The international Family Affluence Scale (FAS): Charting 25 years of indicator development, evidence produced, and policy impact on adolescent health inequalities.

In the absence of suitable indicators of adolescent socioeconomic status, the Family Affluence Scale (FAS) was first developed in Scotland 25 years ago. Since then, it has been adapted for use in the Health Behaviour in School-Aged Children (HBSC) Study to research inequalities in adolescent health in Europe and North America. FAS has also been used as an indicator of adolescent socioeconomic status in research studies outside of HBSC, worldwide. There has been a need for FAS to evolve and change its component items over time in order to take into account social and technological changes influencing the families of adolescents. This paper uniquely charts the development of FAS describing the methodological work carried out to validate the measure internationally and over time. It also presents an overview of the body of evidence on adolescent health inequalities produced over years from the HBSC Study and other research studies. Interviews conducted with policy stakeholders reveal that the evidence from FAS-related HBSC work has influenced their strategic work to raise awareness of inequalities and make the case for action to address these. Finally, the future of FAS is discussed with respect to its continual evolution in the context of technological, environmental and social change.

The Impact of Blood Glucose Test Strips Reimbursement Limits on Utilization, Costs, and Health-care Utilization in British Columbia.

OBJECTIVE: People living with diabetes and not using insulin may not derive clinically significant benefit from routine glucose self-monitoring. As a result, in 2015, British Columbia (BC) introduced quantity restrictions for blood glucose test strips (BGTS) coverage in public plans. We studied the impact of this policy on utilization, costs, and health-care utilization. METHODS: We identified a cohort of adults (≥18 years old) with diabetes between 2013 and 2019. Using BC's administrative data, we studied utilization and costs among individuals with at least one PharmaCare-eligible BGTS claim. Using interrupted time-series analysis, we studied cost savings and determined the level of policy adherence. In addition, we investigated longitudinal changes in all-cause and diabetes-specific physician visits, all-cause hospitalizations, and health-care spending in the 3 to 5 years after policy implementation. RESULTS: Over the study period, 279.7 million BGTS were eligible for PharmaCare coverage, on which the government spent $124.3 million. After policy implementation, we observed an immediate decline in average utilization and PharmaCare expenditure on BGTS, leading to an estimated $44.6 million in savings between 2015 and 2019 (95% confidence interval $16.9 to $72.3 million). We found no association between the policy's implementation and health services utilization or overall health-care spending over the long term. CONCLUSIONS: Restricting reimbursement for BGTS in BC resulted in significant cost savings without any attendant increase in health services utilization over the subsequent 5 years. This disinvestment freed up resources that could be channeled toward other interventions.

Policy analysis of the protection of Iranian households against catastrophic health expenditures: a qualitative analysis.

BACKGROUND: Despite the adoption of various policies and strategies in recent decades, the Iranian health system has not succeeded in protecting households against catastrophic health expenditures (CHE) and impoverishment. Accordingly, this qualitative study aimed to critically analyze current policies for reducing CHE. METHODS: This qualitative study was conducted as a retrospective policy analysis based on a document review and semi-structured interviews with key informants between July to October 2022. Two theoretical frameworks were used, including the Analysis of Determinants of Policy Impact (ADEPT) model and Walt and Gilson's "Policy Triangle framework." The country's related documents were searched through databases. In total, 35 participants were interviewed. Interviews and documents were analyzed using directed content analysis in MAXQDA v12 software. Interobserver reliability, peer check, and member check were done to confirm the trustworthiness of the data. RESULTS: Twelve main themes and 42 sub-themes emerged from the data. The findings revealed that policy accessibility, policy background, and a clear statement of goals influenced the policy process. However, resources, monitoring and evaluation, opportunities, and obligations negatively affected the implementation process. In addition, a policy analysis based on the policy triangle framework demonstrated that the main factors affecting the policy on reducing CHE in Iran were "conflicts of interest," "contextual factors," "monitoring and evaluation," and "intersectoral relationship" factors. CONCLUSION: The present study reflected the multifaceted nature of the barriers to reducing CHE in Iran. The implementation of the policy on reducing CHE requires the political will to improve intersectoral collaboration, strengthen the stewardship role of the Ministry of Health, design monitoring and evaluation mechanisms, and prevent personal and organizational conflicts of interest.

China's experience in developing green finance to reduce carbon emissions: from spatial econometric model evidence.

The objective of this study is to attempt to assess the effect of green finance in reducing carbon emissions in China, analyze the transformative role of policy impact in the development of green finance markets, and investigate the impact mechanisms of how green finance affects carbon dioxide emissions. Our time frame from 2007 to 2018 is selected for the empirical study by integrating the availability of data due to the scarcity of relevant statistics in the early days of green finance. Location of this study is in China where 30 provinces are included, excluding Tibet due to severe data shortage. As for methodology, we construct a green finance evaluation index system containing five indicators by entropy weight method, choose dynamic spatial Durbin model (DSDM) for empirical research, and perform mechanism analysis of restructuring industry and greening technology as intermediary channel. Our findings demonstrate that green finance in China does significantly reduce carbon emissions, and its spatial spillover effect and long-term effect are also verified. Furthermore, green finance tends to reduce CO2 emissions through restructuring industry and greening technology. Correspondingly, policy implications are recommended. First, improving green financial market and strengthening information disclosure of green financial market are crucial to facilitate green finance development. Local governments formulate carbon emission reduction strategies focusing on space by joint conference or coordination mechanism like river head system. Lastly, a mechanism should be developed to strengthen the transformation of industrial structure and to promote greening technology.

System dynamics modelling to simulate regional water-energy-food nexus combined with the society-economy-environment system in Hunan Province, China.

Nexus approaches provide an efficient way to analyze the dynamic evolution of the water-energy-food nexus (WEFN), yet there is a need to close the science-policy divide by making simulation models more practically relevant. This study incorporates society, economy and environment systems (SEE) into the WEFN, simulating a broad environmental system. A system dynamics model is constructed to simulate and dynamically track the development of the WEF-SEE system in Hunan Province, China. The developed model is applied to assess WEF-SEE system trajectories from 2021 to 2035 against nine policy goals formulated by the Hunan Provincial Government. Baseline results suggest that Hunan Province will have a surplus of grain production and will be in a state of "self-sufficiency" in water resources. The energy security situation is not as optimistic, with imports being required to meet demand. The sustainable development of the WEF Nexus will be constrained by resource shortages. As the future development of Hunan Province outpaces environmental protection policies, water pollution and CO2 emissions and are expected to increase. Intra-system trade-offs and synergies under the impacts of different policies indicate that the implementation of an indicative policy has the intended impact within its particular subsystem, but may lead to trade-offs in other subsystems. Due to system interconnectedness, the simultaneous implementation of multiple policies may increase or hinder progress towards certain goals. For example, expanding planting area increases food production, but increase agricultural water demand and water pollutant discharge, counter to water security goal and environmental protection goals. Cross-system impacts must be considered when choosing policies. This study advances environmental system analysis and evaluation, and contributes to practical policy recommendations, providing useful insights for Hunan Province, especially considering potential trade-offs and synergies. Such information could lead to more effective, holistic environmental policy formulation.

Descriptive Analysis for the Trend of Pharmacovigilance Planning in Risk Management Plans on New Drugs Approved During 2016-2019.

BACKGROUND: Japanese pharmaceutical authorities have conducted regulatory renovations of pharmacovigilance planning (PVP) since implementing new procedures for developing post-marketing study plans in 2018 in order to promote more focused and scientific approaches. This study aimed to descriptively assess the effects of those regulatory renovations on PVP for new drugs in Japan. METHODS: We identified PVP information (drug characteristics, efficacy and safety issues, and additional activities) from the first version of risk management plans for new drugs approved between 2016 and 2019. The following indicators were analyzed: (1) proportion of the number of drugs with at least one efficacy issue among all the drugs, (2) proportion of the number of safety issues with additional activity among all the safety issues, and (3) proportion of database studies among all additional activities. RESULTS: In total, 168 drugs, 1212 safety issues, and 301 additional activities were identified. The proportion of drugs with at least one efficacy issue decreased from 91.4% in 2016 to 27.3% in 2019, and the proportion of safety issues with additional activity also decreased from 93.9% in 2016 to 53.7% in 2019. In contrast, the proportion of database studies increased from 0 to 19.2%. The percentages of additional activities targeting important identified and potential risks also gradually decreased during the 4-year period. CONCLUSION: Notable changes in the three indicators during 2016-2019 were observed, which suggests that regulatory renovation has affected PVP in Japan.

A Comparative Study of Various Land Use and Land Cover Change Models to Predict Ecosystem Service Value.

Ecosystem services are closely related to human well-being and are vulnerable to high-intensity human land-use activities. Understanding the evolution of land use and land cover (LULC) changes and quantifying ecosystem service value (ESV) are significant for sustainable development. In this study, we used land use and land cover data and other data from 2000 to 2020 to analyze the evolution of land use and land cover and ESV in Tongliao, China. With the goal of exploring the characteristics of different cellular automata (CA)-based models, CA-Markov, Future Land Use Simulation (FLUS), and Patch-generating Land Use Simulation (PLUS) models were used to simulate future land use and land cover, and the results were verified and compared. Considering the impacts of policies for capital farmland (CF) and ecological protection red line (EPRL) in the context of territorial spatial planning, four scenarios (inertial development, S1; CF, S2; EPRL, S3; EPRL and CF, S4) were set. The results showed that from 2000 to 2020, farmland and built-up land increased the most (341.18 km2 and 220.56 km2), while grassland had the largest decrease (380.08 km2). The main mutual transitions were from grassland and farmland. The total ESV showed a decreasing trend (from 52,364.56 million yuan to 51,620.62 million yuan). The simulation results for 2035 under four scenarios were similar, where farmland would decrease the most (96.81 km2). The ESV in 2035 would decrease from 51,620.62 million yuan to 51,541.12 million. In addition, under scenarios for the impact of policy, the land showed a trend of scattered expansion. This study provides a scientific basis for making regional sustainable development policy decisions and implementing ecological environmental protection measures.

Impact of Policies in Nutrition and Physical Activity on Diabetes and Its Risk Factors in the 28 Member States of the European Union.

Since healthy eating and physically active lifestyles can reduce diabetes mellitus (DM) risk, these are often addressed by population-based interventions aiming to prevent DM. Our study examined the impact of nutritional and physical activity policies, national diabetes plans and national diabetes registers contribute to lower prevalence of DM in individuals in the member states of the European Union (EU), taking into account the demographic and socioeconomic status as well as lifestyle choices. Datasets on policy actions, plans and registers were retrieved from the World Cancer Research Fund International's NOURISHING and MOVING policy databases and the European Coalition for Diabetes report. Individual-based data on DM, socioeconomic status and healthy behavior indicators were obtained via the European Health Interview Survey, 2014. Our results showed variation in types and numbers of implemented policies within the member states, additionally, the higher number of these actions were not associated with lower DM prevalence. Only weak correlation between the prevalence of DM and preventive policies was found. Thus, undoubtedly policies have an impact on reducing the prevalence of DM, its increasing burden could not be reversed which underlines the need for applying a network of preventive policies.

Effects of ecological protection and restoration on phytoplankton diversity in impounded lakes along the eastern route of China's South-to-North Water Diversion Project.

Traditional lake phytoplankton diversity studies do not take into account the impact of ecological protection and restoration project policies. Here, a difference-in-differences (DID) model, which is commonly used to analyze the relative importance of economic factors, was used to evaluate the impact of such policies on phytoplankton diversity in lakes. Dongping Lake was used as the experimental group, and the upstream Nansi Lake was used as the control group. The phytoplankton diversity index of the experimental group and the control group was used as the explanatory variable of the DID model. Six environmental and socioeconomic factors, temperature and precipitation, were used as control variables in the DID model. The effects of ecological protection and restoration project policy on phytoplankton diversity in lakes were analyzed. Under the influence of policy implementation, the phytoplankton diversity in the experimental lake was improved by 2.79% compared with that in the control lake. Temperature and precipitation were the main factors affecting phytoplankton diversity in the two connected shallow lakes in the Shandong Peninsula. This study verified that DID models can be used to quantitatively analyze the impact of ecological protection and restoration project policies on phytoplankton diversity in lakes.

Alcohol policy has saved lives in the Russian Federation.

Alcohol use has been determined to be one of the main risk factors of, and contributors to, premature mortality in Russia, but no formal analysis of the impact of alcohol control policies has been undertaken so far. The present contribution is a commentary on a policy impact study undertaken by the World Health Organization on the effects of alcohol control measures on mortality and life expectancy in the Russian Federation. As part of the case study, all alcohol control policies in Russia from 1990 to 2018 were examined, and periods with differing policy intensity were distinguished based on the known effectiveness of different measures. Trends in all-cause mortality during these periods, and the shifts in trends between periods, were analysed using interrupted-time series methodology. As predicted, the intensity of alcohol control policies strongly impacted all-cause mortality. The experience of the Russian Federation in reducing the burden of disease caused by alcohol is a strong argument that effective alcohol policies are essential for improving the prospects for long and healthy lives.

Sustainability of 'mHealth' interventions in sub- Saharan Africa: a stakeholder analysis of an electronic community case management project in Malawi.

Background: The global health community and funding agencies are currently engaged in ensuring that worthwhile research-based programmes are sustainable. Despite its importance, few studies have analysed the sustainability of global health interventions. In this paper, we aim to explore barriers and facilitators for the wider implementation and sustainability of a mobile health (mHealth) intervention (Supporting LIFE Community Case Management programme) in Malawi, Africa. Methods: Between January and March 2017, a qualitative approach was used to carry out and analyse 13 in-depth semi-structured interviews with key stakeholders across all levels of healthcare provision in Malawi to explore their perceptions with regards to the implementation and sustainability of the mHealth programme. Data were analysed thematically by two reviewers. Results: Overall, our analysis found that the programme was successful in achieving its goals. However, there are many challenges to the wider implementation and sustainability of this programme, including the absence of monetary resources, limited visibility outside the healthcare sector, the lack of integration with community-based and nationwide programmes, services and information and communication technologies, and the limited local capacity in relation to the maintenance, further development, and management. Conclusions: Future developments should be aligned with the strategic goals and interests of the Ministry of Health and engage with national and international stakeholders to develop shared goals and strategies for nationwide scale-up. These developments should also focus on building local capacity by educating trainers and ensuring that training methods and guidelines are appropriately accredited based on national policies. Our findings provide a framework for a variety of stakeholders who are engaged in sustaining mHealth programmes in resource-poor settings and can be used to develop an evidence-based policy for the utilization of technology for healthcare delivery across developing countries.

Credibility of subgroup analyses by socioeconomic status in public health intervention evaluations: An underappreciated problem?

There is increasing interest amongst researchers and policy makers in identifying the effect of public health interventions on health inequalities by socioeconomic status (SES). This issue is typically addressed in evaluation studies through subgroup analyses, where researchers test whether the effect of an intervention differs according to the socioeconomic status of participants. The credibility of such analyses is therefore crucial when making judgements about how an intervention is likely to affect health inequalities, although this issue appears to be rarely considered within public health. The aim of this study was therefore to assess the credibility of subgroup analyses in published evaluations of public health interventions. An established set of 10 credibility criteria for subgroup analyses was applied to a purposively sampled set of 21 evaluation studies, the majority of which focussed on healthy eating interventions, which reported differential intervention effects by SES. While the majority of these studies were found to be otherwise of relatively high quality methodologically, only 8 of the 21 studies met at least 6 of the 10 credibility criteria for subgroup analysis. These findings suggest that the credibility of subgroup analyses conducted within evaluations of public health interventions' impact on health inequalities may be an underappreciated problem.

Assessing the policy and practice impact of an international policy initiative: the State of the World's Midwifery 2014.

BACKGROUND: Understanding how policies lead to changes in health systems and in practice helps policymakers and researchers to intervene more successfully. Yet identifying all the possible changes that occur as a result of a new policy is challenging not only methodologically and logistically, as limited resources are available to conduct indefinite evaluations, but also theoretically, as a complete mapping and attribution of post-hoc changes requires a full understanding of the mechanisms underpinning all change. One option is to identify possible changes across a number of policy impact domains. METHODS: Using a Policy Impact Framework, we brought together data from media, documents and interviews to identify changes to midwifery policy, practice and provision, following the launch of a new global policy initiative, the State of the World's Midwifery (SoWMy 2014) report published in 2014. We used these identified impacts to develop a map of the mechanisms underpinning these changes. RESULTS: SoWMy 2014 contributed to a number of changes at national levels, including increased status of midwifery within national governments, improved curricula and training opportunities for midwives, and improved provision of and access to midwifery-led care. These contributions were attributed to SoWMy 2014 via mechanisms such as stakeholder interaction and acquisition of government support, holding national and international dissemination and training events, and a perceived global momentum around supporting midwifery provision. Policy initiatives of this kind can lead to changes in national and international policy dialogue and practice. We identify factors and mechanisms that are likely to increase the scope and scale of these changes, at contextual, national and global levels. CONCLUSIONS: Identifying changes following a policy using a policy impact framework can help researchers and policymakers understand why policies have the effect they do. This is important information for those wishing to increase the effectiveness of future policies and interventions.

Variations in non-prescription drug consumption and expenditure: Determinants and policy implications.

This paper analyses the determinants of cross-regional variations in expenditure and consumption for non-prescription drugs using the Italian Health Care Service as a case study. This research question has never been posed in other literature contributions. Per capita income, the incidence of elderly people, the presence of distribution points alternative to community pharmacies (para-pharmacies and drug corners in supermarkets), and the disease prevalence were included as possible explanatory variables. A trade-off between consumption of non-prescription and prescription-only drugs was also investigated. Correlation was tested through linear regression models with regional fixed-effects. Demand-driven variables, including the prevalence of the target diseases and income, were found to be more influential than supply-side variables, such as the presence of alternative distribution points. Hence, the consumption of non-prescription drugs appears to respond to needs and is not induced by the supply. The expected trade-off between consumption for prescription-only and non-prescription drugs was not empirically found: increasing the use of non-prescription drugs did not automatically imply savings on prescription-only drugs covered by third payers. Despite some caveats (the short period of time covered by the longitudinal data and some missing monthly data), the regression model revealed a high explanatory power of the variability and a strong predictive ability of future values.

The ramifications of recent health policy actions for cardiovascular care of women: Progress, threats, and opportunities.

Women's health and well-being are shaped by a combination of healthcare policies that impact the type of health insurance coverage they benefit from, as well as access to preventive, screening, and treatment services. Furthermore, more distal policies, such as those that pertain to housing, education, and employment, as well as social determinants of health, such as issues of socioeconomic status and women's status in society, also impact their cardiac health. Before the passage of the Affordable Care Act in 2010, women were at greater risk of facing barriers to coverage, reflecting gender rating and the higher likelihood of the existence of preexisting health conditions such as a previous pregnancy. The ACA made substantial progress in responding to women's health needs by expanding the numbers of low-income groups eligible for Medicaid (for the 32 states and Washington, DC that expanded the program) and other subsidized healthcare, as well as access to preventive health services. Although health reform efforts to eliminate the ACA failed in 2016, the administration and Congress are using a variety of channels, including the new Tax Cuts and Job Act, to implement policies such as the elimination of the individual insurance mandate, as well as the elimination of premium subsidies, that will likely impact women differentially, potentially undoing the progress that has been achieved over the past decade.

Early Impacts of Marijuana Legalization: An Evaluation of Prices in Colorado and Washington.

Following the legalization and regulation of marijuana for recreational purposes in states with medical markets, policymakers and researchers seek empirical evidence on how, and how fast, supply and demand changed over time. Prices are an indication of how suppliers and consumers respond to policy changes, so this study uses a difference-in-difference approach to exploit the timing of policy implementation and identify the impacts on marijuana prices 4-5 months after markets opened. This study uses unique longitudinal survey data of prices paid by consumers and a web-scraped dataset of dispensary prices advertised online for three U.S. medical marijuana states that all eventually legalized recreational marijuana. Results indicate there were no impacts on the prices paid for medical or recreational marijuana by state-representative residents within the short 4- to 5-months window following legalization. However, there were differences in how much people paid if they obtained marijuana for recreational purposes from a recreational store. Further analysis of advertised prices confirms this result, but further demonstrates heterogeneous responses in prices across types of commonly advertised strains; prices either did not change or increased depending on the strain type. A key implication of our findings is that there are both supply and demand responses at work in the opening of legalized markets, suggesting that evaluations of immediate effects may not accurately reflect the long run impact of legalization on consumption.

The impact on healthcare, policy and practice from 36 multi-project research programmes: findings from two reviews.

BACKGROUND: We sought to analyse the impacts found, and the methods used, in a series of assessments of programmes and portfolios of health research consisting of multiple projects. METHODS: We analysed a sample of 36 impact studies of multi-project research programmes, selected from a wider sample of impact studies included in two narrative systematic reviews published in 2007 and 2016. We included impact studies in which the individual projects in a programme had been assessed for wider impact, especially on policy or practice, and where findings had been described in such a way that allowed them to be collated and compared. RESULTS: Included programmes were highly diverse in terms of location (11 different countries plus two multi-country ones), number of component projects (8 to 178), nature of the programme, research field, mode of funding, time between completion and impact assessment, methods used to assess impact, and level of impact identified. Thirty-one studies reported on policy impact, 17 on clinician behaviour or informing clinical practice, three on a combined category such as policy and clinician impact, and 12 on wider elements of impact (health gain, patient benefit, improved care or other benefits to the healthcare system). In those multi-programme projects that assessed the respective categories, the percentage of projects that reported some impact was policy 35% (range 5-100%), practice 32% (10-69%), combined category 64% (60-67%), and health gain/health services 27% (6-48%). Variations in levels of impact achieved partly reflected differences in the types of programme, levels of collaboration with users, and methods and timing of impact assessment. Most commonly, principal investigators were surveyed; some studies involved desk research and some interviews with investigators and/or stakeholders. Most studies used a conceptual framework such as the Payback Framework. One study attempted to assess the monetary value of a research programme's health gain. CONCLUSION: The widespread impact reported for some multi-project programmes, including needs-led and collaborative ones, could potentially be used to promote further research funding. Moves towards greater standardisation of assessment methods could address existing inconsistencies and better inform strategic decisions about research investment; however, unresolved issues about such moves remain.

Impact of financial agreements in European chronic care on health care expenditure growth.

Various types of financial agreements have been implemented in Europe to reduce health care expenditure by stimulating integrated chronic care. This study used difference-in-differences (DID) models to estimate differences in health care expenditure trends before and after the introduction of a financial agreement between 9 intervention countries and 16 control countries. Intervention countries included countries with pay-for-coordination (PFC), pay-for-performance (PFP), and/or all inclusive agreements (bundled and global payment) for integrated chronic care. OECD and WHO data from 1996 to 2013 was used. The results from the main DID models showed that the annual growth of outpatient expenditure was decreased in countries with PFC (by 21.28 US$ per capita) and in countries with all-inclusive agreements (by 216.60 US$ per capita). The growth of hospital and administrative expenditure was decreased in countries with PFP by 64.50 US$ per capita and 5.74 US$ per capita, respectively. When modelling impact as a non-linear function of time during the total 4-year period after implementation, PFP decreased the growth of hospital and administrative expenditure and all-inclusive agreements reduced the growth of outpatient expenditure. Financial agreements are potentially powerful tools to stimulate integrated care and influence health care expenditure growth. A blended payment scheme that combines elements of PFC, PFP, and all-inclusive payments is likely to provide the strongest financial incentives to control health care expenditure growth.

A TRANSDISCIPLINARY APPROACH TO HEALTH POLICY RESEARCH AND EVALUATION.

An integrated perspective consists of macro- and micro-level approaches to health policy research and evaluation is presented. Analytical strategies are suggested for policy analysis, targeting on health disparities at individual and population levels. This systems approach enables investigators to view how scientific public policy analysis can be implemented to assess policy impacts. In this special issue, five papers are introduced.

Payment reform and changes in health care in China.

This paper is intended to assess the primary effects on cost, utilization and quality of care from payment reform of capitation and open enrollment in Changde city, Hunan Province of China. Open enrollment policy was introduced to deal with possible cream skimming associated with capitation. Based on the longitudinal Urban Resident Basic Medical Insurance (URBMI) Household Survey, this study analyses the URBMI data through a set of regression models. The original data included over five thousand inpatient admissions during the study period between 2008 and 2010. The study finds the payment reform to reduce its inpatient out-of-pocket cost by 19.7%, out-of-pocket ratio by 9.5%, and length of stay by 17.7%. However, the total inpatient cost, drug cost ratio, treatment effect, and patient satisfaction showed little difference between Fee-For-Service and capitation models. We conclude that the payment reform in Changde did not reduce overall inpatient expenditure, but it decreased the financial risk and length of stay of inpatient patients without compromising quality of care. The findings would contribute to the health care payment literatures from developing countries and open further research tracks on the ability of open enrollment to compensate for capitation drawbacks.