based preventive or promotional, and legislative or mass media. Second, we classify which interventions' deliveries can be improved or changed within their channel or by switching to another channel. Finally, we do a meta-review of both published and unpublished reviews to examine the evidence for a range of strategies designed to overcome supply and demand bottlenecks to effective coverage of interventions that improve child survival, health, and nutrition. Although knowledge gaps exist, several strategies show promise for improving coverage of effective interventions-and, in some cases, health outcomes in children-including expanded roles for lay health workers, task shifting, reduction of financial barriers, increases in human-resource availability and geographical access, and use of the private sector. Policy makers and planners should be informed of this evidence as they choose strategies in which to invest their scarce resources.

From where are tuberculosis patients accessing treatment in India? Results from a cross-sectional community based survey of 30 districts.

BACKGROUND: Tuberculosis (TB) notification in India by the Revised National TB Control Programme (RNTCP) provides information on TB patients registered for treatment from the programme. There is limited information about the proportion of patients treated for TB outside RNTCP and where these patients access their treatment. OBJECTIVES: To estimate the proportion of patients accessing TB treatment outside the RNTCP and to identify their basic demographic characteristics. METHODS: A cross sectional community-based survey in 30 districts. Patients were identified through a door-to-door survey and interviewed using a semi-structured questionnaire. RESULTS: Of the estimated 75,000 households enumerated, 73,249 households (97.6%) were visited. Of the 371,174 household members, 761 TB patients were identified (∼205 cases per 100,000 populations). Data were collected from 609 (80%) TB patients of which 331 [54% (95% CI: 42-66%)] were determined to be taking treatment 'under DOTS/RNTCP'. The remaining 278 [46% (95% CI: 34-57%)] were on treatment from 'outside DOTS/RNTCP' sources and hence were unlikely to be part of the TB notification system. Patients who were accessing treatment from 'outside DOTS/RNTCP' were more likely to be patients from rural areas [adjusted Odds Ratio (aOR) 2.5, 95% CI (1.2-5.3)] and whose TB was diagnosed in a non-government health facility (aOR 14.0, 95% CI 7.9-24.9). CONCLUSIONS: This community-based survey found that nearly half of self-reported TB patients were missed by TB notification system in these districts. The study highlights the need for 1) Reviewing and revising the scope of the TB notification system, 2) Strengthening and monitoring health care delivery systems with periodic assessment of the reach and utilisation of the RNTCP services especially among rural communities, 3) Advocacy, communication and social mobilisation activities focused at rural communities with low household incomes and 4) Inclusive involvement of all health-care providers, especially providers of poor rural communities.

Promoting emergency medical care systems in the developing world: weighing the costs.

Despite the global health community's historical focus on providing basic, cost-effective primary health care delivered at the community level, recent trends in the developing world show increasing demand for the implementation of emergency care infrastructures, such as prehospital care systems and emergency departments, as well as specialised training programmes. However, the question remains whether, in a setting of limited global health care resources, it is logical to divert these already-sparse resources into the development of emergency care frameworks. The existing literature overwhelmingly supports the idea that emergency care systems, both community-based and within medical institutions, improve important outcomes, including significant morbidity and mortality. Crucial to the success of any public health or policy intervention, emergency care systems also seem to be strongly desired at the community and governmental levels. Integrating emergency care into existing health care systems will ideally rely on modest, low-cost steps to augment current models of primary health care delivery, focusing on adapting the lessons learned in the developed world to the unique needs and local variability of the rest of the globe.

A reengineered hospital discharge program to decrease rehospitalization: a randomized trial.

BACKGROUND: Emergency department visits and rehospitalization are common after hospital discharge. OBJECTIVE: To test the effects of an intervention designed to minimize hospital utilization after discharge. DESIGN: Randomized trial using block randomization of 6 and 8. Randomly arranged index cards were placed in opaque envelopes labeled consecutively with study numbers, and participants were assigned a study group by revealing the index card. SETTING: General medical service at an urban, academic, safety-net hospital. PATIENTS: 749 English-speaking hospitalized adults (mean age, 49.9 years). INTERVENTION: A nurse discharge advocate worked with patients during their hospital stay to arrange follow-up appointments, confirm medication reconciliation, and conduct patient education with an individualized instruction booklet that was sent to their primary care provider. A clinical pharmacist called patients 2 to 4 days after discharge to reinforce the discharge plan and review medications. Participants and providers were not blinded to treatment assignment. MEASUREMENTS: Primary outcomes were emergency department visits and hospitalizations within 30 days of discharge. Secondary outcomes were self-reported preparedness for discharge and frequency of primary care providers' follow-up within 30 days of discharge. Research staff doing follow-up were blinded to study group assignment. RESULTS: Participants in the intervention group (n = 370) had a lower rate of hospital utilization than those receiving usual care (n = 368) (0.314 vs. 0.451 visit per person per month; incidence rate ratio, 0.695 [95% CI, 0.515 to 0.937]; P = 0.009). The intervention was most effective among participants with hospital utilization in the 6 months before index admission (P = 0.014). Adverse events were not assessed; these data were collected but are still being analyzed. LIMITATION: This was a single-center study in which not all potentially eligible patients could be enrolled, and outcome assessment sometimes relied on participant report. CONCLUSION: A package of discharge services reduced hospital utilization within 30 days of discharge. FUNDING: Agency for Healthcare Research and Quality and National Heart, Lung, and Blood Institute, National Institutes of Health.